Driving Down Claim Denials With a Digital Workforce

Manual errors and oversights, many beginning at the front desk, cause claims to be denied. According to a recent Black Book study, “33% of denied claims stem from inaccurate patient identification or information, costing the nation’s healthcare system $6 billion annually, or $1.5 million, on average, per hospital each year.” Data integrity is an important aspect of healthcare and errors can lead not only to reimbursement challenges, but to the quality of patient care.

According to research from the American Medical Association, nearly 20% of all claims processed have errors, costing the healthcare system billions each year. The industry could save an average of $15 billion annually, if companies processed claims correctly the first time. Manual claims are fraught with errors. Automation improves accuracy, timeliness, and transparency, #bridgingthegaps of a distributed workforce, and the challenge of “dollars in the door.”

Reduce Manual Data Entry
This reduces errors. The MGMA states “most claim denials are associated with breakdowns in front-end processes, such as patient eligibility (23.9%), missing information (14.6%) and authorization (12.4%).” Manual data entry processes are susceptible to human error. It takes, on average, 10 minutes to manually check patient eligibility. Unfortunately, remote staffing, multiple billing systems, and decentralized staff just don’t have the bandwidth to manually correct most errors. Instead of losing this revenue stream or adding complexity to an already bulky process, automation checks for accuracy, or missing information, and in many cases, corrects them without placing the burden on human employees.

“Our goal was simple. Make sure the claims leaving our billing system are accurate so there are fewer rejections down the line. We had a very large sum of money tied up in accounts receivable because the claims weren’t clean. At times it was as much as several thousand accounts and millions of dollars. When you start talking about amounts like that, it becomes very important to find tools to speed up the process. That was our task.”
– R. Walker, Financial Analyst, Phoebe Putney Memorial Hospital

Find Missing or Incomplete Information
Hospitals face many challenges with varied prior authorization procedures and requirements from payer to payer. These nuances and endless rules seem to have magnified with COVID-19. By submitting clean claims for authorized procedures the first time, denial management is simplified, reducing the time people spend analyzing incomplete data and identifying incomplete progress notes, lack of signatures or dates, and/or medical necessity rules. The Duke-Margolis report points to “three data elements that are commonly missing from medical records of individuals who undergo testing for COVID-19 through clinical labs: race/ethnicity, address and telephone number.” By filling in this missing information, automation ensures that all of the data that needs to be included is included, with no extra time spent by a human workforce.

Phoebe Putney Hospital took a close look at its billing system and was able to identify the coding errors that could potentially cause problems. Based on their analysis, a script was built in Boston WorkStation that searched and flagged any claims that fell into these problem areas, enabling the hospital to identify issues quickly and address them, rather than searching through each claim, which was time-consuming and inefficient.

The ROI of an Automated Workforce
Revenue cycle departments become much more strategic when focusing on health system strengths rather than administrative burden. Costly, labor intensive, error-prone tasks are exactly where automation shines, transforming the business of healthcare and taking the waste out of the system. Actionable insight to improve clinical, financial, technical, and organizational performance is gained by automating the following claims processes:

  • Denial Management
  • Prior Authorization and Eligibility
  • Payment Processing
  • Emergency Department Billing
  • Re-submissions
  • Medicare/Medicaid Corrections

As margins shrink, it’s becoming more difficult to absorb the cost of denials as merely the “cost of doing business.” By incorporating a seamless, scalable “digital ally,” claim denials can be handled without a heavy administrative component. This closes the loop in billing and bridges the gaps in revenue cycle health.

Why Boston Software Systems?
Put the power of Boston WorkStation to work on your next project. By offloading process tasks to Boston WorkStation, human staff can focus on higher value issues like patient care. Give us a call. We won’t take up much of your time, and look forward to discussing your issues in claims management.

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