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Knowing When It’s Time to Send Your Old Claims Management System Packing

By ZirMed | August 09, 2017

“That’s the way we’ve always done it.” Who among us hasn’t heard that phrase at some point in our careers?  

It’s definitely a common refrain in business. Change can be difficult, which means it’s much easier to continue doing what you’ve always done, working the way you’ve always worked, than to implement new processes and systems – even if they have the potential to yield significant improvements.

This type of corporate inertia may form the path of least resistance, but the short-term benefits of maintaining the status quo can damage the long-term success of the business. One of the key areas where this applies to provider organizations is with claims management.

Ongoing shifts within the regulatory and payment landscapes have made it imperative for healthcare organizations to capture all the revenue that they are due with the minimal amount of delay or additional effort.

Here are 8 signs that you should send your old claims management system packing:

  1. Your clean claims rate is not where it should be – This one should be obvious, but a surprising number of providers don’t pay enough attention to this metric. Submitting claims that are complete and accurate the first time is essential to improving your cash flow, minimizing your days in accounts receivable, and preventing lost revenue from denied, delayed, or partially paid claims. Your clean claim submission rate should at a minimum be greater than 95%, with a goal of moving it up to 97% to 99%. If you’re not meeting these goals, it’s definitely time for a change.
  1. You are manually checking claim status – Manually checking the status of each outstanding claim via phone calls and visits to individual payer websites is one of the most time-consuming components of the entire claim workflow. Worse, much of this time may be wasted if the claim is still processing. By automating claim status checking, you can reduce this unproductive time and instead focus on more value-added activities.
  1. You lack the ability to work by exception – If claims are proceeding as they should, there is no reason to look into them further. Yet that is the way many healthcare organizations manage their claims, wasting time and money that could be better-spent elsewhere. The better approach is to use automation that enables staff members to focus only on claims that need attention so they can address any issues before the claims are denied.
  1. You struggle to make sense of claim rejection messages – Claim rejection messages can be difficult to understand, requiring additional time to research before you can address the issues. The result is that the resolution (and payment) are delayed. Your claims management vendor should provide easy-to-understand translations of claims rejection notifications that walk you through how to resolve a rejection or error notice.
  2. You have no proof that you filed your claim on time – Every payer has its own specific rules regarding when claims must be filed for processing. Your team must be aware of these payer rules to prevent missed billing opportunities. The claims system you use must also be able to generate proof of timely filing in case payers deny claims they say did not make the deadline.
  1. Your claims batches are held when only a few claims need rework – Some claims management systems hold entire batches of claims when only a few need to be reworked. This process can significantly affect cash flow at a time when healthcare organizations are already operating on razor-thin margins. The better approach is for the claim management system to hold only those claims that need attention while allowing the rest of the batch to move to the payer. This approach will save days in accounts receivable and help ensure your cash keeps flowing.
  1. You assume the payer enrollment burden – One of the barriers that keeps providers from upgrading their claims management systems is the prospect of having to set up every payer manually in the new system. If that is on your mind, it’s actually a sign that it’s time for a change. Your claims management vendor should provide automated payer enrollment capabilities that remove you from the burden of setting up payers while prioritizing new enrollments based on claims volume. These capabilities minimize disruption while making it easier for you to get up to speed in the new system.
  1. You don’t have an advocate – Many health plans offer online portals to make it easier for providers to do business with them. But sometimes you need to speak with an actual human being to resolve issues or discuss denied claims. Having a claims management vendor advocate in your corner who can tackle these issues on your behalf will save much time and many headaches. Vendors focused on customer service will also spot the root causes of certain issues occurring on a mass scale and proactively make changes on your behalf, sometimes before you even become aware of the issues.

If you do what you’ve always done, you’ll get what you’ve always gotten. In today’s dynamic healthcare world, that may not be good enough. By upgrading your claims management capabilities, you can save time, improve revenue and cash flow, reduce denials and ensure your staff remains focused on delivering the greatest value to your organization.

Are you seeing these signs in your organization? How have they affected you? Leave your thoughts in the comments below or contact us at https://info.zirmed.com.