Fixing Healthcare’s Broken Pre-Authorization Screening & Verification Model

Fixing Healthcare’s Broken Pre-Authorization Screening & Verification Model

  • June 27, 2016

By David Dyke Among the processes that influence the healthcare revenue cycle, pre-authorization stands out—but not in a good way. It lacks the foundation of a widely-adopted electronic data exchange, resulting in repeated manual, ad hoc methods of securing and confirming payer approval for non-emergency medical services. And, all too often, there’s no centralized responsibility for obtaining pre-authorizations, with the necessary tasks scattered across even the most integrated of care delivery networks and, within those networks, even across various types of service. It’s time to take a closer look at the current state of pre-authorization and ways in which existing…

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Ten Steps To Reduce Denials, Win More  Appeals, And Improve Hospital Performance

Ten Steps to Reduce Denials, Win More Appeals, and Improve Hospital Performance

  • June 24, 2016

By Tammie Phillips, R.N. Every day, someone at a health system or hospital asks me a variation on this question: How can I better manage denials? There’s tremendous pressure to reduce denials. According to CMS, 20% of all claims are denied, 60% of lost or denied claims will never be resubmitted, and 18% of claims will never be collected.1 Reworking each claim costs around $25.2 The problem is worsening as the complexity of claims processing intensifies. Our population is aging rapidly, and care needs are increasing. Medicare enrollment is rising. Comorbidities and chronic conditions are more prevalent. And population health…

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Journey To Value: The State Of Value-Based Reimbursement In 2016

Journey to Value: The State of Value-Based Reimbursement in 2016

  • June 13, 2016

There's no turning back from value-based care and value-based reimbursement. Payers are 58% along the continuum to VBR, up from 48% in 2014. And Providers are now 50% down the road to value. That's according to a national study of 465 payers and hospitals conducted by ORC International and commissioned by Change Healthcare. Yet despite tremendous growth in capitation/global payments, pay for performance, and episode of care/bundled payments, many payers and providers still face obstacles in the transition to value-based care. See where healthcare stands in its journey to value and what it means for the industry in Journey to Value: The…

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Five Strategies For Maintaining Healthy Revenue During An EHR Transition

Five Strategies for Maintaining Healthy Revenue During An EHR Transition

  • February 29, 2016

You’ve heard the horror stories. Now hear how making clinical and financial data “inseparable” can help ensure a smooth migration that doesn’t blow up the revenue cycle. By David Dyke and Carmen Deguzman Sessoms Your EHR migration can cost you twice. But the second cost is avoidable if you know where to look and what to do. The first cost is obvious. It’s the cost of the migration itself, which, for hospitals, can run from under $10,000 to over $50,000 per physician, with ongoing monthly fees of $300 to $700 per doctor. For a large provider network, that can mean…

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Beware The EHR “Ripple Effect”

Beware the EHR “Ripple Effect”

  • February 29, 2016

EHR conversions can be complicated and disruptive. So don’t make them more problematic by making unnecessary changes to revenue cycle management systems. By David Dyke Like any major IT system implementation, an EHR conversion can be seriously disruptive to hospital operations—and finances. In addition to the many technical and clinical considerations of these projects, hospitals and health systems typically face an array of revenue cycle implications that may pose significant financial risks. Most of the pitfalls, however, are entirely avoidable, and those providers that align the technical, clinical, and financial elements of the project from the start can convert a…

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Getting In Front Of The Problem: How Can Hospitals Empower Denial Prevention And Management?

Getting in Front of the Problem: How Can Hospitals Empower Denial Prevention and Management?

  • November 22, 2015

Healthcare providers are chiefly concerned with two things: Ensuring patients receive the highest quality of care, and getting paid for that care. Despite advances in medical technology and a declining number of uninsured Americans, hospitals still experience difficulty getting paid fully and in a timely manner today. Hospital and health system CEOs have named financial challenges as their No. 1 concern every year from 2012 to 2014, according to the American College of Healthcare Executives.1 Claim denials are a significant contributor to these challenges. Denials are a pervasive and persistent problem, as up to 1 in 5 claims is delayed…

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Five Ways To Improve Medi-Cal Claims Processing

Five Ways to Improve Medi-Cal Claims Processing

  • September 23, 2015

Roughly one in three California residents— approximately 12 million people—are enrolled in Medi-Cal, the state’s publicly funded Medicaid program. To put this in perspective, California has 12% of the U.S. population, and yet accounts for 17% of the nation’s Medicaid enrollment. And the enrollment is growing—with 2.7 million people added since federal healthcare reform was enacted. Given the large percentage of revenue that Medi-Cal claims constitute for California hospitals, efficient and accurate Medi-Cal claims processing is a high priority for healthcare providers. But in reality, many providers find that Medi-Cal claims can be difficult to manage. The root causes of…

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Revenue Cycle Payment Clarity

Revenue Cycle Payment Clarity

  • April 10, 2015

What It Is, Why It Matters, and How It Can Help Your Patients and Your Bottom Line Healthcare providers today are principally concerned with two things: first and foremost, providing quality care to patients; second, getting paid for that care. Unfortunately, while advances in medical science and technology are making it easier to help patients get well, a tidal wave of reform is making it harder to get paid. Higher deductible plans and cost sharing mean that insured patients owe more. And as patient out-of-pocket expenses rise, so will the amount of bad debt carried by hospitals. Hospitals’ total cost…

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The Top 10 Things Payers And Providers Can Do Today To Start Aligning With VBR Tomorrow

The Top 10 Things Payers and Providers Can Do Today to Start Aligning with VBR Tomorrow

  • March 11, 2015

CMS says VBR is now an imperative. What can you do to make the grade? By Carolyn J. Wukitch and Andrei Gonzales, M.D. The stakes have just been raised for payers and providers who are besieged by a rapidly changing market. In an announcement that reverberated throughout healthcare, HHS Secretary Sylvia M. Burwell introduced an initiative to make alternative payment the standard for 50% of Medicare reimbursement by 2018. That’s the first time HHS established goals for alternative payment models for Medicare. HHS wants 30% of fee-for-service payments to be tied to quality or value through ACOs, bundled payment, or…

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Credible, Defensible Estimates

Credible, Defensible Estimates

  • October 14, 2013

More Accurate Upfront Financial Calculations Bring Increased Revenue, Satisfaction With Entire Care Experience By David Dyke Executive Summary In healthcare, every interaction with the patient matters. Especially in today’s environment of continuous improvement, efforts have been concentrated on coordination among providers, the patient care experience and quality outcomes–all laudable goals. Often overlooked in these improvement efforts are the front-office and back-office functions that intersect with the care experience from beginning to end. A patient’s perception of the care experience begins when the phone rings for the initial appointment or appearance in the ED, and doesn’t end until the final bill…

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