How to Tell When You Need a New Claims Management Solution

By Moliehi Weitnauer, Vice President of Product Management and Strategy | Posted: 11/08/2017

Are you certain that your claims management solution is still helping you get maximum reimbursements quickly? Technology advancements, work process changes and increasing payor complexities could be eating away at the effectiveness of your solution.

Here’s how to tell if it is time for a new solution: 

1. Too many denials

You receive denials for medical necessity errors or mutually exclusive procedures, which would be preventable with the right claims edits. Most electronic medical records (EMR) systems require a new grouper or editing package that you may have to purchase and load into your system. With the right technology you get the payor rules quicker – less errors.

2. Rejections

High rejection rates at your claims clearinghouse – an acceptance rate of less than 98 percent – means you should consider a change in technology to increase claims acceptance for payment and adjudication.

3. Stagnant claim rates

Stagnant clean claims rates may indicate that your claims management technology vendor does not support upstream improvement processes. A solid claims solution leverages automation to improve your processes,  clean claims rates and reimbursements.

4. Payor non-response

Many times, noncompliant and unresponsive payors don’t follow their own rules and reject claims even when they’re correct, or they give vendors kickbacks and incentives based on the amount of data they submit, so you may have trouble getting anyone to listen. A better option – collaborate with an independent solution partner that does not align with any payors and advocates on your behalf for correct payment and noncompliant rejection reversals.

5. Changing rules

If your vendor reacts to industry rules changes and quarterly Centers for Medicare & Medicaid Services (CMS) updates, consider collaborating with a technology vendor that is proactive, and continuously monitors and pushes out payor edit releases to keep you up to date, and increase clean claims. 

6. Invisible errors

To understand the upstream root causes of claims problems, you need to be able to see them. A good claims management solution provides pre-built edit categories you can use, or customize your own to identify and eliminate root causes.

7. Hidden problems

If you aren’t sure where your biggest denial problems are, use a technology that offers in-depth reporting capabilities to reveal where denials come from, how often they occur with each payor, and other data to help you benchmark and track performance. Without enough information or no ability to customize them based on current processes, you’re missing the tools you need to tackle the issues.     

8. Overdue claim submissions

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

9. Volume pile-up

Your billing staff can’t keep up with the workload.  Technology is now available to help with the task; automated processes and routines reduce the burden of menial, repeat tasks so your team can concentrate on higher-value activities.  

10. Late reimbursements

Your claims reimbursements take longer than 60 days. Many factors 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 maximize reimbursements and prevent denials. Call 678.323.2500.