Hospital Billing Solutions: Clinical Process Improvements and Federal ERISA Appeals

Clinical process improvements are one of the latest trends in hospital management. These improvements are designed to hold two solutions – they help the patient receive better care, while the making the billing processes go much more smoothly. However, they aren’t a perfect solution. While clinical process improvements do help, many hospitals still end up with unpaid commercial health insurance claims, which can only be cleared up by filing under the Federal ERISA process.

What You Need To Know About Clinical Process Improvements

The best way to begin discussing the importance of clinical process improvements is by defining what they are. According to Becker’s Hospital Review, the key characteristics of these clinical process improvements are that “it is a process that produces outcomes, which drives value, it is a continuous process, it involves culture and technology, it is constantly evolving, [and] it involves reducing variation.” That same article goes on to define this process as something that is great because “’because excessive variation in care delivery is an ongoing problem generating a tremendous amount of wasteful spending,’ said Brita Hansen, MD, CMO at LogicStream Health. ‘Provider organizations are facing unprecedented cost pressure while patients and payers are demanding greater value for their healthcare dollars. Continued focus on process improvement in the clinical space is the disruption of healthcare needs.’”

These clinical process improvements are multi-faceted, as you can see by the many different types of processes included in each of them. The process needs to be refined and changed as needed in order to meet the hospital’s needs, and it must utilize the technology available. Ideally, this new technology will help make the billing process go much more smoothly. We have already pointed out the importance of the billing process, including the need for well-coded notes, a list of solid procedures, and even how to properly track your unpaid claims to come up with a list of the main reasons why they remain in this state. Although clinical process improvements do help, they only go so far. Everything else must fall into place for them to truly work.

This Doesn’t Always Stop Unpaid Claims and State-Level Appeals

Although improving your clinical process can help your financial status, it doesn’t solve everything. In order to maintain positive cash flow, hospitals need commercial health insurance companies to pay their bills. These bills are sent out daily, usually immediately after a procedure or hospital stay has been completed. The billing employees are responsible for coding the bills (there are numerous codes, depending on the contracts set into place with the insurance companies), ensuring that the patient’s identifying information and amounts are correct.

This process doesn’t always go as smoothly as possible. The commercial insurance companies can refuse to pay the hospital’s claims, sending them back for a number of reasons that vary from wrong amounts to incorrect codes. Once they are sent back, the billing employees can send them out again up to three times. These are called state-level appeals. Every insurance company handles them differently. This means that the employees might have to fill out a different form, send them to a completely new address, and jump through a number of virtual hoops – after they’ve confirmed that all of the claim information is correct. (And if it isn’t, they need to correct it before sending it back for appeals.) Even after going through this process, the claim might still remain unpaid.

Sometimes State-Level Appeals Fail

After the three state-level appeals are completed, there are several outcomes. Either the claim has been paid, which makes the hospital board or its overseers happy. If this happens, then nothing else needs to be done. More often than not, this isn’t the case. The claim usually ends up being denied outright or underpaid. A denied claim is one that the commercial insurance company refuses to pay. On the other hand, an underpaid claim is slightly different. This occurs when the hospital recovers only part of what’s owed. Again, the reasons for this vary. The percentage of these denied or underpaid claims depend on the hospital and the commercial insurance company. It’s hard to cite a specific percentage. However, it is possible for them to make the difference between a financially healthy hospital and one that’s on the brink of bankruptcy. For most hospitals, these unpaid or underpaid claims might be the beginning of the end.

Those Unpaid Claims Then Begin To Pile Up

Once your hospital has exhausted its state-level appeals, most uncollected claims end up in a file with all of the others. It’s the virtual end of the road for them, as the accountants place them on the wrong end of the balance sheet. However, this isn’t the only option – you can file a Federal ERISA appeal.

How does this work? Well, the process of filing an ERISA (Employee Retirement Income Security Act) appeal is somewhat complicated. Even if it were taught in medical billing and coding courses, those employees are too busy filing new claims and dealing with the state-level appeals to file these ERISA appeals for their hospitals. In fact, information on ERISA, which was initially created to protect employee retirement accounts and then expanded to health care, isn’t taught in most law schools either. You need to find a specialist who can handle them for you. You need a company like us, ERISA Recovery.

The Best Solution to This Problem

When you contact ERISA Recovery, you receive two things – appeals filed through ERISA on your behalf, and a handy guarantee. Yes, we offer a guarantee. We guarantee that as long as we have access to your records and other documentation, in a 12-month period, we’ll recover $1,000,000 worth of these claims. It all starts with some basic paperwork. Those commercial health insurance companies need to pay you.

Why call us? Well, we know the ins and outs of the law. Although there are a few health care plans that are exempt from the law, including those that are administered by a church or the government, the majority of them are covered. This means that those unpaid and underpaid amounts can be collected. It all starts when you contact us. We don’t even charge up front since we operate on a contingency basis.  We’ll get paid when you do. All that we need to get started is a set of reports showing the amounts still owed to you. We’ll go through them, ask you for supporting documents (if necessary), and file your ERISA appeals. Our experts have the time, knowledge, and access to forms that your hospital billing employees don’t.

Call Us Today

We speak with representatives from hospitals every day. Don’t wait until it’s too late to reach to us. One phone call or filled out contact form can prevent your hospital from ending up in financial distress or even bankruptcy, even after you’ve made some clinical process improvements. Remember – they don’t solve everything and you can still end up with a stack of unpaid commercial health insurance claims. If you’re ready for the best solution, call us at (972) 331-4140 or fill out the contact form on our website. One of our experts will call you back.