The financial hardships faced by medical practices continue to intensify, showing little sign of relief. Healthcare providers are caught in a dual struggle: rising healthcare costs due to inflation and a surge in claim denials.

According to a report by the Kaiser Family Foundation (KFF), medical prices increased by 2.2% in March 2024 compared to the previous year. Unfortunately, this figure is markedly below the overall annual inflation rate of 3.5%. Meanwhile, the claim denial rate has escalated, surpassing levels seen in 2023.

Maintaining a practice and handling the intricate claim submission process to ensure optimal reimbursement often leads to burnout among physicians. The administrative burden is siphoning off valuable time from patient care and making it challenging to stay financially sustainable. This predicament signals a risk where patient health could be compromised, calling for immediate action.

Healthcare providers must adopt a proactive and holistic approach to revenue cycle management. A streamlined claim management process enhances financial stability, allowing physicians to focus on delivering high-quality patient care.

Let's discuss some efficient claim management strategies that will enable practices to reduce administrative burdens, improve reimbursement rates, and ultimately ensure a sustainable and effective healthcare system.

6 Tips to Streamline Your Claims Management

Despite the rising trend of claim denials among providers, a remarkable 11% of healthcare leaders have managed to lower their denial rates, underscoring that addressing and mitigating denial challenges is attainable with the right approach and strategy.

Here are six practical tips to streamline claims management and elevate your practice revenue.

1. Bolster Team Expertise via Training

Inefficient claim capture often stems from overburdened staff. When your team is stretched thin, mistakes and delays in insurance claim processing are more likely to occur. 

Staff shortage, a persistent issue, is prevalent across all departments, impacting doctors, nurses, and administrative staff alike. The growing demand for care and the high staff turnover exert undue strain on the existing workforce, negatively affecting their efficiency and productivity.

Providers can address this challenging scenario only by enhancing staff expertise through continuous training. Regularly conducting training sessions on the latest payer policies, coding standards, and best practices ensures your team excels in coding and billing skills needed to manage claims effectively.

Moreover, investing in continuous education, such as attending workshops, online courses, and refresher sessions, helps maintain a skilled and knowledgeable workforce. A well-trained administrative team can handle claims more efficiently, mitigate coding and billing errors, and identify and resolve issues before claims are submitted. 

2. Decipher Payer Contracts

Medical services delivered to patients are generally standard, encompassing treatments, diagnostic tests, and preventive care. However, the payment for these services differs significantly between payers. Commercial insurers, government programs, and employer-sponsored plans use distinct coverage criteria, payment models, reimbursement processes, and contract language. 

Healthcare providers must meticulously review each contract agreement, compare the parameters with other payers, and thoroughly understand the nature of the relationship they are entering into. When evaluating a payer contract, you must:

• Scrutinize Payment Models — Assess the payment model outlined in the contract, whether fee-for-service, capitation, value-based care, or another approach. Evaluate the pros and cons of each model, considering how they impact revenue and influence the delivery and prioritization of services. Choose the model that best aligns with your goals and objectives.
• Review Reimbursement Process — Analyze the timelines for claim submissions and payments. 
• Assess Prior Authorization Requirements — Identify the criteria required for prior authorization and the typical time needed to obtain approval. Be cautious of long wait times, overly stringent authorization procedures, or prior authorization requirements for common procedures, as these can be red flags indicating potential inefficiencies or barriers in healthcare delivery.
• Analyze Contract Terms — Contracts often contain complex legal terms and conditions with significant implications. Carefully review definitions, payment terms, and dispute resolution procedures to avoid potential conflicts.

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3. Ensure Provider Credentialing

A frequently overlooked cause of claim denials is provider credentialing. When provider credentialing isn’t conducted or contains errors, insurance payers might mistakenly think a provider is out of network, leading to claim denials due to lack of prior authorization.

Accurate credentialing involves confirming key details such as board certification, tax identification, National Provider Identifier (NPI), and taxonomy code. Keeping these details precise and current prevents billing errors and ensures smooth claims processing. Moreover, providers must undergo re-credentialing approximately every two years to update their performance data for future evaluations and to ensure continued compliance and accuracy.

4. Understand Patient Coverage Nuances

Managing patient claims efficiently requires a thorough understanding of their coverage nuances and proper coordination of benefits (COB) with multiple payers. For example, when a patient has both primary and secondary insurance, it’s crucial to identify which payer is responsible for the initial claim. The primary payer covers a significant portion of the charges, while the secondary payer may cover the remaining costs or co-pays after the primary payer’s contribution. 

In patients with Medicaid coverage, Medicaid typically acts as a secondary payer, covering costs that the primary insurance doesn’t fully cover. Once the primary insurer processes the claim and provides an Explanation of Benefits (EOB), the remaining balance is submitted to Medicaid for consideration.

5. Capitalize on Technological Innovations

The increasing volume and complexity of claim-related tasks and the need for effective cost-containment solutions have driven the demand for claims management systems.

In 2023, the global healthcare claims management market was valued at $15.6 billion. The IMARC Group projects that this market will expand to $31.6 billion by 2032, reflecting a robust compound annual growth rate (CAGR) of 7.94% from 2024 to 2032. This highlights the increasing reliance on advanced claims management solutions.

Here’s how you can capitalize on these advancements:

• Automated Claim Processing — Automation tools can handle repetitive tasks, such as data entry and claim adjudication, reducing manual errors, speeding up processing times, and freeing up staff to focus on more complex issues.
• Electronic Health Records (EHRs) — EHRs provide complete and up-to-date patient information, ensuring all necessary documentation is available and easily accessible, reducing the chances of claim denials due to missing information.
• Artificial Intelligence (AI) and Machine Learning — AI can analyze patterns in claim data to flag anomalies, suggest corrections, and even automate decision-making processes, improving overall accuracy and efficiency.
• Cloud-Based Solutions — These systems offer scalability, flexibility, and real-time access to data, enabling healthcare professionals to collaborate remotely and streamline claims management.
• Advanced Analytics — Data analytics tools examine trends and performance metrics to pinpoint areas for improvement and empower providers in making data-driven decisions to enhance overall efficiency.

6. Outsource RCM

Handling in-house revenue cycle management (RCM) can be a real headache for providers. Dealing with claim denials, managing complex billing codes, and navigating ever-changing payer requirements can divert your focus from your main priority — providing excellent patient care. That’s where outsourcing RCM comes in. By handing these cumbersome tasks to specialized experts, you can lighten your administrative load and focus more on patient care.

Outsourcing revenue management lifts the administrative burden from your team and improves productivity. RCM specialists manage everything from claim submissions to follow-ups, so your staff isn’t bogged down with paperwork and billing issues. Moreover, they are adept at navigating complex billing codes and payer requirements, ensuring your practice submits clean claims and stays compliant. 

Delegate the Task of Claim Management to Glenwood

Is revenue management keeping you from spending time with your patients?

Pass off the hassle to us! Glenwood Systems has shouldered several practices in managing their admin hassle so they can devote their attention to patient care. From eligibility verification to denial management, our cloud-based solution tracks every minute detail to ensure maximum charge capture and optimum reimbursement.

Furthermore, our advanced claim management system — GlaceEMR, GlaceRCM, and GlaceScribe — streamline eligibility verification, documentation, claim submission, and denial resolution, enabling efficient practice workflows.

Ready to simplify administrative tasks and maximize your reimbursements? Contact us today to explore our personalized practice management solutions.