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Back to Basics in Claims Management

How to achieve major improvements in three key areas.

"Getting back to basics" is a tried-and-true adage for situations that have escalated into too much complexity. For many healthcare organizations, claims management falls squarely into this category.

In recent years, 5010 and ICD-10 have necessitated major process changes to claims management workflow.

Today, value-based reimbursement adds new challenges. In an environment fraught with complexities, claims management will likely never be a simple process.

It can, however, be simplified, and this simplification can yield benefits such as streamlined workflow, improved staff productivity and higher claims revenue.

Playing Catch-Up 

Ten years ago, Ninth Street Internal Medicine Associates (NSIMA) was a six-physician practice with manual claims management processes.

Fast-forward to 2016, and our organization now has 11 physicians, two nurse practitioners and a nutritionist to meet diverse patient care needs, often caring for two and three generations within the same family.

Located in Philadelphia and serving the entire Delaware Valley, we are one of the first physician practices in the country to become certified as a Level 3 Patient-Centered Medical Home by the National Committee for Quality Assurance.

While the organization had grown over the years by adding new providers and services, NSIMA hadn't updated revenue cycle management (RCM) to meet its faster pace and higher patient volume. The claims management processes that worked 10 years ago weren't meeting our needs.

Our leadership team realized the slow, heavily manual claims management processes meant we were leaving revenue on the table. By overhauling claims management, NSIMA would be able to build optimal processes that meet the thriving practice's needs and help maximize revenue.

SEE ALSO: Reassessing Your Revenue

Leveraging Automation & Integration

When NSIMA began its claims management overhaul, workarounds and delays were an ingrained part of RCM processes; for instance, I pulled an all-nighter every Tuesday waiting for all NSIMA's claims files to transfer to its clearinghouse. The DOS system was cumbersome and time-consuming, and as a result, our team's time wasn't as productive as it could've been.

Our team began evaluating new clearinghouse options with an eye toward optimizing effectiveness and efficiency in three basic components of claims management: claims submission, denial and rejection workflow, and staffing and supervision. After selecting Navicure as our clearinghouse, and with the back-to-basics approach, we developed new claims management processes in these areas:

Claims submission - As NSIMA evaluated claims submission processes, we identified two essential components to the newly redesigned processes: integration and automation. First, we wanted a claims management process that was fully integrated with our EHR vendor. Logging out of the EHR and into the current clearinghouse, and vice-versa, was proving time-consuming; we knew an integrated solution could potentially save hours per workday.

Beyond the EHR-clearinghouse integration, we added comprehensive support to our evaluation criteria. We wanted peace of mind that the clearinghouse could answer questions about the EHR integration down to which field to click to generate certain reports. By having a support team on standby that could provide this level of information, we could come closer to getting the most out of both solutions.

Lastly, our leadership team identified automation as a necessary component to the overhaul. We knew automation was the key to realizing immediate cash flow benefits as well as sustaining long-term process changes. In addition, though, we recognized the importance of paper-based claims. Despite the pervasiveness of e-submission, being able to submit paper claims effectively is critical. This capability was further down on the list of evaluation criteria, but it was still important as it represented revenue.

Denial and rejection workflow - Any automation of our current processes would've been beneficial; however, we saw the advantage of doing a complete overhaul all at once. Denial and rejections benefited the most from automation: we went from waiting up to two days to receive rejection notices to learning about them real-time and receiving automated notifications. We also went from reading scores of printed dot-matrix pages to spot claims errors to receiving an automated worklist that shows rejections and requires a fraction of our time.

To leverage automation, we created the optimal workflow for each member of the claims management team, entering this information into the clearinghouse solution. Our staff has designated days for working denials and rejections and now receive automated worklists based on these predefined workflows. These worklists show our assigned tasks and allow us to track progress. Integration has also improved denial and rejection workflow: before, we had to create entirely new claims, and now we can make edits directly in existing claims and then resubmit them.

Staff Supervision and Reporting - Claims management requires both extreme attention to detail as well as a top-level view of trends. To that end, it's important for all staff, especially supervisors, to have access to robust reports. Our team only had paper-based reporting prior to the overhaul. We wanted reporting for two key purposes: First, we wanted to track staff progress and make sure we were performing as needed (and if not, pinpoint the problem areas, such as rejection or denial category type, for training or coaching). Second, we wanted to view performance and trend data categorized in various ways; for instance, by payer, or by type of denial or rejection. Even though our team frequently felt like we were "drinking from a fire hose," we knew we would soon get to a point where we could be more disciplined about leveraging this type of data to make improvements.

Achieving Not-So-Basic Results

At this point we can approximate $4,000 of savings per year on mailing costs alone, and at least 200 hours of time saved per month based on the benefits we have received from the new claims management process. We frequently talk to peers who have claims workflow challenges and leave revenue from denials on the table.

Whether our peers are redesigning claims workflow, evaluating clearinghouses or both, NSIMA leadership always stresses the value of automating as much as possible, and leveraging everything-from product features, support services and training-our clearinghouse vendor offers. Any organization can get back to the basics, evaluate the main components of their claims management process and identify areas to improve. We opted for the complete overhaul, and as a result, we have realized benefits that go far beyond the basic. 

Chauntae Joyner is the billing manager at Ninth Street Internal Medicine Associates in Philadelphia.

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