We denounce with righteous indignation and dislike men who we are to beguiled demoralized by the charms of pleasures that moment, so we blinded desires, that they indignations.
The AR team and billing team systematically followed up with the insurance team and prioritized tasks based on following work flow. This resulted in a 12%, 18%, 19%, and 22% rise in provider revenue in each of the quarters of 2023–2024.
By outsourcing their billing services and AR follow-up, providers have also been able to reduce the yearly salary salaries of their in-house billing staff by 60–40%.
AR WORK FLOW :
Divide A/R tasks:
A/R tasks fall into four primary categories: billing, which includes pre-billing activities, claim edits, and attachments; insurance A/R, which includes denials, rejections, and appeals; cash posting, which includes payment posting, reconciliations, and balances/refunds; and self-pay A/R, which includes incoming calls, financial counselling, and bad debt processing.
Categorizing A/R tasks in this manner makes it easier to create more precise workflows, enables more meaningful data analysis, and ensures that staff are able to fully “own” the work within their category.
Analyse staffing:
Do you have the right number of people to manage the workload in each A/R area? Do some simple math to find out.
Let’s say you typically handle 30,000 claims per month. Your goal is for 10% or fewer of those claims to require follow up. This means insurance A/R employees will need to manually follow up on 3,000 claims.
If your productivity standard for insurance A/R is 4 claims per hour, that means it will take 750 hours each month to follow up on the 3,000 claims. 750 hours equates to approximately 4.57 full-time employees.
Of course, the numbers we’ve used in this example are variables. Adjust them as needed based on your actual claims load and KPI targets. Then, repeat this formula for each of the four A/R categories we defined in step 1 to see how your actual headcount compares to the optimal headcount.
Balance workloads
Now that you have an idea of how many staff members you need, it’s time to analyze the hours your employees are actually working.
Here’s a look at the typical task division compared to the optimal task division in an average organization.
Typical task division
50% Billing
30% Insurance A/R
10% Self-pay A/R
10% Posting
Optimal task division
50% Insurance A/R
25% Self-pay A/R
15% Posting
10% Billing
As you can see, a disproportionate amount of time is typically spent on billing.
When RCM workflows are fully optimized, billing should be mostly automated. This means using technology to handle tasks like routine claim changes.
When claim edits are required, the responsible department should work its own edits. A dive into your claims data can show you where those edit needs are originating.
Optimize insurance follow-up
Insurance follow-up eats up a huge amount of labour. We can reduce the burden by taking an aggressive approach to denial management and maximizing first pass yield.
First pass yield measures the number of claims paid upon first submission. Focusing on first pass yield as a KPI forces us to also focus on denial prevention, since denials are what prevent claims from getting paid the first time around. Minimizing denials improves first pass yield, which means faster cash flow.
By using technology to analyse denial data, we can drill down to the root cause of denials and better focus our mitigation efforts.
Track productivity and outcomes
There are many ways to analyze your claims data, and each one offers valuable context that can help you continuously improve your RCM workflows.
For example, you can analyze by employee, tracking productivity based on the action taken and comparing different workers against one another. You can analyze by payer, assessing the proportion of denied claims and the reasons for those denials. Both of these views (and others you configure) can inform the design of your RCM workflows.
Additionally, tracking revenue-related metrics like collection rate, resolution rate and appeal success rate will help you make better decisions about where your RCM workflows can be improved.
Reducing not only the number of denials, but the number of touchpoints each denial requires will improve your first pass yield and ultimately put you in a more comfortable financial position.
We take a deeper dive into the analytics mentioned above in our recent post on improving revenue cycle KPIs with analytics.
Denial Management Work Flow
We have certain WQ, s within EHR system which is mention below. Example, ECW (e Clinical Works).
Also, based on weekly/monthly Open AR value, claims segregated by their DOS age wise. Example Below.
DOS Age: 0-15, 16-30, 31-60, 61-90, 91-120, 121-180, >180
Priority: To work & resolve “Highest $ value & Greater Aged claims”
WQ’s Strategy
Insurance Accepted
Claims billed & accepted by payer.
TAT to address claims from this bucket after 30 days from claim entry date
ERA PAYER DENIED
Claims denied by payer and ERA was released against denial. Such claims automatically routed to this WQ. Claim from this bucket will be assigned to AR collector
Allocation strategy is to PT & INS wise to have PT accountability model
TAT to address claims from this bucket is 4 days from claim entry date
Denials
Claims denied by payer and paper EOB was released against denial. Such claims being routed to this WQ. Claim from this bucket will be assigned to AR collector
Allocation strategy is to PT & INS wise to have PT accountability model
TAT to address claims from this bucket is 4 days from claim entry date
Crossover
Medicare as primary process the claim and forward to PT secondary insurance
Such claims automatically routed to this WQ
TAT to address claims from this bucket is after 30 days from claim entry date
Coding Return
Claim denied by payer due to clinical or coding related issues
Coding team review such claims and route qualified claims in this WQ along with their findings
TAT to address claims from this bucket is 1 days from claim entry date
Appeal/Insurance Reprocessing
Claim sent to insurance for reprocessing over the call
Claim sent to insurance for reprocessing along with 1st level appeal or redetermination
TAT to address claims from this bucket after 15 days from claim entry date
Have any Question? Ask us anything, we’d love to answer!
