The CBO (Central Billing Office) of your hospital or clinic is in charge of sending commercial health insurance claims out to be paid. They also handle all of the other billing tasks, including those that are sent out to patients, in addition to tracking unpaid and underpaid claims. Recent studies have been done in order to fully analyze these processes to make them more efficient. This has led to the utilization of what people are calling a blockchain. Even though this won’t prevent some claims from ending up going through the state-level appeals and Federal ERISA process, it will help in the long run.
Blockchain Utilization and the CBO (Central Billing Office)
Although the word “blockchain” has its origins in cryptography and computer languages, it also refers to programs that are designed to share data. Specifically in healthcare, these blockchains, “can’t solve every problem in healthcare IT, one doesn’t have to buy all the hype to appreciate the pain points where blockchain can make a difference: a lack of data sharing in real-time across multiple parties, insufficient transparency, difficulty in determining the provenance of data and inadequate security.” This comes about “as value-based contracting arrangements increasingly require payers and providers to collaborate around data sharing, interoperability issues that have long prevented effective exchange of clinical and claims data take a heavier and heavier toll on patient care. Frequently, interoperability problems create significant challenges for multiple HCOs to view and share patient data while at the same time maintaining a comprehensive and up-to-date record of a patient’s diagnoses, medications and treatments.”
Essentially, as explained above, the more data that’s exchanged, the better the records are, and the clearer the billing process. The average CBO (Central Billing Office) can use these blockchains in their revenue cycle management (RCM) process. As the article explains, Tthe result of these disagreements for providers is often a claim denial, a costly problem that is preventable, yet still frustratingly prevalent. Through smart contracts, blockchain provides a way to reduce the burdens of slow payment and denied claims common to the RCM process.” Basically, the process will go more smoothly when it’s managed properly and blockchains are used to track and connect all everyone who plays a role in a patient’s care. Overall, this will help hospitals and clinics keep a close eye on their operating margins.
Operating Margins and The CBO (Central Billing Office)
All of the technology in the world can’t help the state of healthcare today if it isn’t utilized properly. According to a recent article in Becker’s ASC Review, “a Moody’s Investors Services report released in April showed that median operating cash flow margins at nonprofit and public hospitals dropped to 8.1 percent in 2017 from 9.5 percent in 2016, press reports indicate.” That same report did a poll on hospital leaders about their concerns and came up with some interesting results. “The poll asked executives about their top concerns, and their responses should come as no surprise to providers navigating today’s complex landscape: shrinking reimbursements; a transition from fee-for-service to value-based care; dwindling margins; not enough workers; technology gaps; and an increasing consumer-focused marketplace.” The main concern here is the mention of those “dwindling margins.” This means that 2018 isn’t going to be any better than the previous two years. Those state-level appeals may not be enough. You need a way to get those claims paid after those are completed unsuccessfully.
State Level Appeals Still Occur
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.
Where The Federal ERISA Process Comes In
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.
How We Can 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.
Contact Us Today
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.