The holy grail for hospitals continues to be a high clean claims rate, though approaches can differ, a focus on performance metrics remains an important piece of the puzzle. When it comes to improving hospital claim collection rates, solutions continue to develop on software and process management fronts.
Sondra Akrin, Vice President of Revenue Cycle Transformation for Hayes Management Consulting, is quoted in a recent article on improving claim collection rates. She recommended that RCM teams “focus on revenue loss/leakage. Start by looking at write-offs for denials that you couldn’t appeal because a process failed (i.e. timely filing) or you were missing critical data (i.e. authorization). These write-offs are essentially lost revenue and drive down your collection efficiency. By focusing on refining processes and ensuring appropriate upfront data collection can prevent or minimize the loss of revenue.”
SSI Claims Management provides a 99.25% clean claim rate (one of the highest in the industry) via smart technology offered through its clearinghouse system. SSI’s clearinghouse streamlines your administrative process and eliminates the lag time between claims submission and payer acceptance. This is long-time solution focus for The SSI Group, with nearly 30 years as a clearinghouse maintaining strong relationships with providers and payers.
In an article on developing KPIs — Key Performance Indicators — RevCycleIntelligence.com advises that one focus for all hospitals should be a clean claims rate, writing that: “According to the HFMA (Healthcare Financial Management Association), the clean claims rate equation is the aggregate number of claims that do not require edits before submission divided by the total number of claims accepted into a hospital’s claim processing tool for submission.” Furthermore, “healthcare organizations should aim to have a clean claims submission rate around 97 percent. Higher clean claim submission rates indicate that hospitals are getting paid faster due to fewer claim errors.”
Even with this focus on clean submissions rates and other claims related KPIs, payments can still be a snag in the revenue cycle process. Providers need to be aware of “Pseudo-denials” that come in as payments, but they are at a significantly lower reimbursement rate than they should be. An article at Morning Consult observes that “despite billions invested in achieving efficient claims payment, more than 7% of claims are not paid correctly the first time, the second time, and sometimes even the third time. The remediation process costs health plans more than $43 billion annually. An entire sector of the industry has evolved to examine claims retrospectively, identify inaccurate payments, and reconcile over- and underpayments. This broad “pay and chase” approach increases administrative costs for the entire industry.” As Peter Drucker famously said, “You can’t manage what you can’t measure.” Healthcare providers who aren’t actively watching or installing technology to track and manage issues like these risk leaving money on the table.
Becker’s recently published an article focusing on “3 Best Practices for Hospital Claim Denials Management.” The article goes into great detail on each practice, summarized here:
- Use data analytics to go beyond the traditional claim denials KPI. One recommendation for this is that “hospitals may want to consider creating claim denial management KPIs for each payer. Knowing which payer denies the most claim submissions is key to identifying claim denial management improvement opportunities.”
- Implement the right claim denials management technologies. The article cites former Spectrum Health Director of Patient Financial Services, Frank Gless, who explained that “a solution that integrated with the health system’s medical billing system was beneficial. Moving away from the health system’s Microsoft Access database and to a bolt-on solution allowed staff to receive electronic remittance data from payers and create reports based on the information.”
- Engage clinical staff in claim denials management improvement to prevent denials. The article gives some real-world anecdotal evidence for this collaborative tactic, noting that, “HFMA also recommends that hospitals develop a multidisciplinary team approach to claim denials management. Clinical and revenue cycle management staff should collaborate to understand clinical documentation challenges.”
Along with a collaborative approach for denial management, we believe the solution for improving hospital claim collection rates includes robust and evolving billing and claims management software plus a comprehensive clearinghouse solution to achieve the best ROI in the revenue cycle. The SSI Group’s Billing Solution offering is in a SaaS environment which gives hospital revenue cycle management teams a streamlined workflow for the collections process.