Is your healthcare organization getting the most revenue possible out of your insurance A/R?  It's a loaded question,  we know, but it's a vital one to ask.

Accounting for the many steps in the lifecycle of a claim, there are probably areas that could be improved to increase payments. Each aspect of the claim lifecycle contributes (positively or negatively) toward your collections rate including timely claim release, denial reasons, payment processing and aged A/R.

Like a cog in the wheel, each factor of the claims process may be minor on its own, but necessary to the adjudication of payment. Let’s take a deeper look at some of these key steps in the lifecycle of a claim:

Provider’s Documentation

What may prevent or delay clean claims from getting to payers in a timely manner?  Starting from the visit, the provider needs to document it. If it takes the provider a long time to document this will delay the rest of the process as nothing can move forward without the proper documentation. For example, the patient’s visit cannot be coded without it. How often are your providers documenting? Daily, weekly, monthly? Require providers to complete documentation within 48 hours of the visit.  

The Importance of Coding

Are there complexities or barriers that your coders are facing that would prevent them from accurately coding?  Once the provider documents the visit, it’s time for the coders to translate the health visit into ICD-10 and CPT-4 codes. If the documentation received isn’t thorough or specific enough, coders may have difficulty coding accurately, or the coder might not select the proper code that best fits the care services rendered. Once the codes are entered, the claim is officially born and goes onto be submitted to the payer, but before it can it has to pass a few more checks.

Claim Submission

To actually submit the claim to the payer, there are usually multiple sets of edits the claim must clear at an internal, clearinghouse, and payer level. It is extremely beneficial to review what edits you are seeing in your inventory the most and fix the underlying problem that may be causing the edit rather than fixing them individually every time. Are your claim edits being scrutinized and resolved quickly?

Payer’s Adjudication

Now that the claim has reached the payer’s adjudication system it has to be processed, you’re not finished yet.  Most payers are looking for reasons to not pay, that’s why it is so important to follow up on your A/R that is outstanding with payers.  Are you seeing the same claim denials over and over again from the same payer?  Quite often insurance payers will have specific guidelines that must be followed in order for payment to process; these are typically outlined in the payer’s provider manual. It’s up to your claim follow-up staff to determine the issues that cause claims to continually deny and correct the underlying problem to meet the payer’s specifications, rather than correcting each claim on an individual basis.

Payer Pitfalls

To avoid another common mistake, ensure that you’re following the payer’s corrected claim or appeals submission process to the letter. Most payers have their own specifications about how they will receive claims. Also, think about paper claims:  paper can be very messy. There are stories about payer’s processing offices with stacks on stacks of paper claims piled up on the desks. Do you think they ever lose some of these?   All the more reason to submit electronically whenever possible.

Payment Delays

Often times we will hear that the payment posting department is behind, and this can cause all kinds of unnecessary follow-up whether it be with the payer or internally through payment posting issue processes.  How are your payments received from the payer, electronically or by mail, additionally, do you have a lockbox set up?  Are payers indicating that payment was released, but you haven’t received it?  You need to verify with payers that they have the most up-to-date payment address, oftentimes they just need a W-9 to update this.

The Tough Stuff: Aged A/R

If you have aged A/R, review each payer and identify what remains past the payer's timely filing limit.  Consider adjusting.  Now this is sometimes difficult and you can make the decision on what you would consider being a high dollar that may still pay, but you have to ask yourself why are we holding on to this?  In the words of Elsa, let it go, let it go!  Additionally, how is your staff working on the A/R?  

Strategize to Optimize

Adjust work strategies to focus on A/R prior to hitting the timely filing age for each payer eliminating unnecessary aging.  For example, UHC’s original claim filing deadline is 90 days from the date of service, this means your work strategy should drive to follow up on these earlier than a carrier that has 1 year.

What good is a work strategy if staff isn’t following it? Check that your staff understands the strategy and is working on it. A simple way to ensure this is by doing random monthly audits on claims worked for a day. Does it appear they are working what you expected them to be working that day?

The Bottom Line

If you can identify small barriers, you can focus on solutions that will make a big impact on your collections rate. As you review these key areas please download the Quick Reference Checklist and answer honestly without any bias. As you make changes remember to communicate the expectations to your team clearly. If the team doesn’t know what the expectation is, how can you expect them to meet it? Good luck in coding, submitting, and getting claims paid cleanly and accurately the first time.