EXECUTIVE SUMMARY
Our client, a nationwide medical billing and software company for anesthesia practices, had challenges when it came to billing volumes and AR recovery. The California market is one of the most complex and often a nightmare for the medical billing industry. This is predominantly because of the complex setup of IPA’s, several programs that link hospitals with the payors, and payors have limited filing time. It is mission-critical to ensure claims are sent to the correct payor the first time. This is where the necessity to do insurance verification arises.
By adapting our best practices from years of experience, along with our quality-centric services and efficiency, we were able to overcome a surge in claims and cashflow errors in a complex payor mix with our insurance verification solution.
The Challenges
There were several challenges our client faced. Incoming volumes were erratic and exceeded 200% of our client’s capacity.
The stress in the EMR system were resulting in large number of errors impacting cash flow and AR.
Additionally, in order to be able to make necessary corrections to claims, our payment entry team and AR follow up team, and insurance verification team all were brought in to solve these eligibility challenges.
The Solution
Overcoming influx of volumes, over capacity:
Volumes can be categorized into two formats: Paper tickets that are manually handed over by the provider to our client’s office, and data imports (EMR formats).
“We have had a huge increase
and you guys really came through
for me this month! I know you
worked hard, and long hours and I
am very grateful. Let us finish out this
month and take a sigh of relief!”
After carefully studying the volumes patterns, our team identified that the paper tickets are often held back with the providers and are handed over after accumulating volumes; often, these volumes are not sent in a timely manner. This was one of the factors that influences volume fluctuations. •
Constant communication with our clients and providers ensured that these tickets were turned in on time and mitigated the volume inflow.
The provider’s hospital set up is in such way that they see a lot more cases and perform a higher number of procedures on weekends. This caused significantly higher volumes every Monday wherein three days’ worth of charges are received to be processed. To mitigate the stress and errors caused due to this influx, our team worked with our client and quickly rolled out Auto-Eligibility (EDI 270 Eligibility) for the Top 3 payors. In a phased manner, each top payor was transitioned into auto-eligibility while analyzing the impact on AR and for an unusually higher percentage of denials.
An increased usage of web checking for eligibility from 16% to 79% directly resulted in significant productivity gain allowing to manage higher volumes. The stress in the system causing human errors were impacting cash flow. Although our overall quality score was above 98%, the 2% of errors translated into 400 claims a month with an estimated charge value of $580K.
Our team worked hand-in-hand with our client and their IT team and created kick-out reports, which would capture errors when selecting the plan and carrier codes. Corrections would be made for all cases captured on this report. Missing or invalid demographic information would be captured on an error report and all claims on this report would eliminate majority of those 400 cases impacted. Additionally, we made sure it was imperative for our specialized teams to share knowledge such as Demo Entry, Payment Entry and AR follow up for them to able to be make necessary corrections to the patient’s insurance details. All documented instructions are shared evenly and timely manner, and periodic calibration exercises were conducted between all the various functions.
The Results
Our team worked through over $20 million of charges each month for our sub-client, and as a result, staffing was planned around hitting these goals daily for such a large volume; our team was able to quickly customize this need and were worked by a combination of paper tickets entered into the system by the charges team and EMR cases released by Insurance verification team post verification.
Additionally, when it came to paper claims, the age between the date when tickets were scanned into the system and date when the claim was billed out is measured periodically. This is one of the metrics our client is obligated with their providers. The charge lag day should always be under 3 days ,and our team was averaging 2.3 days; this means each function such as Insurance verification, Coding, Demo entry and Charge entry would get only 1 shift to get the incoming volumes to completed & audited. Any delay on the verification would impact other functions and overall process. In summary, our team was able to solve these influxes of charges with a complex payor mix, roll out auto eligibility, and therefore improve cashflow and reducing AR backlog.