- Without transparency throughout the claim denials management process, healthcare organizations are leaving a significant portion of potential revenue on the table.
Limited access to timely claim denial and reimbursement data can prevent providers from recouping revenue that is rightfully theirs. As a result, providers are passing up an opportunity to recover reimbursement for up to 63 percent of denied claims, a recent Change Healthcare study revealed.
Urgent Care Now in New Jersey used to be one of those practices. Despite the help from several outside medical billing companies, the urgent care group suffered financially, with accounts receivable reaching 65 days.
The billing companies they hired failed to go after all denied or low-paid claims, missing opportunities to recoup reimbursement. With cash flow lagging, the practice had little insight into their revenue cycle and overall financial performance.
“The biggest problem was transparency,” John Kulin, DO, FACEP, Urgent Care Now’s President and CEO, recently explained to RevCycleIntelligence.com. “By that I mean, it was getting a report. Understanding our data typically included saying, “’Okay, I need to see this report for these dates’ and they would say ‘Okay, we’ll get that to you.’”
“But it was taking a week, two weeks, even three weeks to get these reports run,” he continued. “Then, I would get it back and it was with somewhat outdated data at that point, making it hard to try to figure out where we were and where we were having problems.”
In addition, the medical billing companies working with the urgent care group created inefficiencies throughout the entire claim denials management process.
“The other thing was the outside billing companies were just going after the low hanging fruit,” he said. “They weren’t really following up on anything other than that. It took more than the basic submit the claim and get paid for it. And it’s a hard follow up, but they weren’t doing that.”
The medical billing companies also neglected to notify Kulin and his staff in timely manner about claim denials they failed to fix, leaving Urgent Care Now without enough time to rework the claims.
“There was no easy way of seeing where a claim was in the process when dealing with them,” he stated. “By that time, it was months later we were getting this information back, typically. It just wasn’t working for us. We were struggling at that point.”
Kulin and his staff could not assess payer performance as a result of lagging claim denial information.
“They weren’t really following through on making sure the payers were paying us correctly,” he added. “There was no easy method to make sure that if we had a contract or a certain rate, were we getting paid by the due date? Or according to other provisions on paper?”
Kulin faced a critical business question: could his practice afford to stay open with revenue opportunities fading in the rearview mirror?
“It was tough making business decisions about where we were and that was limiting our growth,” he elaborated. “At that point, we were a very small practice and it should have been much easier to manage. We were realistically taking in payments of about $60,000 a month. We were struggling. It was trying to keep the office open type of thing.”
To address claim denials management challenges, Kulin prioritized data collection alongside his clinical responsibilities.
“I am all about data,” he said. “I like to know and keep track of where we are. A lot of physicians are so busy in their daily work that it almost becomes an afterthought and it is ignored until it is almost too late, which is part of the problem with the revenue cycle. It is relegated to an office manager, who is doing multiple other tasks. There’s no dedication to it.”
He added that he has worked with other practices that have seen their revenue drop, but practice leaders did not address the issue until it was too late. Rather than having a dedicated revenue cycle leader to correct challenges as they occur, practice leaders end up trying to pinpoint the root cause of revenue cycle and claims denials management challenges long after the issue arose.
“You can’t get caught like that. You need to have that instant access to data and transparency these days,” he stated.
Kulin gained access to real-time claims data by partnering with athenahealth to implement what he described as a hybrid medical billing system. The practice management tool incorporated a medical billing component that allowed Urgent Care Now to do their own billing with the support of a rules engine.
The rules engine aggregated claims denial information from its network of over 87,000 healthcare providers using the system.
“Just the idea that we learn from one another,” he explained. “If someone submitted a claim and it bounced back or got rejected because certain parameters weren’t met or whatever, that rule would be put in to what athenahealth calls the Rules Engine. Now if I drop a similar claim from our practice, it would get flagged instantly instead of going through the cycle and taking several weeks to come back.”
The system also addressed and attempted to correct all claim denials for Urgent Care Now.
“They were going after everything,” he stated. “When they weren’t able to accomplish it, it came back to us and then we were able to follow up on those few cases.”
After three months of system implementation, Urgent Care Now saw about a 30 percent increase in collections. Days in accounts receivable also dropped nearly 18 percent down to approximately 26 to 27 days.
Not only did the medical billing system boost financial performance, but the additional revenue allowed Urgent Care Now to stay open and remain independent.
“We are still an independent practice and it’s nice to be able to do that and remain independent these days,” he said. “I see so many practices getting absorbed and bought by hospital systems.”
With a real-time view into his practice’s financial performance, Kulin also cultivated an extensive database that enabled his practice to collaborate with larger healthcare organizations in initiatives previously unavailable to the small urgent care group.
“We have about 211,000 distinct patients in there. Not visits, but distinct patients in there,” he stated. “From a billing and claims perspective, we have grown large enough with our database that we are actually connecting with the health information exchanges of two large insurers in the state to exchange information back and forth at the time of service, which is quite exciting for us to now be able to impact value-based care and population health initiatives that weren’t available to urgent care before with us kind of being on the outside.”
He attributed his practice’s progress with improving financial performance and joining value-based care initiatives to the reproducibility and voracity of the data he gained through implementing a rules-based medical billing system.
“If you don’t have access to that data in real-time, I don’t think you can survive these days,” he stated. “I don’t know how you would survive.”