Payers and providers connect, both formally and informally, through the reimbursement process. In past times, the relationships were stormy. Today, market forces push the need for better understanding of margin defense and revenue cycle performance. Streamlining internal operations addresses many of these new market demands. For example, patients demand higher value for care pushing more review of claims which push greater need for consistent documentation.
Denied claims cost healthcare organizations a lot of money each year. Often times, the denials could have been easily avoided. Let's look at the anatomy of a denied claim.
Claims get denied for a variety of reasons - some of them are extremely simple to remedied, while others may require entire shifts in your organizational structure. The question is, could any of them been prevented? Many claim denials are completely avoidable - and in fact there are practical ways you can combat claim denials. Look at the following common claim denial reasons and see if any of them have happened to you recently.
The AMA reports that up to 5% of claims are denied, and that number is only expected to rise (perhaps by as much as 200%) with the initial implementation of ICD-10 later this year. Medical billing and coding, which is undergoing enormous changes with the implementation of ICD-10, is always an area where additional training for staff can be a positive investment in denial management. Providing continuing education for coders can help them be better prepared to identify potentially problematic documentation, and be able to code with the highest level of accuracy. It’s often been said that the best defense against denials is — frankly — avoiding denials, but if that’s proving uneasy, if it seems to be near-impossible, the next best defense is to do a root cause analysis so that you understand why the denials continue.
It's easy to hear the word 'merger' and think of negative associations. We think of the big, bad companies swooping in and buying out the helpless little guy who didn't stand a chance. Right? But when it comes to hospital mergers in 2015, it doesn't always mean bad news. Mergers offer their fair share of benefits to both smaller organizations and the communities they serve. In this post, we'll examine a few ways they do just that.
Back in 2013, Medicare proposed changes to its practices in reimbursement for telemedicine by adding seven new codes for this type of remote healthcare. These changes have been slowly making progress and put into action by practices and healthcare systems who are looking to increase their number of patient visits with the aid of technology and telehealth.
We would like to suggest a different approach that promulgates that lean implementation should begin at the microlevel; if a lean project is to be implemented only for a specific area, then the definition of “senior management” will turn out to be the “senior management of the specific area where the implementation is conducted.”
We mentioned that the lean philosophy calls for value creation through elimination of waste. These wastes are common in all industries and are not unique to healthcare. The following is a summary of these wasteful activities:
Recipes for implementation and lessons learned from failures have been reported; the common threads of these were that organizations need to change at a behavioral and cultural level and this should be translated directly into an endless process of continuous improvement. Despite these being framed in the realm of tangible strategic business direction, “cultural changes” and “endless improvement” are abstract concepts; furthermore, these principles imply that there is no horizon for successfully completing the task because the improvement process is infinite.
In healthcare, as in numerous other industries, lean management is gathering increasing momentum. In a 2013 article for the National Center for Biotechnology Information titled Lean Management—The Journey from Toyota to Healthcare (©2013 Teich and Faddoul), Sorin T. Teich, D.M.D., M.B.A., and Fady F. Faddoul, D.M.D., M.Sc. provided a comprehensive overview of what lean management is, and how its principles can be applied to the healthcare industry: