In 2019, payers denied 18% of claims because of the exclusion of services. They denied the rest because of… Missing prior authorizations… Submission errors… Missed deadlines… or Other process issues. Denied claims lead to huge financial consequences and losses. Thus, providers must submit “clean” claims every time that don’t have any errors. Every detail of the claim must be correct, including… Patient information… Diagnosis codes… File formats… and Timing of submissions. There are some things you can do or implement to help the healthcare provider’s administrative burden and navigate the claims adjudication process.
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UTILIZING AUTOMATION
In 2021, the Council for Affordable Quality Healthcare (CAQH) reported that automation could yield massive costs and time savings for healthcare providers. Electronic claim submissions could save the healthcare industry $1.8 billion annually compared to manual processing. This is because you don’t have shipping, handling, and other human-related delays with electronic claim submissions. In essence, if you save time and minimize human error, then you will reduce costs and gain more from successful claim adjudication. In the meantime, automation could save 22 minutes per claim status inquiry. Automation is even better than electronic claims because it streamlines the adjudication process for both healthcare practices and insurance companies. When organizations process thousands of claims each month amidst growing staffing pressures, automation is key to improving your revenue cycle.
FRONT-END EDITS AND CODING CHECKS
During the claim adjudication process, insurance companies comb through claims to make sure everything is as it should be. If there’s something incorrect with the claim, it will fail the payer’s initial automated review. In turn, this can lead to denials or getting pushed to the side for manual reviews. As I mentioned before, time is costly in the healthcare world, so manual reviews will cause delays and increase costs. These problems can have a significant impact on the healthcare entity’s revenue cycle. To avoid disruption in the organization’s finances, providers need to keep themselves up-to-date with current coding requirements and universal, local, and payer-specific edits relevant to the claim. The best way to avoid these issues is to either use software programs to run automated checks or use a clearinghouse to run the checks for you. Both these solutions can find errors that might prevent reimbursement. For example, a clearinghouse can identify a missing prior authorization section or incorrect coordination of benefits codes. By the way, we at Etactics offer an automated clearinghouse experience.
STANDARDIZATION OF CLAIM ADJUDICATION
Unfortunately, each insurance company has its own rules for claim submission. This means that providers must spend hours reformatting, recoding, and re-checking claims and relevant data to make sure the adjudication goes well. Automation creates advantages for both providers and payers, as mentioned above. With so many benefits, it makes sense to pay for solutions that will save your budget and your business in the long run. The software can pull policy updates directly from payer websites, helping providers get their claims approved and reimbursed. The right software can also connect with other claim management tools, like the ones I mentioned above, to help with authorization-related omissions.
Nothing is as easy as it sounds when it comes to insurance companies. Claim reimbursement is one of the most frustrating and tedious revenue cycle processes, especially since most of it isn’t in the healthcare entity’s control. Partnering with a clearinghouse like Etactics makes adjudication easier to manage with less stress. We streamline front-end processes and provide insights into each claim’s status. With Etactics, you can get more regular reimbursements with fewer denials.
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