Medical groups often miss opportunities to work on unbilled claims, claim denials, and accounts receivables, resulting in lost revenue and reduced cash flow. Failure to address these issues can lead to delayed payments, denied claims, and increased administrative costs. Effective management of these areas can improve financial stability and help medical groups better serve their patients.
There are 3 healthcare RCM problems that stop your medical group’s collections:
- Unbilled claims/charges.
- Unworked denials.
- Pending accounts receivables.
These problems create a terrible imbalance when it comes to smoothly navigating the revenue cycle of your medical group. Even if a hospital, health system, or medical group has an in-house revenue cycle and medical billing staff. They always tend to miss working on one of these problems.
Why are these 3 healthcare Revenue Cycle Management processes is so important?
Creating and submitting claims/charges is the first and foremost part of any healthcare Revenue cycle management process start. Only when a claim is being billed to the respective insurance the medical group can earn revenue to keep their business running. Failing to work on it or keeping backlogs of unbilled claims/charges can cause devastating impacts on the collections. Most insurance companies do not even consider the claim to be paid if it is being filed after the timely filing limits.
Claim denial is the revenue cycle roadblock that never leads to collections. Addressing denials will allow your group to identify the mistakes in credentialing, contracting, coding, eligibility, etc. To be honest claim denials will allow you to determine whether your group medical billing or RCM staff are working efficiently and measure the quality of work as well.
Accounts receivables are usually pending in 80% of the groups. Due to daily billing tasks, your billers and RCM staff fail to address the thousands of dollars pending in receivables buckets. If the accounts receivable buckets are above 60+ days then it slowly loses the chance of ever recovering it and can cause bad debts written off.
Let us now get into detail focusing on how to solve these 3 healthcare Revenue cycle management problems that stop your medical group’s collections.
Unbilled claims/charges and solutions to track:
Unbilled insurance claims:
Possible reasons – delayed provider dictation or transcription, coding errors, or rejected claims.
Solution – Generate a report to track unbilled claims and determine the reason for each. Submit any outstanding claims promptly. Implement a charge master automated platform or RPA bots for more accurate billing.
Unbilled patient balances:
Possible reasons – payment poster errors or failure to send patient statements.
Solution – Use a report to track unbilled patient balances and reconcile them with account information on the computer. Follow up with revenue cycle staff and send patient statements as needed. Implement an online payment/billing platform for patients.
Medical groups should monitor their unbilled insurance claims and patient balances regularly, and take proactive steps to address any issues that arise. This can help to ensure timely payment and improve the financial health of the group.
Unworked denials and steps to reduce:
Possible reasons – Denials can occur for various reasons such as missing information, incorrect coding, lack of medical necessity, or policy limitations.
Solution – To address unworked claim denials, medical billing staff should first identify the reason for the denial and then take appropriate action to correct the issue. This may involve reviewing the claim for accuracy, obtaining additional information from the provider or patient, appealing the denial with the payer, or resubmitting the claim with corrected information.
Implementing denial management platforms and robotic process automation (RPA) for denials can assist your medical group even if you have no staff to work the denials.
To prevent unworked claim denials in the future, it is important for medical billing staff to have a thorough understanding of payer policies and guidelines, stay up to date with coding and billing regulations, and establish effective communication with providers and payers. Implementing quality assurance processes and conducting regular audits can also help identify and address issues before claims are submitted, reducing the likelihood of denials.
Pending accounts receivables solutions:
Possible reasons: The backlog of pending accounts receivable (AR) in medical billing can be a significant challenge for healthcare providers. The reasons for a backlog can vary, but some of the most common factors include claim rejections, denials, incomplete documentation, slow insurance processing, staffing shortages, inefficient processes, and a high volume of claims.
One of the primary causes of a backlog in medical billing is claim rejections. Errors or omissions in the billing process can lead to claims being rejected, which must then be corrected and resubmitted. This process can be time-consuming and result in delays in payment. Similarly, denials can also cause a backlog, as claims must be reviewed and appealed, which can be a lengthy process.
Incomplete documentation can also cause a backlog, as insurance companies may require certain documentation to process a claim. If this documentation is missing or incomplete, it can delay the processing of the claim and lead to a backlog of pending AR.
Slow insurance processing is another common cause of a backlog in medical billing. Insurance companies may take longer than expected to process claims, which can result in a backlog of pending AR for medical groups.
Staffing shortages in the medical billing department can also lead to delays in processing claims and a backlog of pending AR. If there are not enough staff members to handle the workload, it can be challenging to keep up with the volume of claims.
Inefficient processes can also cause a backlog in medical billing. Outdated or inefficient processes can lead to errors and delays, which can result in a backlog of pending AR. A high volume of claims can overwhelm the medical billing department, leading to delays in processing and a backlog of pending AR.
Solutions:
Review your outstanding claims: Start by reviewing the outstanding claims and determining which claims are past the expected payment date.
Contact insurance companies: If the outstanding claims are with insurance companies, contact them to find out why the claims are still outstanding. You may need to provide additional information or resubmit claims that were denied.
Follow up with patients: If the outstanding claims are with patients, contact them to remind them of their outstanding balance and request payment. You may need to set up payment plans or offer other payment options to help patients pay their bills.
Address denied claims: If claims have been denied, review the reasons for the denial and take appropriate action, such as correcting errors or submitting appeals.
Monitor payment trends: Keep track of payment trends and identify any patterns of non-payment or delayed payment. This can help you identify areas where you can improve your billing process.
Review and adjust billing practices: Finally, review your billing practice and make adjustments as needed to improve efficiency and accuracy. This can help reduce the number of outstanding claims and improve your overall cash flow.
Implement automation: RPA accounts receivable solutions offer several benefits for medical billing, including an automatic population of days in AR and red flags when exceeding the standard reimbursement time period. Automated claim status checks are performed using EDi transactions and accessing payer portals if permitted by bots. This process reduces staff burnout by performing repetitive tasks and increases productivity by 100%. Additionally, the inbuilt AR quality measure helps staff avoid manual errors and achieve quick turnaround times for resolving AR and receiving reimbursement, ultimately improving quality and TAT.
By following these steps, you can effectively manage pending AR in medical billing and ensure that your healthcare organization remains financially healthy.
Hospitals, health systems, and medical groups must focus on these 3 areas that present challenges in terms of streamlining RCM processes, administrative burdens, and revenue loss. Check out our Medical billing services and consultation to learn more.
