Nearly a decade ago, Harvard economist, David Cutler, famously called out Duke University Hospital for employing 1,300 persons to administer billing for only 900 beds. Apparently, that’s what it took in light of the many disparate requirements imposed by multiple payers (patients, insurance companies, the government) in every transaction. Nearly a decade later, healthcare automation offers efficient alternatives in billing as well as many other business processes.

Automated claims processing

As a threshold matter, automating healthcare solutions requires effective health information management. Health information management holds significant promise with regard to eliminating delays and denials in the claims process, which impact payers, providers, patients, and public health in general. Effective health information management not only directly addresses known issues in the claims workflow, but it is also a crucial first step in automating points along that workflow for optimal use of human capital, ROI optimization, and enhancing employee- and patient/consumer-experience.

To wit:

- For every process a payer or provider automates, there’s less need for manual intervention.

- Automated processing enables full visibility throughout the process.

- Intelligent data analytics tools help ensure efficient compliance efforts and enhance data privacy, routing related documents for the most efficient and appropriate reconciliation.

- Predictive analytics tools help providers and payers plan for uncertainties, including appeals and resubmissions.

By way of example, Exela’s deployment of our custom, self-service, rule-based healthcare solutions saved a top 10 payer an impressive 35% in the cost of processing claims and amounted to a 50% reduction in cycle time and a 20% reduction in resubmission rates. In addition, increased transparency for payers, providers, and members vastly improved employee- and patient/member-experience and reduced the demand for customer-service interactions. You can learn more in this case study.

Automating payments

Automating billing can be a game-changer by:

• Reducing the number of persons dedicated to the process, reducing time spent, and errors associated with, manual keying.
• Unifying payment data from multiple channels such as paper checks, debit transactions, collection procedures, etc.
• Enabling an improved patient communication strategy.
• Introducing other valuable efficiencies into the billing process such as HIPAA-compliant lockbox solutions.

In fact, we at Exela know how valuable such steps can be because we’ve seen it first-hand in solutions we’ve provided to our customers. For example, in the case of a major academic health system whose outdated payment operations had been mired in manual, error- and loss-prone processes, we deployed our Patient Financial Services suite to streamline information ingestion, facilitate communications, and optimize workflows, with the result being a 25% reduction in full-time employees needed for these operations and a 30% increase in collector efficiency. You can read more about it in this case study.

In addition to streamlining claims by avoiding denial of payment through improved coding, delivery of clean claims, and facilitating all related inter-stakeholder communications, automation can optimize revenue integrity through, among other things, data mining for the purpose of predictive analytics and revenue forecasting, all in the service of identifying and recovering all amounts in the most effective and efficient manner. For example, when a large healthcare system wanted a way to maximize reimbursement under their many payer contracts (all of which had different requirements, terms, and conditions), Exela deployment of its healthcare automation solutions resulted in 99.6% accurate reimbursement and identified 98.4% of underpayments and calculated predicted reimbursement under all payer contracts. “We look forward to continuing our relationship with Exela for years to come,” commented the customer in this case. “The contingency, success fee based engagement has provided an extremely positive, financial bottom line return, while requiring minimal staff time on our part...”

In addition, our medical lockbox solutions support providers in managing (and reducing the costs associated with managing) a high volume of receivables payments. And our newly-launched Real Time Payments solution can streamline the collection of remainders from patients using secure messaging and convenient payment options (via text message with payment options).

Automating accounts payable

It’s not just the core businesses of stakeholders that benefit from automation. For example, another of Exela’s customers, a national urgent care provider, had been processing more than 50,000 vendor invoices per month, resulting in lost documents and delayed payments to vendors, before turning to Exela to fully automate its burdensome paper-based workflow. In addition to streamlining payment to vendors and lowering the incidence of defaults and discrepancies, the user-friendly interface equipped the provider with the tools needed to readily address discrepancies if they arose and permitted the provider’s vendors to check invoice status online.

In the case of a major pharmaceutical company with a global footprint and driven by constant research and development, Exela was able to harmonize, digitize, and automate the more than 50,000 incoming invoices from 40 different business areas in 19 different countries through a custom-tailored combination of digitization services, data extraction, reporting, and remittance.

Automation Enrollment

Open enrollment is a payer-specific issue, and it’s always challenging. With ever increasing pressure to outperform the previous year’s results, there’s always a need for process innovation to meet increasing demands. Pressures are compounded by a short enrollment timeframe and employees who find the process confusing. The result is numerous queries and insufficient enrollment documentation. A large insurance company customer of Exela had been struggling with this scenario to the point that its satisfaction scores with providers and members were being severely impacted. Exela designed a universal intake and workflow solution to manage all the various modes of communication between the payer and the employees/potential members. In less than 90 days, Exela delivered 240,000 enrollment installations a month at a quality of 99.5% with significant cost savings in the form of reduced call volume and reduced pending items. Customer satisfaction soared.

Benefits to patients

The administrative complexity of the U.S. system also burdens patients, whether they are deciphering bewildering bills or shuttling records between providers. Three-quarters of consumers report being confused by medical bills and explanations of benefits. A Kaiser Family Foundation survey of people newly enrolled in the health insurance marketplace found that many were not confident in their understanding of the definitions of basic terms and concepts such as “premium,” “deductible,” or “provider network.” Insurers and employers spend an estimated $4.8 billion annually to assist consumers with low health insurance literacy, according to McKinsey.

For the full story on how technology can solve costly inefficiencies in the health industry, be sure to check out our Q4 Edition of PluggedIN: Tell Us Where It Hurts: How Tech Can Heal Healthcare.

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Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511963/

https://www.streamlinehealth.net/HIM-blog/revenue-integrity-can-organization-best-achieve/ https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/promoting-an-overdue-digital-transformation-in-healthcare

The COVID-19 pandemic’s impacts have been felt across industries, but none more directly than healthcare. In many parts of the world, the healthcare system has been pushed to capacity - and that doesn’t just mean the doctors and medical staff. Non-medical support staff and operations have been stretched thin as well. Whether it's in a large hospital or small practice, claims processing and denials management play a critical role in maintaining the fiscal health of any healthcare organization.

Denials management is a necessary, and often overlooked, aspect of that process. It’s important here to note the difference between rejected claims and denied claims. A claim rejection means the claim was submitted to a payer with incorrect coding or missing data. Claim denials occur when a claim is repudiated by a payer after being processed. While denials are a natural part of the healthcare billing process, they can be costly, so most hospitals seek to avoid or reduce them.

One of the main goals of the denials management process is to uncover the root cause. The aim is to reduce the risk of future claim denials by modifying the process to prevent unnecessary denials and reduce the overall denial rate. A low denial rate indicates a healthy cash flow. Organizations with a high denial rate should take a look at the causes and make necessary corrections.

Hospitals forgo thousands of dollars annually in revenue through denied healthcare claims. A significant portion of claims are denied annually - the industry average is between 5% and 10%, meaning payers deny about one in every ten submitted claims. Unfortunately, an estimated 90% of these denials could be prevented with solid denial management policies and procedures.

Challenges of Claim Denials Management

Here are some of the most common challenges that lead to high denial rates:

• Disconnected systems and processes- As businesses grow, new solutions are often developed or implemented as the need arises. This often leads to a broken, disjointed internal landscape made up of multiple processes, solutions, and systems that are either poorly integrated with one another or operate completely independently. This leads to massive inefficiencies, backlogs of denials, duplication of efforts, and increased costs. Bringing the entire system together into one streamlined process can significantly reduce the number of denials annually.
• Increasing complexity of claims processing- The health insurance landscape has, in many ways, been growing even more complicated than it was just several years ago. The growth of insurance marketplaces gave birth to an increasing number and variety of insurance plans. At the same time, there’s been a marked shift toward high deductible health plans, which place more of the financial responsibility on patients. When taken together, these two trends lead to an increased number of costlier claims errors and higher rates of denial.
• Lack of visibility- Many claims systems - particularly those built on manual processes or over a variety of disparate tools - don’t provide any insight into denials data. Without this visibility, revenue integrity teams are always playing catch-up, handling denials as they come, rather than identifying and addressing the root causes and preventing future denials.

Due to the costs associated with denied claims, many hospitals are understandably eager to minimize denials and the errors that often lead to them. Here are a few simple solutions that can help healthcare organizations reduce their claims denial rate.

Healthcare Business Automation

Manual processes always leave room for errors and often slow down the entire denials management process. Be it a small practice or a large hospital, manually entering and dealing with multiple payers is not easy.

However, nearly one third of healthcare providers still perform all of their denials management procedures manually on spreadsheets, according to a recent Healthcare Information and Management Systems Society survey.

Introducing business automation into such processes can offer transparency, reduce the chances for human error, and drastically increase the turnaround time, improving efficiency and cash flow. Automated denial management lowers the number of errors in the process while providing useful insights that can drive better decision making and more efficient allocation of resources in the future.

Experienced and Trained Staff

Even with automated processes including automated denials management, having the right people involved makes a big difference. Missing or incorrect information is one of the leading causes of denied claims, and that can often be traced back to overworked or inexperienced staff. Staff members are often burdened by many administrative tasks and required to fill many different roles. They must also deal with constantly changing industry and regulatory trends and regulations, and not having the right staff can impact the revenue flow.

Automation and digitized processes can help ease the pressure on small teams by handling some of the more tedious and time consuming tasks. Some hospitals may also choose to partner with experienced medical coding services to bring in a supplementary workforce of qualified coders to help handle increased workloads.

Preventing Denied Claims

As the old, appropriately medically-themed adage goes, “an ounce of prevention is worth a pound of cure.” For many organizations, the best way to bring down their annual denials-related costs is by preventing denials from occurring in the first place.

Exela’s PCH Global solution uses intelligent automation to identify “Certain to Deny” claims before they’re sent out. This allows for corrections to be made early in the process, increasing first-pass billing accuracy rates by an average of 24-31%, directly reducing the volume of denials.

PCH Global provides a complete claims cycle management solution through digitization and automation, offering greater visibility into the processes. Get in touch with us today to know more about automation in the healthcare industry.