Have you calculated your hospital’s rate of claims denied on the first pass lately? If not, don't be surprised if it rests at or above the 2014 industry benchmark of 20 percent. That's one in five claims denied on the first pass. After reworking claims and pursuing appeals, if necessary, you may still face a 5 percent ongoing denial rate. Imagine, though, how much revenue you could keep if you received your due compensation on the first billing effort and seldom had to re-submit or appeal claims. Would it be substantial enough to implement a technology-driven pre-bill review process?
By implementing data-scrubbing IT for pre-bill audits as part of your clinical document improvement (CDI) strategy, you exploit your unstructured, disorganized data and match it to your quality care metrics and coding protocols. The end result is clean claims and proper documentation to satisfy your payer organizations.
How do you devise an effective pre-bill review process
Before any claim walks out the door, a dedicated pre-bill reviews staff should verify every component for authenticity, code compliance and complete documentation. Once satisfied that a claim is pristine, they can authorize it to be sent. Your pre-bill reviews staff will require knowledge and experience in clinical documentation, coding/ICD-10 and billing.
Map Out a Workflow
Preparing clean claims can no longer be left to one department who pieces together the available information on the back end. With ACA driving value-based compensation away from procedure-based pay, everyone from the intake team and clinicians to the case managers and billing staff must do their part. An efficient workflow through all departments must contribute to the claim with accurate demographic information, verified coverage and treatment eligibility, clinical documentation, pre-authorizations and coding.
By the time the claim reaches the pre-bill review step, very few gaps or stray information should cloud the claim. The pre-bill auditor, however, will scour the claim for any deficiencies and send it back through the channels until it returns to them error-free.
Acquire Automation and Analytics Software
The pre-bill review process can be accomplished manually by gathering information from disparate legacy IT systems. But let's face it, that just doesn't fly anymore. Not when automation, interoperable data transfer and secure cloud computing are becoming de rigueur across the entire healthcare industry. Plus, natural language processing (NLP) and machine learning\artificial intelligence (ML\AI) can radically simplify and monitor the progression of claims from Point A to Point Z while delivering amazingly useful data packages for process and predictive analytics. By hauling your technology out of the cave, you can increase productivity and reduce man hours.
Using your integrated claims processing technology, the activity of every member involved in patient care should show up on the final claim. Once reviewed and submitted, denial rationales can be analyzed to spot recurring weak spots in the chain. If you know where the problems tend to enter claims, you can take action to further train staff to eliminate confusion and mitigate procedural hazards.
Avoiding overpayments, that you know will come back to bite you, and claim denials in the first place will help your hospital’s reputation with payers. When they're relaxed and happy to see your claims because they consistently arrive in good order, you could gain some important leverage in negotiating payer contracts. Renegotiations can further smooth out your administrative burdens. It makes sense to reposition staff to prevent denials rather than chasing them after the fact. The right health IT and a pre-bill review system can make all the difference in the world. Additionally, collecting those one in five claims that may otherwise have gone to appeals instantly fattens your bottom line.