It’s Time to Get Your Due! -TripleAim Approach to Tackling Underpayments in Medical Billing
- SolvEdge
- Sep 16, 2021
- 4 mins read
Hospitals and Medical Practices continue to take new initiatives to prevent underpayments. However, reports indicate that claim denial rates are at an all-time high—with hospitals losing billions of dollars to underpayments in medical billing every year, and about a staggering 33% of hospitals nearing the danger zone at a claim denial rate of
over 10%.
Reworking claims alone cost 20% of the overall revenue cycle operational costs with an average claims rework cost of $25 per claim. From Hospitals to Patients and Pharmacies, claim denials and underpayments could have a significant financial impact on revenues and cash flow, while also affecting patient financial experiences and consumer loyalty.
The good news is that 90 percent of claim denials are preventable. However, care providers need to consider sustainable business models to not just manage but prevent denials at large.
A Triple-Aim Approach to Combat Denials and Underpayments
With TEAM, CMS is introducing dynamic episode-based risk scoring, which requires:
1. Improving Payment Accuracies. Healthcare systems need to integrate automated revenue recovery solutions into their medical billing systems to improve payment accuracies and accelerate cash-flow. Streamlining revenue recovery solutions ensures transparent billing and payment integrity—thereby enhancing patient financial experiences and Patient satisfaction scores. Revenue recovery solutions feature advanced analytics and predictive insights, powered by machine learning capabilities—that identify repeated patterns of denials and underpayments, to continuously improve the overall revenue cycle process for better financial performance. Automated medical billing solutions can also make advanced predictions on coding inaccuracies, duplicate claims, and prior authorizations, filing deadlines and other possible claim denial scenarios—in order to make the necessary claim adjustments before submission.
Revenue recovery solutions feature advanced analytics and predictive insights, powered by machine learning capabilities—that identify repeated patterns of denials and underpayments, to continuously improve the overall revenue cycle process for better financial performance
2. Patient Engagement Solutions – In the world of value-based care and reimbursements, most often, medical billing solutions, especially denial management strategies and revenue recovery systems are centered on creating superior Patient Experiences (PX). Hence, patient management platforms are built with intuitive interfaces that provide hyper-personalized recommendations and high-touch experiences to support transparent billing, and facilitate frictionless patient journeys. These automated and AI-powered platforms work together to significantly reduce denials, and ultimately improve patient collections. Financial counselors in healthcare organizations also use automated patient management solutions to quickly assist patients in terms of financial decisions and patient responsibilities—resulting in enhanced consumer experiences, higher patient satisfaction, and better outcomes.
3. Risk Analysis – Care providers also need to integrate risk adjustment strategies to analyze the intricacies of the financial accounting frameworks. Data analytics and intuitive Business Intelligence (BI) tools can help healthcare systems analyze and bridge the risk gaps, while also improving the quality of care. Risk analysis solutions in hospital management systems also factor in other components like compliance, pharmacy data to provide more comprehensive insights on the overall risk scores. Hospitals and Practices can use these insights to reimagine their digital strategies, streamline their workflows and continuously improve their clinical, operational and financial performance.
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Final Words
As rightly said, it’s the strategy, and not technology that drives holistic business transformation. Hence, healthcare organizations need to orchestrate a comprehensive medical billing strategy that encompasses the right combination of industry best practices, next-gen technologies, proven strategies, denial management expertise, along with an experienced team of SMEs and technologists who can work together to enhance the financial performance of a Hospital/Practice.
To learn more about how your healthcare organization can reduce the spiking denial rates and underpayments,
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