The 3 Phases to Improving Claim Submission

In unprecedented manner, SARS-CoV-2, the disease that causes COVID-19, has seemingly permeated almost every industry of the country in the matter of a few short months. Business activities not of absolute necessity and imperative have intensively come to a halt. Healthcare systems are no exception. Despite being the primary entity combating the virus, being on the front lines takes a toll as strained infrastructure and operational activities threaten an organization’s financial health.

Contrary to our wishes for this virus to vanish just as quickly as it came, providers and organization’s need to prepare for a marathon, not a sprint. Decreases in core revenue generating services and the systemic change or decline in staffing poses an unseen imperative to focus on efficiency and optimization. One potential area for opportunity is improvement in claims billing processes. Avoiding billing pitfalls in upstream workflows alleviates the duress of the financial department’s FTEs and allows efforts to be allocated elsewhere resulting in improved and accelerated cash collection and reduced cost to collect.

1. Looking on from the Outside

In many cases, a simple histogram analysis of an organization’s claim edits reveals one reliable trend: a small sample of claim edits are responsible for most downstream user interventions and delays in claim transmission to the payer. Despite scrubbers playing a critical role in preventing claim denials upon payer adjudication, the confusing outputs of pre-submission data do not allow for quick, reliable and accurate identification of the root issue. Difficulty in deriving the detail and specificity necessary to identify, categorize and trend claim edits by payer, departments, providers, and users yields an organization little visibility to adverse operational and technical factors within Revenue Cycle. Invariably, this proves problematic to streamlining reimbursement. The result: internal issues negatively impacting clean claim rate generally remain persistent and pervasive subsequently resulting in marginalized improvements on the provider’s cost to collect.

2. Unlocking the Key

Developing a successful clean claim rate initiative and improving the efficiency of an organization may seem daunting and complex, but it is crucial in maintaining and improving financial health and position. Perhaps historically, any efforts in this capacity have been unsuccessful or failed to remain beneficial or focused after the initial phases. This should not and does not have to remain the case. Despite the void of data and analytics provided by typical claim scrubbing services, driving down to the root cause and determining high-risk, problematic areas of an organization is quite possible with two critical components: technology and people. Several software solutions exist which take scrubber data, ingest it, match it with an organization’s host EMR and financial data and provide an output which is digestible and functional. With this insight of valuable data, people and decision makers of an organization have the key to easily deduct where to place focus in order to induce change. After all, when you don’t know where the problem lies, it is impossible to know how to rectify it.

3. Being in the Driver’s Seat

Explore the use of streamlined reporting and specific data trends from specialized software solutions and pointed knowledge of experienced, critical thinking people to identify educational

and learning opportunities to improve accuracy. Follow the patterns the data and reporting provide and react with tangible goals for marginal improvement. This may not prove to be the time for widespread change in structure or configuration, but strategic, targeted change and continuous advancement initiatives can provide steady, attainable improvement in financial position and health