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Resolutions for Refining the Claims Audit Process for a Better 2020
By Tom Scott

It’s that time of year: the beginning. The office is charged up. Employees are arriving early. Managers are eager to hit the ground running. Meetings are called to discuss business process improvement. Cutting costs and improving returns are the mantra for January.

But for some, especially in the health care finance department, the beginning of the year can represent an adrenaline-fueled desire to establish a better process to manage the next 12 months of claims, clean up last year’s appeals, and get ahead and stay ahead in 2020.

The following are five actions that health centers can take, along with information on how software can assist, to make sure that the start of the year is a harbinger of the health, wealth, and happiness to come in 2020.

Simplify the claims audit. In most cases, claim audits involve picking out a handful of claims to spot-check, ensuring that those claims were coded correctly and payments were received. According to insurance auditing firm Athenium Analytics, 79% of organizations do not track claims leakage. While this is helpful in capturing a snapshot, it’s not a guarantee that all claims were successfully processed.

Using a software platform to identify and flag errors in real time can help to ensure that this process is handled throughout the year, as opposed to retroactively having to go back to check your work. Employing an automated system rather than asking clinical staff to manually pull charts for spot-checks can also save time for both administrative and clinical staff, as well as help reduce the risk of human error in the claims review process.

Don’t assume bad debt is the cost of doing business. Work with a trusted medical loan company to restructure outstanding debts and recoup costs owed to your business.

According to a 2018 survey from Sage Growth Partners, more than 20% of organizations do not have a bad debt recovery process. Automated claims systems can help by sending out letters immediately when patients haven’t paid their bills. It can also electronically generate a workflow process to designate staff as responsible for following up on specific accounts.

Using a software platform allows health centers to categorize outstanding claims by amount, payer, or days past due to help staff prioritize their efforts and keep other members of the team apprised of their progress.

Track the life cycle of your equipment. If medical equipment fails, it’s already too late. Proactively tracking when equipment needs to be replaced or upgraded can help avoid wasted time and money. A good software platform should include a field to log in warranty information for all equipment and notify users when service is due.

Review and track your operating expenses and profits. Perhaps most important in planning for future success is making the case to payers that your hospital or ambulatory surgery center is operating effectively.

Using software to pull annual case costing can help build a case that’s accurate and ready to go when it’s time to negotiate your payer contracts. A good platform will allow you to break out your costs in categories such as CPT code, physician, and specialty, and examine indicators to drive improvement (eg, staff utilization time, supplies used, supply costs, and turnover time). Case costing is also an essential resource in negotiating for carve-outs in particular instances—implants or specific medications, for example.

Using a software platform to analyze cost nuances can also help identify whether specific provider intervention is needed. For example, data could reveal whether a physician is using a certain type of branded medical supply that can be purchased at a much cheaper rate while still fulfilling the same need and quality standard. Or it may reveal that certain procedures are not being reimbursed at a sustainable rate.

Determining whether profit losses can be addressed through remediation or if certain procedures or practices should be eliminated completely is only feasible if the data are there to assess.

Review employee training. Turnover is a normal part of every business. Ensuring that administrative staff are not only aware of the programs in place to track and manage finances but also trained in using them to their full capacity is essential.

Health center leaders should review human resources policies for onboarding new employees, as well as policies concerning annual training, to ensure that staff are introduced to and aware of resources offered through various software platforms that can help them become more adept in their duties.

If these actions were not taken by your health center in 2019, the new year is the best time to set a resolution in place. By proactively managing and tracking business operations, health centers can save themselves hassle, headache, and heartbreak at the end of 2020 and raise a glass to even loftier goals in 2021.

— Tom Scott is CFO of HST Pathways, a top-ranked software solutions company for the ambulatory surgery center industry.