Revenue Cycle’s Swiss Army Knife: Leveraging Claims Management Technology to Optimize Your Revenue Cycle

Introduction

Hello, and welcome to FinThrive's on demand webinar series. I'm Jason Hergenraider, solution strategy director here at FinThrive. And today, I wanted to walk through, revenue cycle Swiss Army Knife, the claims management system. We'll look at how you can and should leverage your claims management system to do things like improve employee productivity and satisfaction, decrease denials and improve compliance, and drive positive organizational change.

Top Concerns of Revenue Cycles in 2024

So I wanna start with a look at some of the top concerns of revenue cycles in twenty twenty four. In a recent survey of a hundred and seventy six revenue cycle and financial leaders, four of the top responses should really come as no surprise to anyone in health care. In fact, I would venture to guess if you were to look back at the last four years or so of these types of surveys, the same four, issues or concerns would be at or near the top of pretty much all of them. And when we compare that, those concerns with the focus areas for revenue cycle leaders in twenty twenty four, you can kinda start to see some correlation.

Focus Areas for Revenue Cycle Leaders

So for example, automation and technology, which is the largest focus area here, it can help with the staff burden hospitals are facing.

Similarly, reducing denials and maintaining compliance can improve the financial position. And having the necessary insights to drive these changes, and new know where your top opportunities are, is key. Right? So when you take these top concerns in the top focus areas of the revenue cycles, really, all of these, can be addressed through a competent claims management technology, which is why I refer to our claims management technology or any claims management technology for that matter as revenue cycle Swiss army knife.

Misconceptions about Claims Management Technology

Right?

All too often when I hear rev cycle leaders say, clearing house, when they're referring actually to their claims management technology.

And, really, that paints a picture as if it's merely a conduit to transmit and receive data to and from health care providers, and payers.

And while that obviously is a important component of any claims management technology, if you're only viewing it through that lens, you're significantly undervaluing what a claims management technology can and should provide to your organization.

Key Value of Claims Management Technology

So when I think of a claims management technology and the value it should provide an organization, I think of four key items.

First and foremost, the claims management technology is your last line of defense against a rejection or a denial. You know, to that end, ensuring you have the tools in place to ensure compliance is is obviously paramount. Right? Secondarily, your claims management technology should greatly increase staff efficiency.

Not only through the reduction, in rejections and denials, but also through things like automation. You know, you hear the word bridge routines a lot. As well as integration within your patient accounting system, which brings us to kind of that third key feature of a comprehensive claims management technology. And that is its role in in complementing your patient accounting system.

Hospitals made a significant investment in, the patient accounting system. So your claims management technology should ensure that you're getting the most out of that investment through integration that allows you to easily maintain it as your single source of truth. Right? And through that integration, you'll obviously have better visibility into your revenue cycle operations. But in addition to that, your claims management technology itself has a wealth of data, that should be easy to review not only through, things like canned reporting, but also through, you know, intelligent analytics and give you the ability to do some ad hoc reporting because no two, health care systems are the same. Right?

Tools for Denial Prevention

So when you break out those four key components and you break them down, we start with the tools that should be available to you from that denial prevention standpoint, which again, I believe is kinda the the first and most important piece to any, good claims management technology. So things like automation tools, like bridge routines, which I referenced earlier, can be used to complement that patient accounting system to programmatically make corrections to, you know, claim data elements that your patient accounting system may otherwise be unable to facilitate.

Not only helping to prevent denials, but also reducing manual intervention.

Timely filing monitoring. Right? It's another important one. And timely filing monitoring should not only allow you to track at risk accounts, but also to drive workflow based off of, you know, the proximity to timely filing. Right?

And while unsolicited claim attachments are, you know, relatively newer, I would say within the last few years or so, you know, here at Finrite, we started to see more and more payers begin to, accept the submission of those unsolicited claim, attachments, with the claim itself, which can significantly reduce the occurrences of, denials for additional documentation. So for example, Finthrive's claims manager has connections now to over two hundred and twenty, commercial payers as well as, you know, Medicare through Medicare ESMT and thousands of workers' comp and auto payers for the submission of documentation like, you know, medical records or itemized statements along with the claim. Those documents that payers have historically denied for. Right?

Secondary Eligibility Checking and Medicare Integration

And then also secondary second level eligibility checking. Obviously, you know, eligibility checking should be occurring within patient access. However, you know, having that failsafe in the back end in the event front end eligibility checking maybe did not occur, can greatly reduce instances of eligibility related denials. And, usually, that's one of the top denials for for most payers or providers.

For example, you know, FinThrive's claims manager technology utilizes its best in class insurance verifier solution, to check eligibility, for over eight hundred and eighty payers on the back end, allowing the staff to correct those prior to billing. Right? In addition, you know, I can't, stress enough the importance of a seamless Medicare DDE integration.

Real-time Medicare Status Detail

That will also when we talk about eligibility checking, that'll also allow for eligibility checking against heads. Right? And that's gonna alert users of any eligibility discrepancies, you know, prior to claim billing. Furthermore, by providing, you know, that real time Medicare status detail and bringing that back in, not only into the claims management system, but also into the patient accounting system, users will have full insight into, RTP reasons.

Right? Which will allow them to not only correct, RTPs without having to log in to Medicare's system, but also, you know, provides reportable and actionable information, to make changes, you know, upstream to help prevent those RTPs moving forward. Here at FinThrive, we, like to practice, RTP avoidance. So being able to bring in all that information and report off of it and provide it to our providers is paramount.

Robust Edit Library for Claim Errors

And finally, you know, most importantly, a robust and up to date edit library, to catch claim errors prior to billing. And when we talk about what a comprehensive edit library should look like in order to prevent denials, it's important to look beyond, you know, just that standard structural related editing, which, you know, to be fair, most patient accounting systems already provide today.

HFMA best practice rejection rate, as most of you all probably know is less than two percent. And you'll really only be able to get at or below that with a comprehensive edit set, not just those structure related edits. So things like common payer policy edits, LCD, NCD, CCI, MUE, as well as detailed payer editing are are a great place to start for a lot of organizations. But also, you know, editing should be maybe a little bit more sophisticated than that.

Right? It should have that detailed claim comparison logic. For example, duplicate checking, overlap checking, claims that, you know, are in contact with it, or conflict within one another. Right?

Think twenty four hour rule, seventy two hour rule, things like that should be in place to, prevent and further minimize denials. Right?

Furthermore, because your claims management environment, you know, provides insight into common, you know, payer rejections, your claims management vendor should be consistently reviewing, those rejections along with any new payer regulations to ensure that your editing remains up to date without you having to, you know, request hundreds of custom edits and things like that. Right?

And and at FinThrive, you know, the onus is on us, to do do that. We have a dedicated edit content team that ensures our edit library remains consistently updated.

We do edit deployments, twice per week to ensure that it stays updated.

So we take away the burden of having to constantly create those custom edits, by reviewing, you know, payer publications as well as our providers' rejections and denials to ensure that we're consistently editing appropriately. And, you know, to that end, we also serve as advocates for our providers on behalf.

You know, if we see payers that are rejecting or denying invalidly and not acting in good faith, our teams, are advocates for our providers, and we'll challenge those payers, to get them to correct their behavior. And we've been successful at it. We've been doing this for over twenty four years now. So we have a very experienced, not only at a team, but also pay your team to handle those issues and take that burden off of our providers. Right?

Increasing Staff Productivity and Maximizing the Value of Patient Accounting System
Now when we look at increasing staff productivity, and maximizing the value of your patient accounting system, You know, those editing tools obviously are a key component.

But, you know, increasing staff productivity and maximizing the value of your patient accounting system, those two things oftentimes go hand in hand.

By integrating your claims management editing into your patient accounting system, you give your users the ability to correct and validate those corrections, real time within your patient accounting system workflow. So here at Finthrive, we work closely with all the leading patient accounting system vendors, and we have embedded our best practice, our best in the market, editing, within those patient accounting system workflows, which can accomplish a few things. Right? First, it's gonna decrease the duplication of user efforts. So staff no longer have to make corrections within the claims management system, as well as within the the patient accounting system, and that's obviously gonna increase productivity.

Furthermore, by giving the users the ability to work within the patient accounting system, it allows for users to not have to be proficient in multiple technologies.

So when we talk about, you know, one of the the concerns of providers being, hiring and training new staff, this is gonna significantly reduce things like onboarding times, allowing them to only have to be proficient in one technology.

And then lastly, because corrections are made directly to the account within the patient accounting system, it allows for providers to easily maintain that patient accounting system as the single source of truth.

Right? And it's not just editing that should integrate within your patient accounting system. You know, if work is performed within the claims management technology, you should have record of that within your patient accounting system. Items like user notes, within the claims management technology can reconcile back to accounts within your patient accounting system. User actions, like, if a user were to reassign a claim or, place a claim on hold within your claims management technology should all be visible in the patient accounting system workflow when reviewing that account. So this ensures that you're always aware of the status of a claim and where it sits within its life cycle.

Integration within Patient Accounting System

That way your claims management technology isn't just like a virtual black box. Right? So Fin Thrive's claims manager technology can customize, you know, all these files to your specific patient accounting systems, requirements to ensure that there's that proper reconciliation, right, and that you're constantly aware of where a claim resides in its life cycle. Furthermore, payer statuses, payer status updates.

Those can be constantly driven back into the patient accounting system, workflow to streamline, follow-up activity and increase productivity.

Right? And not just those initial payer statuses. Right? Everyone's familiar with, you know, two seventy seven c a.

Those statuses of, you know, was the claim accepted? Was it rejected? Why was it rejected? But looking beyond that, looking into, solicited payer statusing, right, or advanced payer statusing.

Right?

You know, the follow-up process historically has been a manual and time consuming process requiring individuals to either check payer websites or pick up the phone and, sit on, you know, hold with the payer's EDI departments, and you never know if you're gonna get the correct, you know, status from from them. Right? Well, through advanced statusing, we can automate that manual process by, obtaining detailed and updated claim statuses and bringing those back into your follow-up work queue within your patient accounting system. You know, scheduled jobs can be created to fit your unique follow-up timelines and cadences for each individual payer.

So if Blue Cross, you wanna initially follow-up at ten days, whereas United, maybe you wanna follow-up at fifteen days. We can customize that. Right? And the enhanced level of detail provided allows you to automate the follow-up activity within your patient accounting system to ensure that users are only following up on accounts that truly require follow-up.

Automating Follow-up Activity

Right? So this is gonna save a lot of time, a lot of effort within your follow-up team. Finally, while the idea is to route as much of the information back into the patient accounting system as possible, like we talked about earlier, you you claims management functionality still has a wealth of, data from, claims to payer statuses to remits that should be easily mined to provide the necessary data to help influence change or proactive change throughout your revenue cycle operations. Right?

Customized Reporting and Flexibility

And while canned reports can provide good insight, you know, at the end of the day, no two health systems are similar in their reporting needs. So to that end, your claims management reporting should allow for you to be able to customize your reporting and should be flexible enough to fit your unique data needs as well as provide reporting that can be used throughout all levels of an organization.

So in addition to best practice can reporting, claims manager, you know, provides an ad hoc report writer, who's very robust. It can query, and display any data elements on on the claim or on the incoming eight thirty five, as well as payer statuses.

Detail or summary reports can be created to your unique specifications, and those can be run as, you know, one offs if you're just doing quick research or scheduled to run-in the cadence of your choosing if it's something that you're gonna wanna monitor on a daily, weekly, monthly basis.

Furthermore, through our integrated claims analyzer technology, which sits on top of claims management, You know, we offer over twenty prebuilt, analytics dashboards to monitor a whole host of billing related, KPIs and organizational level details to help provide both that thirty thousand foot view as well as the background claims detail so that you can do troubleshoot troubleshooting, get into the weeds, things like that. So really the ability to be used throughout all levels of the organization. And then in addition to that, those prebuilt dashboards, you also have the flexibility of creating your own dashboards that can be, saved as private for, you to review or share throughout the organization if others might be, you might others might find benefit from those.

Conclusion

So, in summation, I wanna say thank you very much for your time today. And I hope you were able to get some valuable information, about what a claims management technology can and should provide to your organization. However, should you have any additional questions, please feel free to reach out to me at any point in time. Have a great day.