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Automation can also aid manual front-end processes. For example, the system
that isolates and separately produces
the claims that require attachments
saves personnel time. Automatic
application of contract information
also saves time when it comes to
comparing billed amounts to expected
collection. If this comparison is not in
the front-end process, it should be.
Heading Off Denials
A major problem hindering healthcare
facilities is the difficulty in hiring and
retaining experienced coders. One
impediment is that there are so few
coders in relation to the demand for
them. As a result, facilities typically
must offer higher compensation to
experienced coders and be willing
to train inexperienced candidates.
Even as new versions of HIM software
provide up-to-date coding assistance, it
is still advantageous and cost-effective
to employ two additional resources:
1) code editing software that can catch
errors that would otherwise creep
into the first submission of bills; and
2) claims clearinghouses that submit
claims electronically and can scrub and
return claims that would likely have
been denied upon first submission.
Investing time as well as money can
pay dividends. Facilities that have
the best results in managing denials
avail themselves of the opportunity
to write appeal letters. Producing the
first five letters or so can be a tedious
and time-consuming exercise, but
as the library of appeal letters grows,
the task becomes more routine,
allowing staff to cut, paste, and adapt.
If a denial is written off as a contractual
adjustment, does it make a noise?
Sadly, no. Harried staff facing
overflowing in-boxes may find it
hard to resist this quick resolution
of outstanding claims, which will be
hidden among legitimate adjustments.
Two detection techniques can combat
this problem. Detective controls in
the software can identify claims that
have been both denied and ultimately
assigned a disposition of contractual
adjustment. Scrutinizing these will
pinpoint the first instances in time
for correction and spread word
among the staff that they cannot
hide this type of claim progression
anymore. A complementary second
detection technique involves
measuring contractual adjustments
in both total number and total dollars.
An increase in either figure is a
signal to look for the root cause.
Building in Data Analysis
One hospital outsourced its entire back
end—collections, posting remittances,
and data analytics—to a contractor that
proved to have many shortcomings.
Among them, the service provider
did not have up-to-date software
to ensure that claims were dropped
cleanly and could not electronically
post remittances for most payers.
It could not follow up on self-pay
accounts in a timely manner. It failed
to adjust credit balance accounts. The
contractor could not provide complete
key performance indicator (KPI) reports
to the client. Payments were slow,
and some potential collections were
forfeited. A/R was misstated. This
hospital had so little monitoring in
place that it took seven months for cash
shortfalls to finally sound the alarm.
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