Data and the capacity to derive actionable insights from said data are crucial to the overall success of the revenue cycle. However, data on payer behavior can be especially useful to prevent denials from occurring in the first place. Technology can help providers capture data on payer behavior during the escalation process, which can inform how claims are formulated on the front-end of the revenue cycle to minimize barriers to reimbursement.
“We use data analytics to create payer scorecards that document things like a payer’s first-pass payment rate,” Ms. Castro said. In addition to using these insights to strengthen documentation processes, Ms. Castro said these scorecards support Conifer’s provider partners’ approach to payer contracting. “We also use this data to bolster contract language to help avoid long-term litigation with a payer,” Ms. Castro said. “We really want to solve potential denials at the lowest level possible without legal teams getting involved.”
The recovery component of denials management is focused on achieving fair reimbursement as quickly as possible. The current high rate of denials nationally complicates this effort as staff can become overwhelmed by denied claims, slowing down the rate of appeals. With data on payer behavior in place, hospitals and health systems can leverage technology-powered machine learning to automate portions of the appeals process. One area this has been especially helpful in is bulk denials. Conifer has been able to group payer issues with a unique “fingerprint” that allows similar denials to be resolved in one bulk appeal by using machine learning and advanced trending methodologies. “You want to be able to create automated appeals for low-dollar, low-complexity disputes,” Ms. Castillon said, adding that machine learning technology can also be leveraged to support staff when working on manual appeals by offering them insights into payer behavior in real-time as they’re working the claim.
“We’re able to create smart texts to really help our clinicians and our technical writers drive home the key parts of the argument an appeal needs to make,” she said.
Once a denial reaches the point of escalation, the human engine of the revenue cycle kicks into overdrive. For effective escalation, the teams tasked with this endeavor must have a sophisticated understanding of claims management. To get the right people in place and ensure staff have the resources to get the job done, providers must optimize workflows. The team members essential to escalation efforts should not have to devote an inordinate amount of time to less rigorous tasks.
“We have an escalation process that’s supported by technology-enabled solutions that helps us utilize our resources in a smarter fashion,” Ms. Castro said. “We are then able to create high-caliber teams that can interact directly with the health plan.”