Category: For Hospitals & Physician Groups

Are you frustrated with billing bottlenecks, your current vendor’s lack of flexibility and limited understanding of your needs? Tired of waiting in a queue? Dreaming about what it would be like to experience personalized client service? It might be time for a change.

Does that realization take you from frustration to fear? It’s true: the thought of implementing a new claims clearinghouse can be overwhelming. How could a new vendor understand our billing cycle’s unique complexities? How could we manage to upload all of our claim files to a new system without slowing down our billing cycle? Even if they manage to set it up, how could a new vendor maintain a high level of on-going personal service? These are just a few of the anxieties that often arise before healthcare providers successfully transition to a new vendor.

Whether you are a new provider deciding on a vendor for the first time, or switching vendors after years of service, implementing a new claims clearinghouse is a significant undertaking that requires an investment of time, money and resources, not to mention a tremendous amount of internal and external collaboration. The best way to conquer your claims clearinghouse change anxiety is to control your implementation and make your expectations known upfront.

When considering a vendor’s implementation strategy, make sure it includes these three vital steps: facilitate, automate, and educate.

• FACILITATE the transition with parallel testing.
  Parallel testing allows your organization to transition to a new vendor system seamlessly without disrupting your billing cycle. Loading duplicates of your outgoing claims into a parallel testing environment, your new vendor can ensure the proper data is present and in the correct format/location. It will also verify that the necessary payer edits are in place and identify any discrepancies between your previous system’s process and the new one. Furthermore, a good vendor maintains a robust network of payer connections to preserve your current streams of revenue and allow for development of new ones.
• AUTOMATE the electronic submission of COB claims.
  One of the most complicated processes in claims management is the COB (secondary/tertiary) claims process. It is not surprising that COB can be difficult to implement. To fully maximize your organization’s efficiency, your new claims clearinghouse needs to minimize the amount of time your staff spends dealing with COB claims. To do that, you need a vendor that can implement three critical facets of COB claim management: 1) automatic or manual creation of electronic COB claims, 2) training for your personnel on management of those claims, and 3) submission of automated electronic COB claims immediately after going live.
• EDUCATE personnel to understand and create custom edit logic.
  Given the complexity of the medical billing cycle, it’s expected that a vendor will create, track, and manage customized edits for the unique needs of your practice or facility. However, the reality is that most practices require more than just what is deemed standard. You should expect a vendor to not only provide you with tools that allow you to write your own customized logic, but also train your personnel to do so.

A claim clearinghouse that offers all five of these benefits will deliver the ultimate benefit you need: increased cash flow with decreased expense. Learn more about our Claims Management Solutions.

Ideally, claim follow-up should only be performed by your staff when taking action defends the reimbursement you deserve. Any action taken that does not directly improve your reimbursement or cash flow, erodes your profit margin by increasing costs without increasing revenue. One way to control follow-up costs is to use advance claim status to identify when claim follow-up makes “cents.”

The key is to know which claims would best benefit from follow-up.
It all begins with knowing where your claims are in your payers’ review process – assuming your claims made it to the payers’ review process.

Looking at the key stages of the payer’s review process, let’s identify when follow-up makes “cents” and when it doesn’t.

• When the claim status is in-process, no follow-up action is recommended. The payer has not yet made a decision on the claim. At this time, it may be more cost-effective to wait. After a certain amount of time has elapsed, a second claim status inquiry can be made.
• When the claim status is to-be-paid, no follow-up action is required. The payer has made a decision to pay the claim and a payment will be received. Any action taken by staff adds cost to confirmed reimbursement. Gaining insight that a claim is to-be-paid at the time of the payer’s internal decision (which may be much sooner than upon receipt of remittance advice), can help your staff avoid unnecessary follow-up.
• When the claim (or line item) is denied, rejected, or pending, it is important the right follow-up action be performed in a timely, efficient manner. To identify the best course of action, it is critical to fully understand why the claim (or line item) has not been paid. Follow-up staff can target next steps and avoid the cost of trial-and-error issue management.

So how do you obtain claim status information? Labor intensive options include calling the payer or accessing the payer portal. Both options are high-cost, low-volume solutions that require manual processing. It is more cost effective to obtain your claim status responses electronically. According to a 2016 study by the CAQH Index,® switching to an electronic process for claim status inquiry can save up to $7.94 on the cost per transaction over manual processing representing an 81% savings. Though automated ANSI 276/277 claim status inquiries and responses provide some benefit, the problem is that payer ANSI responses tend to lack the more actionable data found in payer portals. It is generally the detailed proprietary payer codes and comments found in payer portals that offer the best source of information.

Here’s where Advanced Claim Status (ACS) by Quadax can help. Electronically scraping status information directly from payer portals using web-bot technology, ACS replaces or supplements standard ANSI 276/277 transactions to provide richer, more actionable information. Reporting claim status and denials as soon as one-day post billing, ACS provides electronic access to payer proprietary remark codes and descriptions allowing you to understand why a claim is pending or rejected and to know it sooner. Using more comprehensive information to enable “workflow by exception” processes, ACS avoids the cost of unnecessary follow-up and frees your staff to pursue follow-up on the claims that would best benefit from further intervention.

When managed cost-effectively, and fueled with the right information, your claims follow-up strategy can help maximize your reimbursement and improve your revenue results. For follow-up made easy, learn more about our Advanced Claim Status (ACS) solution.

Going paperless is a green solution in more ways than one. If done smartly, you can save the planet and save your company a bundle of green as well.