What you need for better claims management

Better claims management: ©Kizimik - stock.adobe.com

A physician’s primary concern when they enter an exam room is how to help the patient— not how they will get paid for those services later. In any practice around the U.S., you would be challenged to find someone who entered the health care field because of their passion for finance and business operations. What you would find are people, particularly physicians, who entered the profession to support their community and do right by patients. Maintaining a solid financial foundation is, however, a critical component of being able to provide that patient care.

Over the past two decades, a host of challenges — including rising costs, staffing shortages, electronic health records (EHR), complications with Medicare and Medicaid coverage and more recently telehealth and cybersecurity management — have made operating a financially successful health care practice increasingly difficult. In fact, frustration among providers appears to be reaching a fever pitch; 94% of physicians agree that it is becoming more financially and administratively difficult to operate a practice, according to a 2023 American Hospital Association report. This includes grievances with the way coverage is determined, claims are managed and providers are reimbursed, all of which are complicated processes, to say the least. These complications fuel burnout not only among practice employees but also among the many patients who grapple with a lack of clarity on their end about their coverage and the costs associated with their care.

Despite this, many physicians continue to see investing more resources into financial management practices and billing support as counterintuitive to their focus on patient care. This couldn’t be further from the truth. The reality is that a more proactive and holistic approach to revenue cycle management (RCM) is critical to improving operational efficiency by reducing administrative burden, ensuring providers are appropriately reimbursed for the care they deliver and preventing billing errors or potential financial burdens for patients on the back end.

The workforce factor

Although we’ve heard a great deal about the impacts of staffing shortages on the health care sector in the past several years, those challenges are not limited to nurses and physicians. They also affect administrative departments, with physician practices, in particular, struggling to find qualified employees and maintain a workforce to manage the growing demand for care. For instance, most private practices only have a small handful or even just one full-time employee managing the entire billing operation from beginning to end — including registering patients, coding, filing claims with insurers, sending out patient bills and, perhaps the most difficult, handling situations in which patients cannot afford to pay their bills.

Hiring local employees certainly has many benefits — including connection to the patient community, an understanding of the culture and a boost to the local economy — but it also can have limitations. Even for employees with prior experience, a lack of extensive and routine training or support from a broader network to help adapt to constantly changing regulations and processes is challenging.

Although COVID-19 influenced many physician practices to explore the value of outsourced or technology-powered RCM support, many still remain hesitant despite the return on investment these services deliver, such as improving financial performance and patient experience.

Whether recruiting new staff members, leveling up current staff or searching for a firm to outsource an RCM, there are several actions to implement immediately to operate more efficiently.

Ways to improve claims management — even before sending out a claim

First, understanding your payer contracts is an absolutely critical element to financial success. Unfortunately each payer — whether commercial insurance, government program or employer-sponsored plan — leverages different payment models, reimbursement processes and contract language. For example, different payers may disagree on what is “medically necessary.” Not having a clear understanding of the parameters of each relationship can lead to huge headaches for private practices on the back end. When you receive a base agreement, it’s critical to ensure your team reviews it, compares it with other contracts and thoroughly understands what they’re signing.

The second proactive way providers can ease their practice management burden is by ensuring proper provider credentialing, including the correct tax identification, National Provider Identifier and taxonomy numbers. Because denials can be blinded, practices frequently receive denials requesting authorization because the payer thinks the provider is out of network as a result of improper credentialing. In fact, a practice could receive as many as 10 to 15 different types of denials all tied back to the provider being credentialed wrong. Although seemingly simple, small inconsistencies in the credentialing process can ultimately become large roadblocks for claims as they work their way through the revenue cycle, leading to the claims being paid incorrectly or even not at all.

Finally, the importance of getting patients registered with the correct insurance at the outset can’t be overstated. For example, when a patient has Medicaid, they may also have other primary commercial insurance. Having a comprehensive understanding of each patient’s coverage is crucial to establish the correct pattern of billing at the outset and to ensure a successful outcome for the patient and the practice.

Focusing more on revenue cycle doesn’t mean less on patient care

Theconnection between RCM and patient experience is stronger than many acknowledge. When a patient enters the office, their top concern should not be the bill they are going to receive after the visit. If this can be prevented by investing in recruiting, training or outsourcing RCM, then it is a worthwhile investment. At the end of the day, if the practice is not financially stable, providers cannot achieve their main goal of providing quality patient care.

Jennifer Walen, M.H.A., is senior vice president of physician revenue cycle at Ensemble Health Partners. She has worked in revenue cycle management for Baptist Memorial Health Care and Spectrum Health.