You’ve made a huge investment in your Epic revenue cycle system, to the tune of millions or billions of dollars. But even the best health information systems are primarily a platform-as-a-service when it comes to revenue cycle management.
What they’re missing is a foundation, and by that we mean content.
6 Content Areas to Build-Up to Take Back Your Bottom Line:
1. Address Verification and Patient Financial Profiles
You’re constantly faced with the impact of not having correct patient information up-front in the revenue cycle. But there are ways to change that.
- Address verification: identifies addresses, detects fraud, and directs your return mail operations, raising red flags for suspicious identities and increasing registration accuracy.
- Propensity to pay: helps both your front and back office determine the next best actions to take with a patient balance. High propensity to pay may mean an earlier, pre-service payment discussion to accelerate collection of cash. A lower score may lead to a discussion of a payment plan option. (Both of which bringing you one step closer to actually getting paid.)
- Financial aid determination: also helps with payment plan discussions. It uses consumer data to determine a patient’s Federal Poverty Level (FPL) percentage to determine if your organization should have a charity application or screening discussion with said patient.
Combining Propensity to Pay with Financial Aid Determination builds a patient financial profile that allows your staff to create the ideal patient experience journey while accelerating cash collection. Adding address verification to that increases registration accuracy, decreases denials, and accelerates your cash even more.
2. Real-Time Eligibility (RTE)
Patients are four times as likely to have different insurance information year-to-year than ten years ago. And it’s not uncommon for a single insurance payer to have over 12 different plans, each with different benefits. To a provider, like you, this could mean the difference between collecting a $25 copay or $625 out-of-pocket for something as simple as an MRI or CT scan.
Organizations need to be looking beyond yes/no eligibility. Instead, you need to embed the following directly into your EMR:
- Plan benefits. Not all the benefits you need are in EDI. Sometimes they’re on the payer website. Your vendor must know when to use EDI and when to use payers’ websites to find the most complete and up-to-date benefits. (We call this a super 271 EDI response.)
- Intelligent payer communication. Your RCM vendor must know how to ask the right questions to a payer’s EDI and web infrastructure to discover all the important benefits. A service-type code of 30 for general benefits isn’t enough.
- Plan code validation and denial based alerting. Using the detailed benefit information that your RCM secures, you must be able to identify anomalies in payer responses, indicating potential denials or inaccurate plan information. More than 35% of all registrations that trigger eligibility calls have some form of error that can (and probably will) manifest as a denial later on. Put a stop to that.
- Data pull normalization. Your platform should place all benefits into one place in the EDI response, so you write less data pull rules and gain the ability to track all payer changes throughout the year. One rule equals one payer. Say goodbye to endless writing and rewriting, once and for all.
- Machine learning for payer pattern recognition. You should be able to see what benefits payers are actually using to adjudicate, rather than just accepting what they say the benefit is in the response. Because, let’s face it. Normalization of benefits is not equal for all.
3. Real-Time Authorization (RTA)
Payers are creating more granular authorization rules at the plan level and outsourcing the management of claims, leaving healthcare organizations with no standard connectivity to payers.
The only way to address the authorization problem is to fully understand the rules and policies of the payer, know where to go to secure the authorization request and how to connect with the payers, and assess the quality of the response.
But not many RCM vendors fulfill these needs. Here’s what you should look for:
- Authorization rule management.
- Payer portal routing and connectivity.
- 278 RTA integration.
- Real-time alerts.
4. Notification of Inpatient Admission
Healthcare organizations are required to notify insurance payers in a timely manner when a new patient is admitted. The sooner, the better. Failure to do so results in time wasted and revenue lost. Unfortunately without automation, the probability of missing the one to two day window of notification for certain payers to create and manage an authorization record skyrockets.
But there’s no reason to miss that window. Automating the inpatient admission process eliminates human error and pushes workflow efficiency one step further, reallocating jobs to focus staff attention on high-value accounts, while also giving you access to more payers that may only take notifications via a web portal.
5. Medical Necessity
Both medicare and private insurers have criteria for determining whether a procedure is medically necessary based on the patient’s diagnosis. Some plans might cover the procedure for the given diagnosis, but others may not.
With so many rules and policies in place, it’s important that physicians and staff have the right information to create a care plan that is aligned with patient and hospital payment objectives. With patient’s wallets and health on the line there’s really no room for error.
Your vendor should come with 278N support for payers, covering as many payers as possible. You must be able to upload content directly into Epic to discover NCD/LCD medical necessity requirements. Accurate, integrated content has got to be your organization’s new best friend.
6. Estimate and Payments
Accurate patient out-of-pocket expectations can and should be integrated directly into your EHR along with a branded patient estimate letter.
When an organization doesn’t automate the out-of-pocket estimate pre-service, the patient financial journey stops. For a long time. We’re talking a possible three to six month post service wait. This leads to a lost opportunity to collect cash in a timely manner, increasing the probability that you don’t get paid at all. The result? A poor financial performance and a poor patient access solution.
In order to capture the opportunity of collecting payment prior to service you have to do three things:
- Find the most accurate benefit.
- Calculate that benefit with the specific payer in mind.
- Generate timely estimates.
When a patient is given an accurate estimate of their financial obligation, they are able to take the steps they need to find the money to pay prior to service. And when patients pay a portion of their balance pre-service, they are more likely to pay the remainder of the bill. That’s why it is so important to find a vendor that uses Epic’s scheduling and registration feeds to determine the price of the patient encounter beforehand.
The Wrap Up
Your Epic revenue cycle solution lacks access to payers without EDI, intelligence to manage payer logic, rules and policies to avoid denials, next actions for accounts processed, and alerts to notify staff how to proceed. Moreover, organizations without payer intelligence engines for their EHRs miss critical benefit information, leading to more denials and an even longer payment cycle.
Industry experts estimate that 90% of claim denials are preventable. Yet in 2017, healthcare organizations wrote off 90% more claim denials compared to six years prior. That’s a $3.5 million loss over four years.
As such, integrating curated revenue cycle content directly into your EHR must be your new patient access solution. And now you have the tools you need to do just that.