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Customer Profile: Healthcare Claims and Denial Management
Reclaim Your Healthcare Claims and Denial Management with Monarch Data Pump
Healthcare practices and hospitals often struggle to get paid by insurers. Untimely claims and denial data result in wrongly denied or underpaid claims and other errors. Avoidable write-offs are incurred. This is often because needed data is buried within thick paper reports.
The Solution
Monarch Data Pump automatically transforms existing healthcare reports into data, customized and delivered across the organization, to proactively manage insurance claims and denials without new programming.
As the old joke goes: "My doctor gave me six months to live, but when I couldn't pay the bill, he gave me six months more!" If only health insurers were so flexible. Healthcare providers today must meet stringent filing demands for an insurance claim to be even considered by the insurer.
Claims and denial-related data are often buried within thick paper reports provided by healthcare information systems and third-party claims processors. Data bottlenecks often result: erroneous claims are submitted and rejected; wrongly denied or underpaid claims might go unchallenged. Expensive write-offs are sometimes incurred, because it is so hard to access and work with needed data.
Monarch Data Pump can help. Monarch Data Pump automatically mines data from your existing healthcare system reports, third-party denial reports and more, and delivers customized data to anyone in the organization, with no new programming. Healthcare organizations are discovering Monarch Data Pump is all they need to automatically create and deliver customized data for proactive claims and denial management.
Monarch Data Pump has met this important need with great success, says Rahul Patel, senior consultant for Synapsys, a Massachusetts-based healthcare consulting firm. Synapsys implemented Monarch Data Pump for AEC, a two-physician plastic surgery practice located at Beverly Hospital, in Beverly, MA.
"Many healthcare practices submit insurance claims electronically to a claims processing clearinghouse," explains Patel. "AEC uses McKesson as its claims clearinghouse. McKesson validates that each claim is in the right format, and can even correct minor errors on the claims submitted. The claims are then transmitted via EDI to each respective insurance provider.
"It is possible, however, that the claim may still contain errors not picked up by McKesson. Perhaps the patient's date of birth is incorrect, or the patient's insurance ID has a few numbers transposed. Such claim submissions are, for one reason or another, not 'clean' and are returned by the insurer back to the clearinghouse as a rejected claim. This rejection process can take as much as 30 days. Meanwhile, other claims are accepted as 'clean' claims and go into the insurance company's adjudication system for payment.
"The status of each claim is reported back to McKesson, which in turn generates a text-based rejection report," Patel continues. "Monarch Data Pump Server Edition is used to automatically open these claim documents and identify those claims which have been returned due to errors. Relevant data such as the patient name, ID, date of service, error codes, etc. are mined from those particular claim documents. Also, we have set up Data Pump to do an automatic lookup to an error code database, to include not only the error code number, but a text description of that error.
"We suggest giving serious consideration to Monarch Data Pump as an easily implemented solution to help automate and greatly improve the insurance claim submission and collection process."
"The end result is a single report, created using Monarch Data Pump, listing all claims returned due to errors and all relevant details. Previously, the office staff had to manually open the rejection reports, and visually scan it just to find those claims rejected and pending due to errors. Monarch Data Pump eliminated what was easily a daily 45-minute exercise sifting through each and every claims document! Monarch Data Pump gives AEC back substantial administrative time each week, which is used to do a better job of challenging claims that have been denied for other reasons.
"Every dollar earned from a successfully challenged claim goes straight to the practice's bottom line profit," adds Patel. "Plus, when it comes to healthcare claims, time is of the essence, literally. For all insurers, if a valid claim is not resubmitted within a set period after the date of service, the claim is automatically denied without further recourse. Monarch Data Pump helps eliminate such needlessly lost revenue, by helping to reduce the time necessary to reprocess a rejected claim. With Monarch Data Pump, we expect to reduce AEC's claim write-offs due to automatic denials by 95%! This also frees up AEC's office managers to devote time to dispute other claims that are denied for more substantive reasons, such as a dispute over the submitted procedure code."
Patel recommends healthcare organizations take a hard look at how much claims a healthcare organization is writing off on an annual basis due to automatic denials -- erroneous claims not corrected before the insurer's deadline. Another important consideration is how much office time is being spent on fire drills to hastily find and resubmit erroneous claims near the deadline. "This wasted administrative time reduces the remaining available time to contest other denied claims for other reasons," says Patel. "We suggest giving serious consideration to Monarch Data Pump as an easily implemented solution to help automate and greatly improve the insurance claim submission and collection process."
