Processing claims is not a cookie-cutter process. Payers have different rules and workflows. Federal regulations and mountains of inefficient paperwork cost physician practices time, money and peace of mind. As a result, providers are always looking for practical steps and common sense technology to improve revenue without sacrificing workflow.

At Doctors Care, a multi-state network located primarily in the southern United States with 37 locations and 684,000 annual visits, we re-engineered three steps within our revenue cycle process to reduce denials, control claims and ensure proper reimbursement. Since we do not have an electronic medical record (EMR), we relied on our practice management, revenue cycle, clearinghouse and payer technologies to support the change. Efforts focused on the back-end of the revenue cycle and included the following goals:

-                     Improve clean-claim submission rates (reduce denied claims).
-                     Establish better communication and reporting through technology.
-                     Centralize payer updates and education across all locations to reduce confusion.

Clean claims save time 
Time invested on the front end of a process saves two to three times the effort and frustration when something has to be resolved on the back end. This is particularly true for claims processing. At Doctor's Care, we hold our claims for four days within our HealthPort practice management system. This gives us time to ensure any missed charges are collected and posted to the claim.

Since our clinical documentation process is paper-based, charges are not always reported in a timely manner. In the past, we would submit a corrected claim when a missed charge such as urinalysis, blood stick or other charge was added. These corrected claims caused issues with payers and additional time for our staff -- not to mention, a higher rate of denials. Finally, the four-day hold gives us the opportunity to review and enter all of Friday's charges before submitting claims on Monday. We ensure charges are captured, perform preventative maintenance on the claim and reduce denials.

Technology lends a hand
We incorporated two technology components into our process as a second step in achieving our goals: a revenue cycle management application and a direct connection with four payers. Together, these applications further reduce denials and improve communication.

Once released from the practice management system, claims go to the HealthPort Revenue Cycle Management application where they are checked for a variety of items (e.g., central server edits, HIPAA edits, missing NPI numbers, units for injections, etc.) before electronic submission to payers or the clearinghouse. Each payer has its own unique requirements and some of these have been programmed into the system. At Doctor's Care, about 5 percent of claims errors and are fixed using this process. While the system is not a complete claims-scrubbing application, we submit a greater percentage of clean claims upfront instead of wasting time, effort and money on the back end working denials. And when denials do occur, we have a claims-denial process in place. We continually analyze different denials by payer and track denials within our practice management system.

The second piece of technology that has improved our revenue cycle is a direct connection between HealthPort and four payers: South Carolina Medicaid, Medicare, Tricare and Blue Cross Blue Shield. Within minutes, we can see if a claim will be accepted or rejected and track claims online. If there is a problem with a claim, our staff can make an immediate fix. Staff members no longer have to fumble through paper reports to manage and correct claims. For these four payers, we don't need a separate clearinghouse; as a result, we get quicker response and adjudication. Vendors who already have direct connections established are willing to support this initiative. In the long run, everyone wins through instant access to claim status, more control over the process and less phone calls.