Reinventing Claims Management for the Value-Based Era

Provider claims management can no longer exist as a silo. With the rapid transformation from fee-for-service to value-based models, denial rates remain high despite advances in technology and automation.

For providers to be effective, the revenue cycle continuum must be reexamined for unseen improvement opportunities in the fee-for-service era. One area is claims management, as an integral part of a denials management strategy.

What are the implications for providers? For perspective, consider the savings realized through electronic claims submission. CAQH research reveals that submitting a claim manually costs $1.98, compared to just $0.44 per electronic transaction. Likewise, a manual claims status inquiry costs $7.20 versus $0.94 for processing electronically.¹

Here are some features and benefits of a technology platform geared toward elevating claims management into the realm of denial prevention and management, along with some recommended best practices.

From claim scrubbing to strategic denial management

Simple claims management is becoming obsolete. A new class of integrated claims and denials management solutions augment the traditional approach to include pre- and post-filing activities that help automate and streamline claim submission, proactively monitor status and expedite the appeals process. Denials prevention is a process that leads to cleaner submitted claims and fewer payer denials. But there are a lot of variables that lead to "clean" claims, and a growing number of factors that influence denials, so it's important for providers to initially process claims properly.

Denials prevention means improving the quality of patient data at registration–a leading cause of claim denials. But integrated claim and denial prevention processes span the entire revenue cycle, and technology brings opportunities to manage costs and improve efficiencies.

A successful, comprehensive claims management platform integrates these capabilities:

• Eligibility verification prior to claim submission. Automating real-time eligibility verification data helps identify avoidable denials. 
• Compliance with often-changing payer business rules and regulatory requirements, so that claims go out as cleanly as possible.
• Digitization of attachments: Integrating digital data exchange into the workflow helps providers control costs, maintain regulatory compliance and help streamline claims processing and reimbursement.
• Visibility into claim-status lifecycle lets providers focus on potential "problem" claims earlier.
• Denial management and data analysis to guide corrective action and prevent future denials.
• Creation and tracking of appeals for denied claims helps cut down on manual work and streamlines the appeals process.
• Automation of repetitive tasks such as checking payer-portal claims helps drastically reduce the amount of staff time.

Pulling it all together

Once you've integrated these capabilities, consider the following to improve denial management and prevention:

• Embed denial management within the entire workflow--Strong edits lead to clean claims.
• Adopt analytics-driven claims management connectivity channels to payers, to produce a wealth of operational information.
• Resolve issues before they result in denials--Providers should always know claims location and status. Be ready to identify claims denials and submit appeals.
• Nationwide revenue cycle statistics show that 1 in 5 claims are denied or delayed and can be avoided with the right technology and better business processes. Identifying denials and submitting appeals to supply information not included on the initial claim can recoup lost revenue.

Claims management is moving quickly toward analytics-driven, exception-based processing. By implementing and leveraging these capabilities, providers can look forward to accelerated cash flow, reduced denials, increased automation and lower IT overhead.

1--2015 CAQH Index™ Reporting Standards and Data Submission Guide--Health Plans Numbers of Transactions and Costs per Transaction Data for Calendar Year 2014, Version 1, March 13, 2015.

© 2017 Change Healthcare Operations, LLC. All rights reserved.

About the Author: Carmen Deguzman Sessoms, FHFMA, AVP, Product Management, Change Healthcare