Better Claims Software Can Bring Workflow Efficiencies


While the patient is definitely at the center of the care experience, it often doesn’t seem that way for clinicians and office staff. Dealing with prior authorizations, phone calls, claim rejections, job turnover, and delayed reimbursements takes valuable time away from the central mission of patient care.

Asked about the greatest challenge facing medical practices in 2023, 58% of respondents in a poll said staffing, well ahead of other top challenges, including expenses (20%) and revenue (17%). However, many practice leaders told the Medical Group Management Association (MGMA) that prior authorizations, claim denials, and long appeal processes were hurting the timely delivery of care and negatively impacting revenues. Other practice leaders also noted challenges adapting to changes in evaluation and management (E/M) coding for claims.

Submitting timely claims that are paid the first time is critical to the success of every medical practice, but it’s an area where many practices fall short. Even before the pandemic, competent coders were difficult to hire and retain. And if a coder leaves, finding and training a suitable replacement could take months (or longer). In the interim, the quality of claims will likely suffer, hurting reimbursements. It’s important that practices utilize robust claims software to submit clean claims and provide a straightforward means of correcting any rejected claims.

Get it Right the First Time
The U.S. Bureau of Labor Statistics and the American Hospital Association both foresee a need for more medical record specialists and coders over the next few years, noting the field is among the fastest-growing healthcare professions.

Coders need powerful and intuitive claims software that promotes electronic processes to speed payments and reduce days in accounts receivable (A/R days). In a small study, reducing administrative burdens that can include claims processing was shown to positively impact organizational efficiency. With a few workflow tweaks, an intervention group could offer 48% more slots for patient appointments than the control group.

The Council for Affordable Quality Healthcare (CAQH) estimates that healthcare could save $20 billion annually by fully adopting electronic transaction methods. Imagine increasing practice revenues while delivering care to more patients at a time when there is a large shortage of providers.

Despite increasing use of technology to process claims, federal and commercial payers are taking longer to evaluate claims and denying more money per claim. The average denied professional charge is nearly $300, and the time from claim submittal to initial payer response increased by 30% to 13 days. The cost to rework a claim has been estimated at $25-$30.

How many denied claims does your practice have each month? Use the rubric below to determine your revenue opportunity:

Number of denied claims x $300 – number of denied claims x $25 =
Revenue opportunity from reworked claims

Don’t Settle for Inferior Claims Vendors
Denied claims lower practice revenues and increase A/R days for claims approved after being reworked. While every practice should diligently rework denied claims, a much better strategy is to avoid denials in the first place. That can be achieved through robust billing and coding workflows, combined with a simplified process to rework claims.

Every member of the practice must work as productively as possible, from the doctors and nurses to assistants, medical billers and coders, and front-office staff. Reducing manual processes wherever possible can bring increased revenues while freeing staff to perform more value-added tasks.

Less-than-optimal claims practices can spill over to billing as patients are responsible for an increasing amount of the care they receive. Nearly one-half of practice leaders note that their A/R days increased in 2021, and 70% of providers say
it takes more than 30 days to collect from patients following a visit.

Claim.MD has been committed to medical practices since the 1980s, delivering powerful claims software that’s easy to use, with a unique method for returning rejected claims that makes reworking them a snap. Users also get one-click access to technical support to get their claim-level questions answered by experts. Get a personalized demonstration to learn more.

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