Claims Submission, Adjudication & Reimbursement

Throughout 2020 and into 2021, the US government provided substantial financial support to hospitals, health systems, and providers in the form of accelerated and advanced payments, provider relief funds, expanded Medicare payments, and paycheck protection, which helped hospitals through the initial shock of the COVID-19 pandemic. In some cases, commercial payers also helped to support health systems through expanded eligibility, waived co-pays, and advanced payments, as providers experienced cost and revenue reductions due to care delays, and expanded expenses resulting from treating COVID-19 patients. As government and payer support has now been removed, hospitals and health systems are facing increased demand for deferred care, as well as repayments from the support provided, creating pressure across the revenue cycle.

The current environment faced by finance and revenue cycle teams is one of great difficulty, where delayed payments, combined with escalating operating costs, are creating an increased burden on hospital finances. Reviewing claim submission processes, auditing claims to identify problem areas in adjudication, training on new codes, and working to renegotiate contracts to ensure payment are all top of mind for finance and revenue cycle executives.

Claim Submission: Fast & Accurate

In a setting where denials are a leading difficulty for hospitals and health systems, ensuring claims are submitted to either payers directly, or via a clearinghouse, as accurately and quickly as possible is of essential importance. This requires a nuanced approach to claim preparation, including accurate translation of supporting procedural notes and heightened precision and alignment of CPT codes. Collaboration across the revenue cycle team including coding, clinical documentation integrity, finance and healthcare providers is ensuring claims are submitted as quickly as possible and in all cases prior to contractual deadlines. While technology has brought claims submission to new levels of efficiency, effort must still be focused on more technically challenging claims, and complex cases requiring manual attention.

Smoothing Claim Adjudication

As payers review the claims submitted, there are numerous red flag areas that can result in the claim being returned to the provider, from missing information, incorrect codes, and exclusions. Either working internally as a team to track, correct, and update claims, or working with a clearinghouse partner to process claims, this process is one of great intensity, with some indicating claims adjudication and administration constituting between 3-6% of revenues for providers and payers. With the number of claims facing payment delays increasing, having the resources to monitor and track claims, to identify problem areas that could be corrected in the future, is of increasing importance.

Coding & Claims with New Procedures or Therapies

Service lines including cardiovascular, neurology and orthopedics have seen an influx of new procedures, technology, and correlating codes, as well as new therapies being covered in service lines such as oncology and rheumatology, which need to be considered as claims are being prepared. The use of unlisted codes is also on the rise, and is paired with the requirement of providing additional documentation which often leads to denials or requests for additional documentation, slowing reimbursement processes. Challenges range from educating coders and providers on the correct codes required, as well as educating payer partners who are often also not up-to-date on procedural terminology.

Contractual Payments – Overcoming Delays

While payers and providers have agreed to payment terms during negotiations, providers are reporting significant delays in receiving payments, with some noting 30-day payments not being received for 60-days or even more. There is also a theme of reluctance from payers to return to the negotiating table with providers, as well as difficulties caused by slowdowns in adjudication with many payers now off-shoring this process, creating time-zone delays and fractured workflows. These delays in payment are impacting hospital finances and revenue cycles, and require executives to consider new opportunities to identify and capture revenue.

Benchmark Progress & Discuss Solutions

With the vast majority of hospitals and health systems facing a difficult reimbursement environment, it is more important than ever to collaborate as an industry and share best practices centered on solutions to these pressing issues. The healthXchange Patient Financial Services meeting taking place live online this October 11 & 13 provides an opportunity to discuss issues confronting hospital revenue cycle and finance teams, with breakout sessions on claims submission, reimbursement, and coding, led by industry executives from organizations including the Children’s Hospital of Philadelphia, Heritage Valley Health System, Brigham and Women’s Hospital, UCLA Health and Methodist Health System. Join us, live online, to share your perspective and hear from others on overcoming these hurdles.