Healthcare experts have come out with a number of predictions for the New Year that involve things like revenue cycle management and claim denials, among other things. In some cases, these experts are absolutely correct, as they manage to determine exactly what will happen in the industry. In other, they are wrong, because sometimes it’s tough to truly decide how things will go. No matter what direction revenue cycle management and claim denials end up taking, you thankfully have one good solution at your disposal – the Federal ERISA law. Now, let’s go into these predictions a bit more and then discuss claim denials and the revenue cycle in some depth.
Every year, healthcare professionals look at trends in the industry in order to see if they can guess which direction certain things are headed in. For example, some think that claim denials are going to rise dramatically. This expert said, “I anticipate denials increasing [at hospitals] and actual write-offs increasing from the insurance companies. As we’ve seen, denial rates actually have come down over the last couple years; I think we’re going to see those increase again as payers and providers are fighting for that last [reimbursement] dollar.” Overall, it’s entirely possible that these claim denial rates will go back up.
Others are looking at the technology involved in revenue cycle management. They think that “there will be some technology changes in scrubbing claims on the front end of the revenue cycle. I think anything you as the provider or practice can do besides checking the typical name, address, such as scrubbing for current procedural terminology code or ICD-10 acknowledgment will also be important. Additionally, any kind of technology pertaining to denial management will be big next year — what denials are you the provider seeing, how quickly do you see those, how quickly can you correct those to get claims out the door.” Technology can make a big difference when it comes to claim denials, especially since it can help you track them and determine patterns.
No matter what’s involved in these claim denials, you need to develop a way of avoiding them.
How to Avoid Claim Denials
The best thing to do is to avoid these claim denials. Many are sent back by the commercial health insurance company because the amounts are wrong, they are miscoded, or proper approvals weren’t requested and received. When the health insurance company sends back an unpaid claim, they’ll explain why. Your billing employees will need to check on this reason and find a way to correct it before resubmitting the claim.
At this point, the clinic has their billing employees send in an appeal to the health insurance company. According to current laws, there are three of these appeals available at the state level. The insurance company then goes over the newly appealed claim denials and comes up with a new judgment. In some cases, the claim is paid. This makes everyone involved happy. The hospital no longer has to worry about that unpaid claim and they under with more money in their bank account. In other cases, the insurance company might just pay a portion of the claim. This is called an underpaid claim. The reasons for these depend on the allowed amounts and any preapprovals – basically the same as the ones from the first round of claim denials.
On top of this, the insurance company could also keep refusing the claim outright. As we already stated, the hospital or clinic can go through three rounds of these appeals, even if the claim is underpaid. The collections process allows for this. Every time that the claim is sent back for an appeal, the odds that it will get paid go down. In some cases, the claim is partially paid and then partially paid again, leaving a balance by the end of the appeals process. Each time this happens, it costs the hospital more money and creates additional work for the billing employees.
Claim Denials Tend to Pile Up Over Time
After the three state-level appeals process is completed and the claim denials are still in place, your hospital or clinic has a choice. That money usually ends up going uncollected. It goes to your accountant’s office where it ends up in what we call a “debt bucket.” This is a list of permanent debts on a balance sheet. The medical facility needs to make even more money to make up for this growing list of debts. Since hospitals and clinics have bills to pay so that they can stay open, this list of debts can be extremely problematic. The reason why most hospitals go bankrupt and close their doors is due to them.
Thankfully, there is a solution to getting those claim denials paid. This involves the Federal ERISA process. While many hospital administrators have heard of it, they aren’t sure about how to even begin using it.
Collecting on Those Claim Denials With the Federal ERISA Laws
A Federal ERISA appeal can be filed on all of those unpaid or underpaid claim denials. The problem with this is that many of these hospital administrators aren’t sure of the process. As you can imagine, this federal process is quite complex, meaning that many billing departments don’t know how to work through it. They aren’t taught this in schools. Plus, many of the employees in those billing departments are busy either with sending out current bills or wading through state-level appeals. They just don’t have to time to figure out Federal ERISA appeals. This means that in most cases, those claim denials are written off and add to an already growing pile of debt.
What is ERISA? It stands for the Employee Retirement Income Security Act. It was enacted back in the 1970s and was initially designed to protect employee retirement plans. Over time, it’s become a federal law that protects self-funded healthcare plans as well.
Essentially, the Federal ERISA appeals process is designed to get your hospital the money that it’s owed from those commercial insurance companies. Using it requires the use of a specialized billing process. It all starts with your accounting personnel. Rather than having them place your money in a debt bucket, call in a specialist. Take those claims and place them in a file. Then call in an expert, such as ERISA Recovery. We’ll need a few things from you, including that list of claim denials and some other information. We can take it from there and will file those Federal ERISA claims for you. On top of this, we have a guarantee in place stating that we’ll recover at least one million dollars in denied claims for you within 12 months. We also don’t charge anything up front.
You Need The Help of an Expert
Is your hospital or clinic burdened with commercial health insurance claim denials? You don’t want your hospital to end up going bankrupt or shutting down – not when there’s money out there that you can still collect. This is why you need to contact ERISA Recovery today. You can reach us at (972) 331-4140 or by filling out the contact form on our website. It’s time for you to move forward and take control of your hospital’s financial future!