Looking for solutions that can free your entire organization from repetitive administrative tasks and ensure vastly improved collections? Automating the reimbursement process from patient access to Revenue Cycle Management (RCM) will bring relief, increase bottom-line profits, and minimize staff scaling issues in real-time.

In a downward reimbursement environment where fee schedules are consistently under pressure, you are reliant on the ordering provider’s accurate collection of demographic and insurance information. One wrong entry creates a cascading event that negatively impacts the entire RCM process. Whether a hospital outreach lab or clinical lab, your organization’s financial health would greatly benefit from capturing the low-dollar claims that currently are often written off as bad debt.

The Problem: Avoid Writing Off Low Dollar Claims Without Scaling Up Lab Billing Staff

An ongoing frustration with labs is the elevated low dollar write-offs that occur for a variety of reasons and that are out of their control because the resolution rests with the ordering provider, including:

  • Missing or incorrect patient demographic information
  • Outdated insurance verification and eligibility information
  • Non-existent or incorrect prior authorizations
  • Tests performed that are not considered a covered benefit

These lab claims are then denied and, according to CMS, at least 15-20% are abandoned without follow-up. A typical threshold of $50 is used to determine if a claim will be worked and resubmitted. This constitutes a large, uncontrolled drain on cash flow and points to the lack of automation and lower collection recoveries.

Solutions to Enhance Low-Dollar Claims Collections

The answer to capturing these low-dollar amounts that are continually written off as bad debt is to engage a process that utilizes up-to-date automation techniques—including Artificial Intelligence (AI) and machine learning. The following discusses ways that labs can be proactive in a difficult situation where they lack direct patient interactions and must rely on their ordering partners.

Patient Access and Prior Authorizations

We now participate in an industry where high-deductible health plans make up over 47% of the private health reimbursement market. Patients are now collectively the fastest-growing private payer in the country, and this only appears to be increasing. With this new level of patient participation, we are also seeing a rise in laboratory bad debt write-offs as patients are surprised by bills they receive due to inaccurate information or missing pre-certifications.

With an automated prior authorization solution, labs would be able to manage by using smart automation and bi-directional integration of the following:

  • Determining if an authorization is needed and, if one is required, submitting paperwork to the payer
  • Unifying workflow—all authorizations would be monitored
  • Receiving alerts/notifications when approved authorizations are received
  • Automating follow-ups on delayed authorizations
  • Availability of highly trained specialists to handle any exceptions
  • Analytics and reporting would be available to ensure system success.

Revenue Cycle Management and Claims Denials

Claim denials account for roughly 35% of write-offs and are often abandoned because the cost of follow up and rework has been deemed too high. But what if you had an automated denial management system with an AI-enhanced delivery as part of the RCM workflow?

Utilizing an automated solution with machine learning and predictive intelligence, denials would be assessed, prioritized, and next steps determined. Without delay, they could then be appealed and tracked for follow up in real-time with certified specialists available to tackle the hard to collect outliers.

With an automated and intelligent approach to the healthcare payment lifecycle, your organization will be collecting more of the revenue due, and in a much more efficient and timely way. Teaming with an innovative leader in the automated patient billing space with AI and machine learning capabilities and a scalable workforce of highly trained specialists allows your organization to focus on providing stellar patient care.

Contact us to explore our patient access and RCM solutions today.