10 Signs You May Need a New Claims Management Solution

By Moliehi Weitnauer | Posted: 05/20/2017

Written by Moliehi Weitnauer, Vice President of Product Management and Strategy

Your medical claims management solution is humming right along, helping you submit claims correctly and get reimbursements as quickly and efficiently as possible – or is it? Technology advancements, work process changes and increasing payor complexities could mean you’re not getting as much from your claims solution as you should. Here are some signs it might be time for a refresh.

1. You receive denials for medical necessity errors or mutually exclusive procedures.

These denials are preventable with the proper claims edits, but most electronic medical records (EMR) systems don’t keep edits up to date by default. Instead, they require a new grouper or editing package you may have to purchase and load into your system.

2. You have high rejection rates at your clearinghouse.

You should never have to worry about claims being accepted for payment and adjudication so you can collect your money quickly. If your acceptance rate is less than 98 percent, you could be due for a change.

3. Your clean claim rate is stagnant.

Most claims management technology vendors don’t support upstream improvement processes. You may be missing opportunities to leverage automation to improve processes and, in turn, your clean claim rate and reimbursement.

4. Your payors are noncompliant and unresponsive.

Some payors don’t follow their own rules and reject claims even when they’re correct. And, because many payors give vendors kickbacks and incentives based on the amount of data they submit, you may have trouble getting anyone to listen. A better option is an independent solution partner who’s not aligned with any payors and will advocate on your behalf for correct payment and reversal of noncompliant rejections.

5. Your vendor reacts to industry rules changes and quarterly Centers for Medicare & Medicaid Services (CMS) updates.

The best way to ensure claims edits are current is to be proactive. You may want to consider a technology vendor that constantly monitors and pushes out payor edit releases to keep you up to date and increase clean claims.

6. You can’t see department or systematic errors.

To understand upstream root causes of claims problems, you need to be able to see them. A good claims management solution will allow you to use prebuilt edit categories or customize your own to identify and eliminate root causes.

7. You aren’t sure where your biggest denial problems are.

In-depth reporting capabilities allow you to see where denials come from, how often they occur with each payor and other data to help you benchmark and track performance. If your reports don’t provide enough information or you can’t customize them based on current processes, you’re missing the tools you need to tackle the issues.

8. You have too many timely filing claim denials.

Payors establish their own timely filing deadlines, which multiplies the number of variables your billing staff must contend with. A built-in timely filing management system can help you control the timeliness of your claim submissions.

9. Your billing staff can’t keep up with the workload.

Managing claims is more challenging than ever, but the technology now available to help is equal to the task. Increasingly, automated processes and routines can reduce the burden of menial, repeat tasks so your staff can concentrate on higher-value activities.

10. Your claims aren’t being paid within 60 days.

Many things can delay payments, but you can’t address the problems unless you know where they occur. A good claims management and billing solution monitors discharge-to-payment cycle times to show how long it takes for claims processing and how long for adjudication so you can pinpoint the slowdowns and eliminate them.

Now what?

If more than a few of these problems sound familiar, talk to an nThrive specialist to see how a new claims management and billing solution can help you optimize reimbursements and prevent denials. Start a chat with us now by clicking the chat box on the bottom right of this screen or, if you're unable to view the chat feature, contact us here.