Protect revenue across the claim lifecycle: 10 steps to enhancing profitability

$42.7 billion: that’s the annual cost of uncompensated care according to the AHA’s last report[1].  The number has been rising for years, as the payer mix shifts, patients gain more financial  responsibility, and events like the pandemic and inflation stretch already thin budgets. These  complications aren’t going away, but that doesn’t mean that providers don’t have options. In fact,  a combination of best practices and modern technology can help healthcare organizations  optimize processes at each stage of the claim lifecycle – ultimately enhancing the patient  experience and protecting revenue.

10 steps to optimizing processes across the claim lifecycle

The lifecycle of a claim – and the opportunities to ensure its timely payment – begins long before  the claim itself exists. It starts with a patient, who must navigate a labyrinth of access and  coverage. From there, it must survive several complex processes, administrative overburdening,  the nuances of the payer ecosystem, and the rigors of billing and reimbursement. At each step,  however, providers can proactively protect their revenue with a strategic approach to the patient  accounting lifecycle.

Prior to care: Scheduling and registration

1. Scheduling/pre-registration

The rise of consumerism in healthcare has given people more options for managing their care, but  also more pressure and responsibility: 78% of U.S. consumers [2] want to know the cost of their  care services before their appointment. As a result, the ability to accurately estimate the cost of  care has become essential, both from a patient experience perspective and as required by the  price transparency mandate [3].

Providers can attract and retain more patients by providing a patient-facing cost estimation tool on  their website. Giving people a clear, upfront understanding of their financial responsibility ensures  that patients are informed and prepared, which ultimately increases the probability of payment.

2. Registration

Once a patient has selected your organization, it’s time to get to know them. Accuracy and  efficiency during registration are critical for good outcomes and payment, but many providers still  struggle to fully vet and verify each patient’s information. In fact, half of denials [4] are caused by  front-end revenue cycle process shortfalls, with one in four of those denials due to registration  errors.

Leveraging an end-to-end eligibility solution that can identify, validate, and even discover  insurance to avoid denials downstream can drive better financial outcomes for patient and  provider. By automating eligibility processes, patient access staff can more easily verify patient  demographic information and insurance coverage, screen for charity care, and provide accurate  estimates of financial responsibility and payment options. It also makes it possible to see exactly  what the patient owes, so you can ask for payment at the time of care.

Time of care: Charge capture, coding, and discharge

3. Charge capture

Both undercharging and overcharging can impact a hospital’s bottom line: up to 1% of net patient  revenue [5] is lost because of errors related to charge capture. In a medium-sized hospital, that is  tens of millions of dollars! That’s a very significant number that providers can’t afford to ignore.

Prevent undercharging and overcharging by systematizing the process. Perform a regular audit of  charge captures to streamline workflows, reduce lag time, and improve the revenue stream.  Consider outsourcing your audit to address potential blind spots or internal bias within your in house team.

4. Coding and documentation

Coding claims can have many failure points, leaving revenue on the table and exposing the  organization to compliance issues. Coders gather documentation and charge entry from multiple  sources – the EHR, physicians, clinicians and other journal entries – and must rely on their  experience and knowledge to ensure accurate coding classifications. Unsurprisingly with such a  people-centric process, as many as 80% of medical bills [6] contain billing errors.

To ensure that charges are captured and that documentation supports the care provided, consider  implementing a Clinical Documentation Integrity Program. Supported by technology that simplifies  and streamlines the coding process, this team of experts can identify documentation deficiencies  so you can better protect earned revenue for care provided.

5. Discharge

This is a big one: providers have a 70% chance of receiving payment [7] at the time of service if  they request it, but only a 30% chance of collecting after the patient leaves the building.

Have the financial conversation with patients at every point of care. Every encounter (pre-service,  registration, discharge, pre-bill, post-bill, etc.) is an opportunity to help the patient navigate their  coverage, costs, and payment. Offering a personalized payment strategy – whether that’s charity  care, needs-based discount, or payment plan – gives you the opportunity to engage with the  patient and dramatically boost the probability of payment.

After care: Claims scrubbing, adjudication, appeals, cash posting, and audits

6. Claims scrubbing

The incredible complexity of today’s payer networks all but guarantees that claim requirements will always change for every plan. To achieve the industry best practice 90%+ clean claim rate,  you need an automated claim scrubber.

Trust the technology on this one. The more people touch a claim, the lower your rate of  productivity and throughput, driving up your cost to collect. When staff doesn’t touch or  manipulate the claim for payment, you can avoid rework and significantly reduce the cost to  collect.

7. Adjudication

By now, all insurance benefits and discounts should be calculated and in place. Taking time to  ensure that all the claim edits, charges and documentation are in place leads to claims being paid  faster.

If it hasn’t been done already, be sure to check potential coordination of benefits opportunities for  further reimbursements. In addition, end-to-end eligibility solutions can validate medical benefits  and/or discover insurance to ensure claims are submitted to the correct payers, even if insurance  is unknown to the patient or provider.

8. Appeal and follow-up

It’s no secret that it’s tough to get paid on an appealed claim. While denials are increasing, appeal  overturn rates are going in the opposite direction: down.

If you can’t win appeals, try to reduce the number that you file. Technology is your friend here as  well, mitigating the need to know every rule for every payer. Leveraging a third-party resource can  help ensure that you’re adhering to specific payer rules and identify denial and underpayment root  causes, so you can improve your upfront processes and adapt your collection strategies moving  forward.

9. Cash posting

The writing is on the wall: it’s more efficient and cost-effective to outsource A/R. 98% of hospital  leaders agree [8], reporting that they are considering partnering with an outside vendor to improve  cost efficiencies.

Labor shortages are at an all-time high, with hospitals reporting that 47% of their workforce [9] plans  to leave the healthcare industry in the next three years (2025). It is critical to ensure your  organization is managing its cash with the best available resources. What does that look like in  practice? Technology-driven solutions combine data, analytics, and workflow so teams can work  accounts more quickly and at lower cost to collect. Advanced reporting and insights can also  uncover root causes, so you can understand the drivers of your A/R and refine your revenue cycle  processes accordingly.

10. Month/year-end audit

Finally, take advantage of government reimbursement opportunities. Yes, the rules change every  day, and yes, the process is ridiculously complex, but you can’t afford to ignore it: providers leave  millions of dollars on the table every year by not exploring these areas for yield.

Perform a thorough monthly audit of reimbursements to identify trends and recover more  reimbursement opportunities. Denials, underpayment, and reimbursement optimization efforts  represent three critical areas to drive revenue recoveries. With the right technology partner, the  information should be clean, accessible, and ready to be transformed into additional revenue that  is defendable on audit.

The lifecycle of a claim will never be simple. Providers can, however, successfully navigate the  complexity of claims management with the right tools, technology, processes, and partners. From  registration to reimbursement, you can rethink revenue management and advance the healthcare  economy at your organization.

[1] Fact Sheet: Uncompensated Hospital Care Cost | AHA

[2] https://www.bcbsprogresshealth.com/community/consumer-tools-to-compare-health-care-costs-and save

[3] https://www.cms.gov/hospital-price-transparency/hospitals

[4] https://www.beckershospitalreview.com/finance/86-of-denials-are-potentially-avoidable-strategies to-better-prevent-manage-denials.html

[5] https://www.hfma.org/topics/article/55358.html

[6] https://www.modernhealthcare.com/finance/identifying-addressing-common-medical-billing errors-pre-post-payment

[7] https://comprehensiveprimarycare.com/paying-doctors-upfront-point-of-service-collections/ [8] https://www.prnewswire.com/news-releases/by-2022-average-hospital-costs-must-be-reduced by-24-to-breakeven-and-outsourcing-may-be-the-solution-says-black-book-300643743.html [9] https://www.forbes.com/sites/jackkelly/2022/04/19/new-survey-shows-that-up-to-47-of-us healthcare-workers-plan-to-leave-their-

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