Improvements for Payers, Billers and Providers: Part I

The Healthcare Billing and Management Association recently identified 10 major challenges to payer relations—and offered solutions. Here is a summary of the article courtesy of Integrated Medical Management:

Challenge: Electronic payment is wrought with confusing codes and non-standard remarks.

Solution: Select from a standard, nationally recognized set of remarks for consistent coding across organizations. Also, explain why a claim is denied and subsequently offer ways to resolve the issue. This would streamline processing and benefit all parties involved.

Challenge: Unpredictable benefit information and separate mailings (with paper payment files).

Solution: Consistent with the Patient Friendly Billing Project recommendations, standard and easy-to-read formats would allow claims to be processed quicker. Additionally, grouping EOBs and checks together would up efficiency and limit misunderstandings, phone calls and the need for looking at one claim multiple times.

Challenge: The claims appeals process is inefficient.

Solution: Provide a clear outline of the process and give providers online access to claims statuses and appeals in addition to a timeline for a response. This would save time and money wasted when claims are tracked down individually.

Challenge: Denials for several visits from several specialists on the same day. When a patient sees multiple specialists in a hospital in one day, oftentimes only the first provider to submit their claim gets paid.

Solution: If payers’ systems were able to edit same-day services by provider specialty, there would be less inquiries and less cost (because claims wouldn’t be handled multiple times).

Check back for Part 2 of the list dealing with medical revenue management later this week!

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