Health care reimbursement isn’t as easy as a provider sending an invoice and the payer cutting a check. Since DRGs were introduced by Medicare in the early 80s, getting reimbursed for services performed has become increasingly complicated. Regulatory and industry changes related to the Affordable Care Act and the ICD-10 mandate have made it even more difficult.
As value-based care takes hold, organizations will continue to need carefully planned strategies and processes, with the goal of more consistency and accuracy in how claims are managed and submitted.
Claims go through a number of steps before ever reaching a payer for payment. First, they’re run through a claims editing system for errors. From there, charge entries and postings are made, and the claims head to processing. Technical edits are then made in the clearinghouse. Finally, they are shipped to the payer, where the claim is either approved and paid, sent back for more information or rejected.
The focal point for health care executives in the above process should be claims errors. Coding, documentation and billing errors must be immediately corrected when found. More importantly, such errors should be prevented if at all possible. Proactive measures can drive lower denial rates and cut long-term operating costs.
By strengthening error identification and correction, organizations can limit costly errors and increase margins. Leaders can then focus on minimizing claims denials and ensuring their organizations are complying with regulations that drive timely and accurate payments. And better reimbursement can also provide leaders with the resources that will allow them to focus on preparing for value-based care.
In the next post in this series, we turn to the topic of preparing for value-based care.