What is your average time to submit a patient claim? How do you know if your revenue cycle and coding processes are optimal? With all the variables that come into play, it can be difficult to tell how efficient your organization is. The following quiz can help provide insights to guide you in your analysis. 0-45 days You’re doing well. You’re submitting claims within the time limits specified by the majority of healthcare payers. Keep an eye on denials to make sure you’re meeting accuracy and timeliness goals. Remember that reimbursements are the key to your bottom line, so submitting sooner means better financial health for your organization. 46-90 days 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. 91-180 days 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. 180-364 days 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. 365 days or more 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. Claims submitted after payers’ time limits have a low chance of appeal. Prevent irrecoverable losses by shortening your claim submission time. Ongoing training for your team will boost efficiency and provide the professional development needed to improve the performance and engagement of your staff, leading to a lower turnaround time for claims. What is your average claim denial rate? 0-5% Your organization is keeping pace with industry recommendations. However, you may still have room for improvement. According to the American Medical Association, some national health insurers deny under 5% of claims. Analyze your denials to determine the top reasons and seek ways to reduce them. 6-12% 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. 13-20% 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? 20% or more 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. Denials can create a dual impact by delaying or preventing reimbursement and by creating secondary work to troubleshoot and resubmit eligible claims. Timeliness and accuracy are two components of a solid revenue cycle management process. But even if your organization is doing well in both areas today, are you keeping up with regulatory changes that happen quarterly and annually? A quality learning management platform ensures that all your staff members stay current and well-prepared. What is your average appeal rate for denials? 0-13% Your organization may be leaving money on the table. If your ratio of denials to resubmissions is high, you may be abandoning valid claims. Change Healthcare reported that up to 65% of denied claims are never reworked. Employ a two-pronged approach by both preventing denials and reworking and resubmitting eligible denied claims. 13-28% 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. 28% or more 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. Resubmissions can indicate that you’re doing something right to increase your bottom line, but they can also reveal problems in your process. Ideally, your clinical documentation staff will strive to achieve a high clean claims rate that will result in a low denial rate. Even with a low rate of denials, you should designate trained staff members for processing eligible resubmissions to maximize your overall reimbursement rate. In which part of the revenue cycle management process does your organization need the most improvement? Submitting claims faster Consider setting timeliness goals, implementing measures to recruit and retain skilled staff members, and providing regular training for your clinical documentation team. Submitting accurate, complete, and clean claims Consider benchmarking performance, analyzing your claims data to determine specific areas for improvement, and providing advanced training for your team. Managing claim denials 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. Your organization may be doing well in all areas of the revenue management cycle. If so, congratulations! If not, you might want to start with the area that will yield the greatest return on investment. Lengthy turnaround times may warrant more staffing or more training for your existing team. High rates of claim rejections due to errors may also indicate a need for more training to improve accuracy and consistency. If claim denials are your main problem, examine the reasons. According to the Medical Group Management Association, managing denials in three areas — prior authorization, missing information, and eligibility — can account for over 80% of all denials. Do you outsource your revenue cycle management process? Yes, we outsource some/all of our revenue cycle and coding processes With success or failure as an organization depending on effective revenue cycle management, the decision to outsource these processes could ensure survival, especially for smaller organizations submitting fewer claims per year. In fact, nearly 25% of hospitals in the U.S. outsource some or all of their activities related to clinical documentation. When selecting a partner to provide some or all of these crucial services, thoroughly investigate to learn how well their staff understands your needs, the areas you serve, and your revenue cycle goals. What kind of training does your outsourcing partner provide to their coding and billing specialists? Even when outsourcing, you still need your own specialists on staff to track performance and ensure revenue integrity. No, our revenue cycle management occurs in house 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. If your organization outsources its revenue cycle management processes, you should communicate frequently with your service provider to ensure that you’re getting the quality services you need. With numerous service providers to choose from, oversight is key. Do they know your operations well enough to identify trends that could help your care teams improve their quality of care? Don’t let these services become a hidden liability in a constantly changing healthcare environment. If your organization conducts revenue cycle management in house, ensure that you build and grow a skilled clinical documentation team that can become an asset to the organization. Choosing your own processing software and education platforms will enable you to focus on areas of specific need for your organization. Work to recruit, hire, retain, and grow the best employees through continuous engagement and education. How productive are your clinical documentation specialists each day? Review each aspect of productivity and consider, on a scale from 1 to 100, how productive your clinical documentation specialists are each day. Charts reviewed 79 and above: Above average 78: Average 77 and below: Below average DecisionHealth reported that the productivity of medical practice coders varies widely by specialty. In their survey, per-day averages for charts reviewed ranged from 31 to 86 across twelve specialties. Compare your team’s averages to benchmarks for your specialty or areas of practice. Claims coded 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. Claims submitted 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. Denials appealed 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. While your metrics on any given day may have a minor effect on your overall bottom line, weekly, monthly, and quarterly averages can have a significant impact on the long-term health of your organization. Small process improvements driven by knowledgeable and well-trained staff members can raise efficiency and optimize revenue. Do you have a clinical documentation integrity or improvement (CDI) program? Yes, we have a Clinical Documentation Integrity Program Congratulations! Your organization is positioned to recapture more revenue than those without CDI. Revenue Cycle Intelligence reported that more than 90% of hospitals with at least 150 beds saw increases of over $2 million per year in revenue and reimbursements after implementing a CDI program. No, we do not have a Clinical Documentation Integrity Program 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. What is Clinical Documentation Integrity? 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. AHIMA describes CDI as the convergence of clinical care, documentation, and coding, which are vital to appropriate reimbursement, accurate quality scores, and informed decision-making. Most importantly, CDI supports high-quality care for a patient’s current care team and those that may treat that patient in the future. While the immediate goal of improving your revenue cycle management involves building and maintaining solid administrative processes, the impacts of fiscally responsible management extend far beyond that. When you work to ensure the integrity of your clinical documentation, you not only strengthen the financial health of your organization, you make possible better outcomes for patients and for your organization’s community of clinicians and providers. What can you gain from RCM/CDI education? Your clinical documentation staff likely includes members with varied professional backgrounds, including former clinicians and healthcare administrators. Many entered the profession because it offered them opportunities to grow and to contribute in a greater capacity within their organizations. In addition, the areas of RCM and CDI are continuing to grow, creating competition to recruit and retain employees skilled in these areas. What can your organization offer to ensure that it can compete as demands in these areas increase? According to the Association of Clinical Documentation Integrity Specialists, professional development is one of the most important things employers can offer. A 2021 survey of clinical documentation specialists revealed that continued learning and professional growth are two of the most important factors for employee retention and for equipping them to do their jobs well. Submit claims quickly Submit accurate and complete claims Prevent denials Better job satisfaction and retention Support for your organization’s bottom line Better patient outcomes Get Started with Relias Relias provides solutions for the entire revenue cycle, enabling you to offer comprehensive education, ensure accurate reimbursements, and increase staff satisfaction and retention. Provide up-to-date training across the revenue cycle to promote staff competence. Reduce denials by ensuring accurate documentation and coding the first time. Promote staff confidence and job satisfaction with always current continuing education. Get Started References American Health Information Management Association (n.d). Clinical Documentation Integrity (CDI). Association of Clinical Documentation Integrity Specialists (2021). Clinical Documentation Integrity Week Industry Overview Survey 2021. Bresnick, J. (2018, October 22). 93% of Healthcare Execs Seeking Improved Data Analytics, CDI, HealthITAnalytics. DecisionHealth (2016). Today’s MEDICAL PRACTICE: Coding Productivity Benchmarks Do you measure up? LaPointe, J. (2017, March 10). Top 4 Claims Denial Management Challenges Impacting Revenue, RevCycleIntelligence. LaPointe, J. (2022, July 5). Claim Denial Rates as High as 80% for Some Marketplace Payers, RevCycleIntelligence. Malloy, G. (2020, October 28). Top 3 Benefits of In-House Vs. Outsourcing Medical Billing: A Practice Manager’s View, Global Health Management Services. Medicare.gov (n.d.). Patient Medicare deadline: File a claim. MGMA Stat (2019, September 26). Strategies for Avoiding Common Insurance Denials, Medical Group Management Association. Moneypenny, M. (2019, June 4). The Comprehensive Guide to Timely Filing for Healthcare Insurances, Etactics. RevCycleIntelligence (2020, October 23). Best Practices When Outsourcing Revenue Cycle Management. Smith, K. (2021, Feb 1). Medical Claim Denials & Appeals: Statistics that You Want Know, DrCatalyst. Stewart, A. (2020, May 21). Which physicians have the most claims denied, resubmitted? A specialty breakdown, Becker’s ASC Review.