A friend of mine kept putting off addressing a health issue because of her preconceived notions about the complexity, time commitment, and success rate of a cure. Her point of view was that it didn’t appear to be life threatening so rather than seek medical attention, she opted to do nothing. As a result, the daily discomfort became the norm in her life. As the months passed, she actually forgot what if felt like to feel good and just learned to live with the pain. From an outsider’s perspective, opting to live with pain every day rather than seeking a cure seems ludicrous. But it happens – and it’s pretty common – with patients and with healthcare providers as well.
Collecting revenue that is owed – from both payers and patients – has turned into a painful undertaking for many providers. Consider that around 9% of medical claims are initially denied by payers. On the surface this may not seem overly painful, but it equates to approximately $262 billion in delayed or denied payments. Couple that with the fact that patients’ financial responsibility for their medical costs has climbed to 30% with about 70% of that amount going uncollected, and you have some serious cash flow discomfort.
Even though the condition appears to be worsening for many, I continue to have countless conversations with providers that, just like my friend, do nothing. Yes, there are scores of reasons: “I haven’t got time to think about this, we’re getting a new EHR next year, let’s talk again in six months, I need to talk to my clearinghouse,” etc. All are signs of a provider that has gotten used to the revenue pain.
I have found that many times the rationale for deferring or taking no action is rooted in some preconceived notions that may be true if you’re trying to cure yourself but often are untrue if you seek the right external partner to help. Here are a few of the top notions:
This is a valid concern as a lot of the providers I speak with are so resource constrained, they can barely keep up with the steady onslaught of denied claims. But being resource constrained is the very reason you should be taking action not the reason you shouldn’t.
All you really need to get the ball rolling is access to your 835 and 837 files. Those who can get this for you are not necessarily your day-to-day staff who are busy working claim denials but rather your clearinghouse or your IT staff.
Utilizing your own data from those files, a learning loop can be created for ongoing detection of denial patterns. Then smart claim edits can be added right back into your system. That’ll take a chunk right out of that 9% initial denial rate.
This really shouldn’t be the case as data science and analytical software have become so advanced that they can provide results more expeditiously than ever. I’ve seen it take around a month to deliver actionable insight once data has been extracted.
Nor should you! Any external partners worth their weight in gold will not require you to implement a new system to solve your payer and patient payment issues. You should be able to use your systems, your data, and your workflows. No new EHRs, no extensive training classes, no capital expense.
If a new system is recommended by your external partner, run in the other direction. Or, at a minimum, get a second opinion.
That may indeed be the case – depending on what you are having installed. In many instances, though, the EHR turns out to be not quite as effective at solving claim denials and driving patient payments as one would like.
I recommend talking with a few of your new EHR provider’s customers to get an understanding of how helpful your new system will be. If they’re less than enthusiastic about the capabilities, you’ll want to proceed with other external vendors who can help you mitigate denials and drive patient payments regardless of your EHR.
Painful health conditions rarely get better on their own. There are a few exceptions but most of the time, they only get worse if left untreated. (Think toothache) Likewise, denials aren’t going to suddenly dwindle and patients aren’t going to suddenly start paying their medical bills in full.
Sophisticated data science and data modeling are effective ways to gain actionable insight to address revenue issues. Just like choosing the right specialist to treat your medical condition, be careful in choosing the right external partner to treat your revenue condition.
Look for an external partner that:
The friend I talked about earlier eventually sought medical attention. It turned out, all her preconceived notions were incorrect and the treatment was not nearly as complex as she anticipated. After just a few short months she was feeling good again. Not just good, but great, and her entire outlook changed.
So, if you’re tired of enduring the same painful issues associated with denials and patient payments, lay aside your preconceptions and do something about it. You’ll be amazed at how good it feels to get rid of the pain and actually feel good again.