By Tammy Taylor, vice president of revenue cycle
As a healthcare provider, managing your revenue cycle can be extremely daunting. If mismanaged at any step in the process, it can severely wound your business’ health and your livelihood. That’s why companies such as Advantum Health exist and why I’ve had a 40-year career in healthcare RCM — to free you from the ever-changing details that spell the difference in your ability to not only survive, but thrive.
You may question the following blanket statement, but denials are preventable. (OK…most denials are preventable.) As a revenue cycle leader, I and the entire Advantum team look for the root cause of each denial. Then we watch for patterns; whether on the provider’s side — front or back office — or ours, together we deal with those root causes to dramatically minimize delayed or denied claims. It can be done!
Let’s start at the very beginning
In so many cases, you can greatly reduce your denials if you get your front-end processes as smooth and efficient as possible, and the information you send to the back-end billing team complete and letter- (or number) perfect. That’s part of what we work with you to do.
The devil is indeed in the details in denial prevention and management. Years ago, information gathering, eligibility verification, payment and patient communications were typically handled within the back-end billing office, today moving these functions to the front office leads to fewer denials, better cash flow and higher patient satisfaction.
Higher patient satisfaction?
Yes. None of us like surprises, and that includes patients who receive bills months after a visit or procedure they may have forgotten about. And even if they do recall it, they’ve long-since received the value of that service, they may not have “spare” money sitting around, and that healthcare bill is dead last on the long list of things they need (and/or want) to spend their dollars on. So, you either go through a retroactive, resource-consuming collection process which often leads to a small percentage or even zero payments and a customer who goes down the street to another provider, or you write it off. If you’re lucky, you collect 20 to 25% of the outstanding balance. Either way, you don’t get appropriately paid and probably lose business.
That was one thing in the era of low out-of-pocket costs and fewer competitors. But with the advent of high-deductible health plans, that patient’s co-pay and unmet deductibles are an increasing percentage of your revenue flow.
This is why so much of effective denial prevention has moved out of the deep back recesses of your office or RCM partner to your front-office team. Over the years, they’ve hopefully been educated or hired for their elevated role in contributing not only to your routine scheduling and check-in but your financial success.
Front-office staff need to understand that every detail is important. It’s not enough to know (and verify) which insurance company the patient has; you need to know exactly which of perhaps dozens of sub-plans a Blue Cross/Blue Shield, for instance, offer in your area. Each plan has different rules for co-pays, deductibles, pre-authorization, referrals, authorized care venues, etc.
Depending on your location and your patients’ comfort level with electronic check-in devices (pads, kiosks or portals), this can be a less-stressful and less staff-intensive process that can lead to fewer denials. But it’s dependent on your patient demographics and population; for instance, some patients may not own or frequently use a computer, so these devices can be more of a hindrance than a help.
Communicate, communicate, communicate
Though they’re designed to walk a patient step-by-step through the registration process, if those information-gathering devices just aren’t appropriate for your clientele, effective person-to-person communications become even more critical. Some helpful tips for effective patient communication include:
- Help patients complete all the demographic and other information you need to empower both your clinical and billing staff.
- Set patients’ expectations. Explain their financial responsibilities — whether a copay or deductible amount — to your patients based on the information they’ve provided.
- Ask patients to pay their portion of the bill at the time of their visit. Give your patients several payment options (credit or debit cards, check, payment plan) and assure them if the final balance ends up being less, they’ll receive a refund.
- Remind your patients that depending on the services they’re having done, there could be additional bills coming from other service providers involved in their care, such as radiology, labs, anesthesiology, etc.
Of course, communication also means internal communication between your front and back-office staff to constantly look for trends, good and bad, and feed denials upstream to the appropriate employee to foster improvements that prevent denials.
Communication also means that once you put these processes in place, hopefully you’ll see an improvement in your patient-satisfaction scores…something required as a factor in measuring your payment in a value-driven system. If you receive higher satisfaction scores, throw a celebration party for the staff as a reward. If it’s a trend of comments, good or bad, regarding a particular staff member, team or process, evaluate it and then have the necessary discussion to improve perceptions…or make changes.
Clean claims don’t equate to zero denials
Back on the claim-processing road, it’s important to note that a high percentage of clean claims doesn’t necessarily mean you’re guaranteed a low denial rate or faster reimbursement. “Clean claim” simply means you filled in all the spaces, dotted the Is and crossed the Ts. At this juncture, it doesn’t mean you submitted all of the pertinent information, completely or accurately.
For example, your staff could overlook a particular CPT code due to insufficient documentation to warrant the E&M level, causing such claims to be held up or denied for not being medically necessary.
Final potential denial or delay: Insurer
Some payers may be slow in processing, adjudicating and reimbursing claims. While this is not a rejection or denial, it leads to a decrease in cash flow and higher days in Accounts Receivable. If you notice this occurring outside of your agreement or their standard payment methods, you should have your staff or RCM partner reach out to the payer or plan’s representative to discuss the situation.
Process + knowledge = results
Whether it’s up-front denials, eligibility or coding denials or payer delays, there are many potential barriers to your complete and prompt payment. Fortunately, the Advantum team has a deep and broad understanding of each payer, plan and sub-plan, each client, and industry trends. We also use proven best practices to sort issues into work queues or “buckets” that are moved upstream every day to the proper staff member for follow-up. Hopefully, their “bucket list” is cleaned out at the end of each work day to keep the revenue cycle process moving smoothly and quickly forward.
Details, delays and denials can make or break your business. With the right revenue cycle services partner and a relationship built on collaboration, communication and seamless processes, you can be assured of a strong financial future.
Tammy Taylor is vice president of revenue services at Advantum Health. To contact her, email firstname.lastname@example.org.