Want to reduce denials? Slim down your RCM solutions

Nearly 70 percent of health systems and physician practices use more than one vendor for revenue cycle management (RCM) technologies—and those that do face higher denials rates, a survey by HIMSS Analytics and Dimensional Insight found.

More than two-thirds of healthcare organizations surveyed use electronic health record (EHR) solutions for RCM, according to the survey. Among those that leverage their EHR for RCM, more than 41 percent use two or more RCM vendors.

Why does the use of multiple revenue cycle vendors contribute to higher rates of denials? Usually, the problem comes down to data:

• Collecting revenue cycle data from disparate sources, like multiple RCM solutions, makes healthcare revenue management challenging. More than 65 percent of organizations surveyed say the use of multiple types of medical billing technology makes revenue reimbursement “moderately challenging,” while nearly 33 percent find it “extremely challenging.”
• When more than one RCM platform is used, 25 percent of healthcare organizations struggle to identify billing errors or keep up with data variances that stem from the use of multiple tools.
• Lack of interoperability between RCM systems is a significant hurdle in achieving revenue integrity, according to more than 67.4 percent of respondents. So are data silos (67.4 percent) and lack of trust in the data collected (30.2 percent) when data come from multiple medical billing software solutions.

How can health systems and physician practices that have more than one RCM solution best leverage these technologies to support cleaner claims? Moving the following four functions to a single RCM platform is key.

1. Benefits eligibility and patient data verification. When claims or patient billing statements are not accurate, patients’ frustration increases—and so does days in accounts receivable (A/R), the average number of days it takes for an organization to be paid the amount due. It’s not uncommon for front-desk staff or patients to make a simple keyboarding error during patient registration, such as an incorrect birthdate or an invalid primary identification number. When these errors aren’t caught before a claim is submitted, they can quickly halt processing of a claim. Software solutions that verify patient demographic and benefits information in real time, at the point of service, can spot these errors and help front-desk staff prompt patients for corrections.

2. Coding assistance. Coding accuracy is critical to achieving revenue integrity. Yet, physician practices in particular frequently face coding challenges, including:

• Undercoding claims, which occurs when physicians select codes that do not fully reflect the intensity of the work performed (typically out of fear that the claim will be denied)
• Neglecting to update old codes or include codes for specific services in the EHR
• Lack of familiarity with coding nuances, such as those related to Medicare or specialty-specific coding
• Failing to demonstrate medical necessity

Automated coding tools provide staff with cognitive computing support that helps match the right medical codes with the right patient within seconds, increasing clean claim rates. The most advanced tools not only are fluent in all coding guidelines, but also the latest insurer requirements, ensuring your practice submits accurate and thorough claims that will be accepted on first pass.

3. Claims-scrubbing tools. Claims-scrubbing software can help organizations spot claims errors and omissions before claims are submitted and prompt staff for follow-up. If your organization’s days in A/R are 40 or higher, it’s important to consider an outpatient solution that validates professional claims and encounters for accuracy against thousands of coding and billing requirements. Such tools review claims and encounters from a payer’s perspective, validating use of diagnosis codes, procedure codes, modifiers and medical necessity. When errors are discovered, claims-scrubbing tools prompt staff for the corrections needed.

In selecting a claims scrubber, look for a solution that achieves at least 95 percent claim acceptance on the first pass.

4. Electronic claims review. Insurance companies place time limits on claims submission (e.g., 90 days from the date of service). These deadlines vary by payer. When providers miss the timely filing deadline, the claim is denied—and the provider loses its right to appeal. Invest in automated tools claims management that can:

• Follow up with payers each time you submit a claim to ensure claims not only have been received, but are being worked (ideally, within five days of submission)
• Track appointments for which claims have not been posted and prompt staff for follow through, minimizing lost revenue

Making the Most of Your Investment
Optimizing your revenue cycle performance shouldn’t require a new EHR—a solution most healthcare organizations would be unable to afford. Instead, strive to rely on a single RCM platform by integrating mission-critical revenue cycle functions under one solution. Doing so will better enable your medical billing staff to optimize use of each of these features without disrupting workflows—resulting in cleaner claims and improved financial health.

Samantha Meyer is director of revenue cycle management, Pulse Systems, Inc.

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