Healthcare Claims, Denials and Rejections: Building process improvement from collaborative insights

Healthcare related businesses come with their own unique set of management challenges from patient experience, processes, and technology. With a growing set of compliance requirements and intricacies for the billing processes, when coupled with patient needs and expanding payer requirements, the task of staying current in the day to day becomes vital to cash flow. As these challenges tax clinical and administrative teams, executing upon denied and rejected insurance claims can start to backlog. Insurance Payers understand this and, in some cases, count on the delays and lack of resources to delay payment. So how can we improve upon this stage of the billing process to optimize cycle time to cash?

Denials from insurance companies are notification to the providers that the claim in its original form does not meet the requirements for reimbursement. This can range from the minor checked box to more substantial processing of the claims data such as missing test results, patient documentation, etc. We can go deeper still as to the time-sensitive nature of denials and each insurance company has differing guidelines for timely filing. To this point, every payer has a different window for submission, from 30 days for initial claims to 90 days for resubmission. With a tight window for correction, quick action is paramount to success.

Denied claims should be monitored and quantified, reason descriptions allocated, and a method of follow up applied. At the time of payment application, all denials should be updated with denial reason codes, allowing for insights and analytics to identify your material process strengths and weaknesses. Collecting as much data as possible allows for actions and prevention of revenue leakage while supporting process improvement strategies, your insights, and analytics. Building the basic tracking and quantified causes by payer becomes a logical next step. Once the behaviors are visible, proactive planning and process strategies may be implemented. Or better still, negotiation points for your contractual arrangements.

Denied and rejected insurance claims can make the difference in an optimized revenue cycle management process and lend to faster cycle time to cash but also an improved patient experience. Spending the time to exam the full processes from new patient enrollment, pre-authorizations and through denial follow up and recovery will be completed in your internal process improvement strategies or part of your outsourced engagement model. In any model, optimization of cash performance is our role and with the access to internal or external resources, the business case for resourcing this area effectively creates greater value in maximizing claim value.

Rob Sherman, Chief Revenue Officer of VWi

The Innovation Track for Subrogation

Expertise in Subrogation is not just about technology but the innovation behind experienced human capital

Subrogration outsourcing

As a business, VWi has spent the last 50 years in the subrogation space, with a deep understanding of the laws and regulations of managing subrogation cases. We are continuously working on our recruiting and finding people who are really enthusiastic about learning the nuances of subrogation. This development of the next generation of experts isn’t so easy for our clients as the people who founded the key processes are buried in a serious time crunch as they try to keep up with the day to day business. So how do you make this sector exciting for the next generation? More important, how do you share the knowledge in a meaningful way to develop the next wave of experts?

Lets start with what’s happening to the experts

A new term has emerged called, claims adjuster burnout. Cases are increasing, claims are getting more complex and the process has become increasing more complicated overtime. Add to this the growing demand of providing an excellent customer experience with a single point of contact, never ending phone calls and a full inbox. It takes an extreme professional with years of experience to manage the end-to-end process. Add to this the complication of age and experience of these industry veterans and you start to understand what will happen next in an industry desperate for the next generation of proficiency.

An evolving job market

The insurance industry has seen a major impact. As the number of claims per year starts to meet or exceed the number of premiums, the industry is thirsty for talent. In a study by the Jacobson Group and Ward Group, they found that from 2010-2015, the number of positions in the claims management area has increased year over year. As the need for more claims adjusters continues to climb, many companies are turning to temp labor, but that merely defers the problem with a lower cost solution, but seldom creates those long-term employees that are now don their way to retirement.

The need for claims adjusters continues to climb year over year.

Using innovation to engage the workforce

Challenging the incoming workforce to be innovative will be essential to keeping them engaged long term. Just as the advancement of technologies has improved our daily lives, innovation in the workplace will be key to keeping them interested and, more importantly, tap into the knowledge of the retiring experts.

As our own business grows, we work with our teams to identify those key employees that show promise in both managing the process and looking for creative ways to circumvent problems. By pulling them into conversations that focus on improving processes or identifying waste within the business, we help them grow to the next level. It also helps them see a path to a career that perhaps wasn’t previously on their radar.

Looking to the future

As the laws that govern the subrogation industry become more stringent, the future becomes more clear that competent people are necessary to foster long term growth and stability. Add to that an incoming workforce that is impulsive and fickle about their employment opportunities and you have a compounded problem. Conversely, VWi sees this as an opportunity to take the subrogation industry to a new level.

By engaging the technology minded Millennials to work with the experience of the Generation Xers and the leadership of the Baby Boomers, VWi is leveraging the key strengths of each generation of the workforce to find solutions that improves the claims management process, reduces risk and increases revenue.

Value based solutions are the focus, not service delivery location

The previous economic downturn has ushered in the politics of protectionism. Sending business to foreign shores to create jobs, infrastructure and skills overseas, when these are needed so desperately on native shores, has a negative impact on corporate and political goodwill — a valuable asset for public image.

In the face of current turbulent times, opting to go onshore to create teams of highly skilled and knowledgeable employees locally is good judgment for many companies – particularly those seeking increased service levels and a higher degree of overall customer satisfaction. Notwithstanding the obvious advantages of offshoring, most companies would still prefer to buy domestic. A CFO magazine survey of more than 150 finance executives showed that only about a third outsource any finance work, and the vast majority of those — 83% — keep delivery onshore.

Corporate managers are simply getting over their infatuation with lower cost international labor and analyzing the total long-term costs of doing business locally compared to say — China or India. There is a dollop of icing on the cake here as well. The topic of focusing on on-shoring to boost employment levels seems to be an area of agreement between bickering political parties the world over.

The past 12 months have also been characterized by social and political unrest, particularly in many developing markets. This has demonstrated the geopolitical risk of locating business services abroad and alerted corporate decision-makers to the fact that while offshoring delivered benefits to the balance sheet, it brings with it the very real possibility of denial of service and the business challenges that come with this.

These factors have shifted the context of a CFO’s thinking when tackling with the offshoring vs. onshoring debate. Yet, what has become more critical to CFO’s is simple – the growing momentum to hire and employ using value based mentality. In other words, corporate executive are thinking diligently about the right operating model for the right outcomes – at the right time. What delivers value to corporations is the investment in people and innovation so that businesses get more time to spend on managing their core business and don’t need to worry about the viability of a location strategy. Undoubtedly, the future direction of the outsourcing industry will see relationships with clients who will be a combination virtual and value based delivery.

The offshoring trend continues, yet in recent years, more companies are finding it beneficial to reverse course and move select operations closer to home, back onshore. The objectives of CFO’s and credit executives when outsourcing Order to Cash functions are the pursuit of cost savings, increasing core business management availability and accelerating transformation. However, along with potential controversy from overseas outsourcing comes a series of real challenges for corporate finance: the risk of reduced cost savings, increased overhead for communications, project overruns, language barriers, risk of poor service, loss of business knowledge and security breaches.

At a time when corporate social responsibility is considered a significant factor in business success, companies may think twice about employing workers in countries with poor human rights records or overly lax labor standards. In the case of customer service, some organizations are deciding it makes sense to focus upon value and outcomes rather than location. And for certain corporations, theirs is an inherent sense that their customers simply prefer to do business with firms that commit to a domestic workforce and add to this the fact that high quality, affordable labor is available in U.S. markets, and it is not surprising that the onshoring trend is gaining currency.

Bob Williams, CEO of VWi

Hello Durable Medical Equipment Industry.

Are you advancing your automation agenda for working capital optimization?

Healthcare Reform has put a strain on budgets and ushered in new complexities when it comes to collections and overall receivables management. One of the key issues is the lack of capability through investment in technology and automation. As budgets continue to be compressed this critical area of advancing automation to ease manual processes and increase cycle time to cash is problematic. But this doesn’t mean the problem can’t be solved with strong partnerships.

We’re here to tell you that it doesn’t have to be as difficult as it sounds. Leveraging collaboration through domain specific partnerships helps. Credit to Cash providers in an outsourced partnership can take some of the complications out of the matter by understanding the new world and customer complexity to solve the impact and the fine details toward improve working capital.

In anticipation of the many changes occurring over the past years, most companies within Durable Medical Equipment industry are working to update their finance and accounting systems and taking into consideration changes that may impact the timely collection of invoices. Financial systems need to be enabled to deliver and support flexibility to reduce impact on business operations. Question is, do you find the capital to fund these initiatives or partner with a provider who brings technology with services?

You can start with analysis to understand how this change can affect the customer relationship. I believe the approach of a specialist by customer and transaction type can support mitigating disputes and reducing complexity to the AR cycle. This can easily be achieved with the right platform and in an outsourced model but maybe problematic, due to expenses, in a captive or shared services infrastructure.

Additionally, the comparable analysis of your product portfolio, revenues and customers will help to better understand the current and new customers, who are the end users, intended use of the product is. Only then can accurately estimate and therefore determine what the true potential for optimized DSO should be.

We believe that determining how customers transact invoice payment comes from a number of factors. Deep business analytics and accurately targeting can change the slow paying behaviors. New advances in analytics and payment modeling have made the DME collection process more effective than ever but an investment or a change to an industry leading domain specific BPO partner is required.

Beyond analysis and system updates, comes the complexity of recording and reporting to ensure you’re in compliance with tax regulations. This requires more oversight and controls from a compliance perspective but also requires more diligence in operations – from taking the order to accruing revenue.

The issue may not be the only provision to slice into profits, but the need for additional resources across F&A becomes another issue burdening business with more expenses. With the availability of technology, just like any particular process, the need for manual intervention will be removed. Additionally, analytics and automation, to drive risk mitigation, support a clear view of what can be expected in the long term. By coupling these strategies you effectively minimize the manual and labor intensive processes, see a reduction of credit risk and sustain the most valuable production actions being delivered.

This may take time for some but others utilizing an outsource strategy today, the expertise and enablement is already leveraged. Business process outsourcing and technology solutions, which come with such engagements, make the entire process seamless and can help ensure you are being diligent in optimizing your working capital. At the same time, controls will ensure the customer experience is being considered to avoid losing what are ultimately good customers who need creative solutions.

David Gallagher – Strategic Business Development

Patient Experience Across Revenue Cycle Management

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Patient Experience Across Revenue Cycle Management: It Counts in Cash

Over the 18 years I’ve been in the healthcare outsourcing field of RCM, I’ve learned efficiency in healthcare billing doesn’t have to be complicated. Although many trends have come and gone, there are 5 key rules that drive highly successful people to consistently exceed expectations and are very straightforward, more so than you may imagine. So let’s count it down:

  • 5. Cohesion – Values and culture act as a North Star on the path to accomplishing our goals. Aligning outsource partners with your internal values creates a unified team with vision and priorities. In our case, as a RCM outsourcing provider, we adopt and look to absorb our client’s culture. A successful partnership is cohesive and transparent with effective communication and trust flowing in both directions.
  • 4. Expertise – Of course, this seems straightforward but healthcare business process outsourcing is immensely encompassing when we delve a little deeper. True expertise in healthcare RCM goes far beyond the hard mechanics such as compliance and efficiency. True expertise includes factors such as empathy (identifying with patients on a personal level, understand to what they are going through). It is having the emotional acumen to respectfully guide a positive resolution, helping the patients, their families and our partners to smoothly navigate the path to recovery.
  • 3. Technology – Pressure will continue to be applied to budgets driving the need for efficiency, automation, and analytics providing insight to the changing conditions ahead. With the right platform effectiveness of a team can be realized, quantified and refined. With the proper balance of People, Process and Technology phenomenal performance gains can be made. Though, in seeking efficacy multipliers such as these, it is important to never lose sight of the patient relationship.
  • 2. Relationship – With the easing of manual processes, it is crucial to leverage human capital intelligently. Performance in the healthcare RCM space and the patient relationship are directly intertwined. The key, focusing the right resources where they count and in turn driving the most valuable level of care and relationship to successfully cure past due balances. The better the patient relationship, the better the payment metrics. The better the payment metrics, the better the client relationship. 

    As we know, patient satisfaction is highly correlated to a patient’s choice physician and facility should they require care in the future. Which leads us to rule #1:

  • 1. Patient Experience – Parents, grandparents, spouses, friends, family and loved ones. The person on the other side of phone calls or correspondence may be anyone these, and under a different set of circumstances it could be you or me on the other side this exchange. Make the conversation matter. Make it bigger than just a call to recover a bill. Raising the bar to what a positive patient experience is. All of the previous rules lead to this point. Patient Experience is the number one priority which multiplies all others including desire to pay. Focus on delivering an informative, helpful, compliant, valuable and pleasant patient experience and all other key metrics will rise as well
  • Patient Experience is the key to greater collections in healthcare, and through my 18 years in the field, these are the essentials to excelling in Revenue Cycle Management that I’ve found most effective for our clients, our teams and myself.

    – Erin Wilson, Healthcare BPO Project Manager of VWi