In healthcare’s complex and administratively burdensome accounts receivable process, managing the rejected or denied claims can be especially frustrating for billing staff at both hospitals and provider practices. Not only does it create large blocks of unproductive time while staff members sit on hold or wait in insurance payer queues, but there are often limits on the number of claims that can be submitted or questioned during each call.
Now multiply this by the number of claims that are rejected or denied annually (over 40 million or 18% according to the Centers for Medicare and Medicaid Services [CMS]), and the cost to the healthcare industry is staggering. By using an intelligent and automated approach, the denials management function can be accomplished in real-time, and claims that were previously often abandoned can be collected, thereby significantly reducing an organization’s AR.
How Can Automating Claims Management Improve AR Results?
This manual process is estimated to cost $7.12 and take 14 minutes per claim according to the 2018 CAQH Administrative Index and takes valuable staff time away from higher-value billing functions or improving the overall patient experience. By automating the claims management process, this solution can ensure an average savings of $5.23 per claim while also saving valuable staff time and lost opportunity that can be redeployed to more important functions.
When evaluating claims management solutions, consider these AI-driven software functions critical to achieving the long-term goal of permanently reducing revenue loss from denied claims:
- The ability to predict recovery, including forecasting the dollars potentially available and the timeline to achieve final collections. With machine learning algorithms, unpaid claims can be evaluated on a number of available parameters, such as aging, payer, and modality.
- Access to predictive and deterministic criteria that prioritize follow-up strategy activities to maximize and focus human intelligence efforts where they can be most effective.
- Automated claim status checks matched with the most-likely cause, i.e., integrated insurance verification and eligibility data, CPT mismatch technology, and DOS and benefits check capabilities. Once the cause is identified, appropriate changes are made, and the claim is resubmitted.
- Auto-creation of required appeal letters, if necessary.
- Automated eFax capabilities, when required.
- The ability to perform a root cause analysis through operational analytics to find where mistakes originate upstream, including insurance verification, prior authorizations, or coding problems, so that processes can be reviewed and upgraded where necessary.
- Adaptability so that if additional areas are identified as automation candidates, integration is possible with ease.
The complexity of a third-party billing system requires diligent review, and follow-up when revenue is held up and the bottom line is affected. With the technology available today that harnesses AI-assisted automation, machine learning, and predictive analysis, each patient encounter can be verified, submitted and followed up on in real-time.
After implementing this type of technology, revenue abandoned because of denied claims should largely be a thing of the past. And maybe most important of all…patients won’t be surprised by unexpected bills—a great source of consumer frustration with the healthcare industry as a whole.
Contact us today to learn more about how your organization would benefit from streamlining the claims management process!