Healthcare claim lifecycles start with patient registration and end when the provider receives full payment for all services delivered to patients. The cycle can take anywhere from a few days to several months, depending on the complexity of services rendered, management of any claim denials, and how organizations collect a patient’s financial responsibility.
Ensuring organizations understand the fundamentals of healthcare claim lifecycles can help providers and other staff operate a smooth revenue cycle and recoup all of the reimbursement allowable for the delivery of quality care.
Building and adjudicating a claim post-appointment
Claim denials are operational headaches that are costly to remediate. It pays to get claims right the first time. There are hundreds of insurance carriers with thousands of plans, all with different rules. Having a system in place enables healthcare organizations to ensure the claim will be submitted clean and has all the necessary elements for payment.
Per Becker’s Hospital Review, one in ten claims gets denied or requires some kind of edit. More touches to a claim translates to increased risk of human error, as well as increased cost-to-collect. When staff doesn’t touch the claim, rework can be avoided and the cost to collect can be significantly reduced. Achieving a 90% clean claim rate is an industry best practice that all healthcare organizations should strive to achieve.
Once a bill is sent to patients, it’s often too late for an organization to make any corrections. It is imperative to analyze and fix any potential errors before the bill goes out to ensure it’s as accurate as possible.
One in five claims have missed charges or aren’t paid properly. Taking time to identify and correct missed charges, denials and underpayments often lead to claims being paid faster. Be smart about which claims will yield payment and quickly optimize your internal processes. Consider adopting technology that will automate this process.
Appealing and auditing claims post-appointment
It is significantly harder to collect payment once a claim is initially denied. When payer rules are not followed, healthcare organizations don’t get paid. As denials increase, they are also harder to resolve. The appeal win rate has declined significantly, down 11% since 2014.
While it can be hard to get paid on an appealed claim, there is a lot to learn from evaluating and optimizing processes on a consistent basis. Ensuring compliance with specific payer rules and identifying the cause of denial and underpayments can help improve upfront processes and adapt collection strategies in the future.
Consider performing a monthly audit of all reimbursements to identify trends. This can help uncover more reimbursement opportunities. Denials, underpayment, and reimbursement optimization are three important areas that drive revenue recovery for healthcare organizations. Hundreds of thousands of dollars are left on the table each year by not exploring these areas.
More and more healthcare organizations are looking for the right partners to help with this process. Look for a partner with technology-driven solutions that combine data, analytics, and workflow, allowing accounts to be worked faster and at a lower cost to collect.
As a whole, the healthcare industry spends $315 billion annually on claims processing, payments, billing, and bad debt. By leveraging an integrated technology solution that combines data, analytics, and workflow, healthcare organizations can work claims faster and at a lower cost to collect.