Many hospitals still use old-fashioned billing systems. While these systems eliminate the need to train your employees on how to use them, they pose a problem for hospitals and clinics that must track unpaid and underpaid claims. In order to refine and modernize their billing systems, many of these healthcare practices are turning to new technology. These technological advances have plenty of advantages, including making the billing process smoother and making it easier for the billing departments to track those unpaid claims as they go through the appeals process. In turn, once those appeals are exhausted, these systems note which claims are eligible for Federal ERISA appeals.
Technology Designed to Help Billing Departments
As you can imagine, “Revenue cycle departments are under dual pressures to provide billing transparency to patients and navigate through provider negotiations to secure fair reimbursement. Hospitals are increasingly turning to outside innovators for help in both of these aims.” While the prices of these outside innovators aren’t exactly inexpensive, many claim that they can refine the billing process, making tracking those claims easier. In turn, these programs essentially pay for themselves.
Many of these programs are designed to do two different things. First, they help patients determine the amounts that are due on their end after their commercial health insurance companies have covered (ideally) their own portion of the bill. According to the experts, “When patients go to pay their medical bills, they want what consumers across industries have come to expect — price transparency. With patient out-of-pocket expenses on the rise and stories about daunting surprise medical bills pervasive in the media, calls for medical bill transparency have intensified over the past two years. With patient payments making up a greater share of revenue, providers have to meet this demand to optimize collections.” This is good news for the people who go to these providers. They won’t have to wonder about which amounts are due and how to pay them.
Secondly, these programs help the central billing office in a number of ways. They are designed to leverage “emerging technologies such as artificial intelligence and data analytics can help providers achieve fairer reimbursement, optimize workflows and maximize the strategic use of human capital among revenue cycle staff.” As you can imagine, this is a large difference between how many of these departments operate now. The only issue lies in training these employees in order to use the new programs.
However, once those programs are in use, they do indeed make the billing system easier. They allow employees to track the amounts due and the appeals process that the claims are sent through. They also contain a lot of the billing codes and amounts that are agreed upon by the commercial health insurance process. This makes billing a lot easier, as there are no outside forms or documents needed – everything is located right there at the employee’s fingertips.
One thing is for certain, no matter how advanced the technology becomes – and as much as it might help healthcare practices track the claims through the appeals process – it doesn’t prevent the commercial health insurance companies from underpaying or outright avoiding paying those claims in the first place. When this happens, these claims are sent through the state-level appeals process.
What You Need to Know About State-Level Appeals
The one thing that every CBO (central billing office) has in common is the appeals that it goes through on unpaid and underpaid commercial health insurance claims. This process includes an automatic three state-level appeals. Once the initial claim has gone unpaid or underpaid, the CBO (central billing office) staff can appeal it three separate times. The computer system utilized by the billing office should track them. After that point, these claims usually end up going into a debt file, where they quickly add up. This is a major problem.
Although at first glance these unpaid or underpaid claims don’t seem like much. They really only make up around 8% of all claims sent through the CBO (central billing office.) However, when you look at the sheer volume of claims that these offices handle, those small amounts can add up quickly. In the end, if the amount of unpaid commercial health insurance claims sitting on the wrong end of a balance wind up being more than what’s coming in, then the clinic group or hospital ends up in major financial trouble. They might even go under.
There Are More Solutions than Bankruptcy
Going bankrupt can be prevented thanks to the Federal ERISA appeals process. The only problem here is that a standard CBO (central billing office) is unable to send the bills through this upper level of appeals. Not only do these billing office employees not know how to do this (it isn’t taught in any healthcare billing and coding courses), but they don’t really have the time. They have plenty of new claims to send out and state-level appeals to file, even when they have software in place to simplify the process.
Many hospital CEOs and those in charge of provider group networks undoubtedly know about the Federal ERISA appeals process. Let’s recap it here briefly, just in case. The Federal ERISA Act was put into place back in the 1970s. ERISA, in case you didn’t know, is short of the Employee Retirement Income Security Act. Despite its name, ERISA covers commercial health insurance claims as well. It’s a federal law that allows hospitals to collect on those unpaid and underpaid claims from commercial health insurance companies. Once the state-level appeals are exhausted, ERISA kicks in, and the health insurance companies have to pay those claims.
Collecting On Claims Requires Outside Help
The main issue is that many clinic groups and hospitals never go through the ERISA process. Their CBO (central billing office) personnel don’t have the time, nor do they understand how to begin the process. As a result, the commercial insurance companies essentially get away with their practices. Yes, it’s true that most medical billing and coding courses don’t cover how to get those unpaid and underpaid commercial health insurance claims paid based on this federal act. To take this even further, many law school courses don’t cover it either. It’s not that the Federal ERISA law is secret, just that there are other things to go over that are deemed more important. However, we know that this is important to your hospital or grouped provider network.
The Best Solution? Reach Out to Us
Stop allowing your accounting staff to write off those unpaid and underpaid claims that pop up after the state-level appeals are exhausted. Instead, contact us, ERISA Recovery. We know the ins and outs of Federal ERISA Appeals and can get that money for you. We understand that your margins are thin. All that we need from you is some paperwork, and our employees will take care of the rest. Are you ready to see how we can help? If so, call us at (972) 331-4140. To make it easier for you, we also have a contact form on our website. Just fill it out, and you’ll hear back from one of our experts.