Navigating the value transformation journey: Addressing reimbursement issues head-on

On the journey from volume to value, generating new capital is an important consideration. In the four articles posted so far in this series, everything discussed—patient access management, medical necessity management, and coding and documentation improvement—can help providers  access capital by reducing costs. In this post, we’ll discuss areas in which reimbursement is directly affected.
Health care margins are shrinking. Bad debt, newly covered patients, changing reimbursement models, health reform and technology adoption combine to make a bitter cocktail for provider finance departments. For organizations that are moving from volume to value—where revenue is at risk—cash flow is critical.

While cost management and revenue optimization needs vary widely among health care providers, I want to point out three areas most organizations can enhance to improve revenue:Miles Snowden, MD, MPH, CEBS Chief Medical Officer, OptumHealth

Denials management: A denied claim is among the worst financial outcomes a provider can experience. Not only does it limit cash flow, it negates the work already completed to file the denied claim. In addition, reworking denied claims makes recovering revenue to which you have a right more difficult. It’s best to stop denials before they happen—hence our focus on patient access, medical necessity, coding and documentation. But in the event of a denial, utilize tools that will help you capture, identify, and correct the root causes of denied claims and manage them to resolution.

Claims management: Sometimes claims are rejected because they do not exactly match the unique ways that specific payers adjudicate claims. Many organizations use claims editing and review technology to identify problems at the least costly point in the claims continuum—before the claims leave their hands.

Collections: As insurance deductibles increase, patients are paying more out-of-pocket. Collecting self-pay portions of bills is never an easy task. Consider using a managed collection service. Such services often combine technology with staff to help providers increase cash flow and net revenue, and reduce accounts receivable days and the cost-to-collect ratio.

Addressing your needs in patient access, medical necessity, clinical technology, coding, documentation and reimbursement will help you to generate new capital. In my next post in this series, I’ll discuss how adjusting your care delivery model can further prepare your organization for this movement from volume to value.

“Navigating the transformation journey” previous posts:

3 thoughts on “Navigating the value transformation journey: Addressing reimbursement issues head-on

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