Revenue Cycle Management

You’re doing acceptably. Most insurance payers have at least a 90-day window for submitting a patient claim. You might benefit from a faster turnaround time to expedite reimbursements and improve patient satisfaction.

Your organization has a good turnaround rate for some health insurance payers. According to provider manuals, time limits for many major health insurance payers range between 90 and 365 days. However, your organization may be at risk for lost revenue from some payers.

You have room for improvement. An analysis by Etactics of over 200 timely filing limits by healthcare insurance payers showed that the median number of days that healthcare payers allowed for submitting a patient claim was 180 days. If your turnaround time exceeds 180 days, you’re losing reimbursements from those payers.

Revenue is at risk. Medicare and a few other large payers have a filing limit of 12 months after the date services were provided. If your organization is regularly taking this long to submit a claim, you should begin improvement measures immediately. You will need to increase the efficiency of your billing and coding processes, since most payers allow a maximum of 90-180 days. 

Your organization aligns with the healthcare industry average. If a majority of your claims are going to public payers such as Medicare, you could have a higher denial rate because public payers tend to issue more denials than private ones. Keep in mind that about 90% of denials are preventable, so it may be worthwhile to look for ways to improve.

You have a higher-than-average denial rate. Your organization can likely reduce that number. Gain a significant return on investment by optimizing your coding, billing, and overall revenue cycle management processes. Are your coders completing regular training? Do you have a clinical documentation integrity program?

Your claim denials may be a liability. In addition to examining your coding and billing processes, take a look at your entire patient journey, beginning with registration and scheduling. Are you starting with accurate information for claim reimbursement? A high rate of denials may come from gaps in your processes.

Your organization aligns with industry averages. A Medscape survey indicated that specialties can range from 13%-28% in claims resubmitted after denial — from pediatrics, ophthalmology, and endocrinology on the low end at 13% to plastic surgery at 28%.  A high resubmission rate may not be ideal because the cost of resubmitting claims can add up. It can cost an organization up to 4x to resubmit a claim compared to filing it correctly the first time.

You have an above-average resubmission rate for claim denials.  While you may be maximizing reimbursement, improving your organization’s initial clean claims rate could be worthwhile. More training could improve the ability of your medical coding and billing staff to avoid denials in the first place. You may also want to explore automated solutions to help eliminate claim errors and flag issues that could lead to denials.

Consider benchmarking performance, analyzing your claims data to determine specific areas for improvement, and providing advanced training for your team.

Examine your claims data to understand where claim errors originate. Continuing education at regular intervals will benefit your staff by enhancing their knowledge and skills of the most up-to-date coding and billing practices. 

If your organization handles all parts of the revenue cycle in house, you have both the benefits and burdens of ensuring that your processes are solid and monitoring their effectiveness.

Maintaining your own team of coding and billing specialists can provide more control over how you conduct these activities and offer insights into whether they are occurring optimally. You also have the opportunity to select your own technology and provide education for your employees.

• 90 or above: Above average
• 89: Average
• 88 or below: Below average

In the same survey as above, DecisionHealth reported that per-day averages for claims coded ranged from 26 for otolaryngology to 94 for orthopedics. Averages can vary widely by specialty or areas of practice.

• 80 or above: Above average
• 79: Average
• 78 or below: Below average

The survey also revealed that claims submitted ranged from 14 to 108, depending on specialty. Compare your averages to benchmarks for your specialty or areas of practice.

• Above 4: Above average
• 4: Average
• Below 4: Below average

Lastly, denials appealed ranged from 0-10, with specialties such as gastroenterology, general surgery, pediatrics, and urology on the high end, appealing an average of 10 claims per day.

Your healthcare organization could stand to benefit from implementing a CDI program. Revenue Cycle Intelligence also reported that 88% of hospitals saw quality improvements within six months of beginning a CDI program. In addition to increased efficiency, CDI programs can reduce errors, prevent financial loss, and ultimately improve patient care.

The American Health Information Management Association (AHIMA) defines a CDI program as one that “facilitates the accurate representation of a patient’s clinical status into coded data.” It further clarifies that this coded data is used for reporting, reimbursement, public health data, disease tracking, medical, research, and other information-driven healthcare metrics.

Part of a robust CDI program is top-quality education for all clinicians and administrators, including training on revenue cycle and coding.