Impact of Health Insurance configurations on Collections and How to manage it
Muhammad FaheemProject Manager/Strategist,Process Expert|ITIL,MPM|Agile,Scrum,Healthcare,ITSM | MTBCHaripur Hazara, Kpk, Pakistan
Insurances being key player of today’s Health Care Industry -- Around 90-92% US citizens got valid insurance coverage. For providers, Insurances are very critical in every aspect. It’s very critical for the medical billing companies to ensure claims submission to right payers and engage them until required reimbursements are made. For billing companies it get more complicated, as they have been rendering the services to practices/providers across the country. In order to ensure effective provider payer enrollment, submission to correct payers and follow-up until legitimate reimbursements, it requires very effective management approach. Big Billing companies got bigger issues to deal with. They have been sometime submitting claims directly to insurances and sometimes there is some clearing house involved. It’s not just about claims submission only, It’s also very important to engage payers for due reimbursements. It’s also very important to track it, whether payer accepted the claim for adjudication or not, how much is being adjudicated and recording it into the system as well.
Today we have IT solution to all these problems, we can get real-time eligibility before patient checked in for appointment, submit claims electronically, get acknowledgment electronically and receive electronic remittance advice (ERA) from payers. To get accurate results from automated systems, it’s very important to feed them with right information -- A minor error can lead to big negative impact.
From prospect of Big Billing companies -- providing services to practices from across the country and have to interact with all type of payers. Same insurance having different properties, they have different addresses for different purposes & locations and different contact numbers depending on purpose of inquiry. Moreover there are clearing houses involve, ensuring claims submission and providing the services like eligibility, claim status etc. Last not the least, one of biggest concern is to protect PHI. No one wants to compromise – sending medical documents fax to wrong number, mailing out claims (HCFA) to wrong address, sending patient statement to wrong person.
To beat these issues and improve the accuracy of automated systems, it’s very important to have very well structured and clean configurations system. At our organization, we have revamped whole Insurance Configurations System with clean and reliable configurations, automated the workflows (Enrollment, Eligibility, Claims Submission, Claims Status and ERA Recording). This has also directly improved accuracy of our Rules Based System which is responsible for Pre-Submission Claims Scrubbing (Conforming LCDs, NCDs, NCCI edits, Taxonomy edits, Age and Genders Edits etc.) and Systematic corrections against denials as per defined rules. Saving Changes...
Good to know. Thanks for sharing. Saving Changes...
Deepa KalangiManager, Program Management, Author, Trainer| CVS HealthCharlotte, NC, United States
Yes, being in healthcare, I totally understand what you are trying to say. It is critical for health care companies to revamp and reorganize any config glitches or use proper tools to reduce gaps in terms of billing and putting out claims, using the right codes etc. I have seen many errors due to automation, that is why we always have a manual coding department verifying these. Saving Changes...
