What are the real challenges with claims processing? Is it the insurance companies or other payers? Is it with your practice management system? Is it your medical coding team? Is it with your physicians not documenting properly? Is it with the lack of clearinghouse claim scrubbing? Is it the lack of reporting so that issues are very difficult to pinpoint for correction? Perhaps none of these potential challenges apply and it is simply that your costs are too high. So many challenges!
Veterans in claims processing have seen a variety of challenges and have had to work through regulation changes, technology shifts, local workforce challenges and in many cases foreign entities providing outsourcing services. Finding the right mix of quality, cost, technology, process and staffing can be very challenging.
Government officials are not strangers to applying pressure on healthcare claims processing. Change is relatively constant and when not adjusting to 5010, ICD-10, or Meaningful Use, the Affordable Care Act is being overhauled by the American Health Care Act of 2017 (AHCA). It is not uncommon to hear about healthcare organizations putting plans on hold for a year to see how the AHCA shakes out. Sound similar to the second round of ICD-10 being announced? Remember how many took a ‘wait and see’ attitude after huge expenditures to prepare the first time around when the initiative was withdrawn? These changes cost more money because of the need to adjust each time one is instituted.
Changes are often necessary, but every change comes with a cost. Add the pressure of reimbursement reduction and quality of care, and financial viability intensifies. Sometimes it seems as if there is no way out and that healthcare providers and taxpayers will ultimately need to shoulder the additional cost. That is not a solution either. Cost must be contained!
So how does an organization figure out the right mix of assets, partners and processes to be more efficient and less costly at the business of claims processing? It might begin with an attitude, and end with a plan that is being executed, measured and adjusted as needed.
Healthcare organizations are not normally known for their business innovation, and why should they be? They are care providers and that is a complicated and often difficult role to play in society and industry. Regulations, good or bad, healthy or unhealthy are chronic and often acute in nature. Claims processing has become such a large responsibility for healthcare providers and is administrative in nature. Wouldn’t it make sense to somehow separate the care provision from claims processing so providers can focus on what they are trained for?
If an organization’s practice management and health record systems are a fixed entity, what is left for them to look at to tackle the remaining challenges of claims processing? Pay as you use software, that is transaction based or results oriented, is one way to potentially automate more functions, reduce cost, minimize errors and get claims paid faster. There are a variety of applications available from the very front end of a healthcare transaction all the way to making certain plan updates are accurately loaded and reconciled. It is still amazing sometimes to see how much work is completed manually when it could be automated, reducing costs and human error.
Claim scrubbing is often a function of the clearinghouse. The term clean claims is used a great deal, but not always in the context that is a true representation. A clean claim should get paid and should not be labeled clean if it doesn’t. Clearinghouse capabilities are critical to associated costs and also getting paid more, sooner. Choosing the right clearinghouse is a pretty big deal and implementing a new one can be a massive undertaking. Therefore, many healthcare providers don’t often change clearinghouse partners and instead may settle for mediocrity versus improvement.
Resource management and cost are another challenge in claims processing departments. Finding quality help may be difficult and may widen the reimbursement to cost gap. Geographic regions vary and the quality of trained healthcare resources may also vary. Given those variables, some providers have opted to outsource claims processing to specialists who only provide those services and yet many others do not. It seems as if outsourcing would make perfect sense, so why wouldn’t most do it? The answer may be the fact that outsourcing partners need to be carefully selected and the relationship built properly with appropriate Service Level Agreements (SLA) and performance metrics. Cost is also a factor. Jamaica and India have low currency value against the US dollar. The Philippines is also relatively low. So given money can be saved the wild card becomes productivity and quality. If either is lacking, real costs will rise and negate some or all the cost advantage.
Choosing those partners wisely, whether domestic companies using offshore resources or contracting directly with offshore resources, is critical. Understanding what is important to you and then comparing that to what potential partners are doing for others is essential. If it matches up, hire them and monitor them closely and communicate frequently to see how they are doing. If you have the right agreement in place with the right partner, the results can be very favorable and profitable. As a pretty sharp guy once said, ‘the proof of the pudding is in the eating.’