By Bruce Ackerman

Just as health care providers and the public were getting used to the many changes brought about by the Affordable Care Act, more upheaval is on the horizon.

Even before the new administration was officially sworn in, Congress leveraged the budget reconciliation process to begin the process of rolling back many of the ACA’s provisions. As the new administration moves to take action, impassioned partisan debate and public commentary about ACA repeal make it clear that the transition to replaced or repaired health care laws won’t be quick and painless. While it seems likely that a systemic overhaul will take months, if not years, it’s time to accept that major changes are on the way for health insurance infrastructure and mandates. Specifics have not yet been determined, but it’s safe to predict that providers will feel even more pressure on their bottom line.



According to CMS figures for 2015, annual U.S. health care costs surpassed $3 trillion, accounting for 17.8 percent of GDP. The federal government sponsored 28.7 percent of total expenditures. Pending reforms are aimed squarely at controlling those costs. Estimates vary, but the general consensus is that approximately one-third of these costs can be chalked up to fraud and administrative waste, and that doesn’t include the amount of time and frustration patients spend correcting erroneous medical bills.

The continuous pressure to increase the efficiency of the increasingly complex and competitive U.S. health care system impacts everyone involved. After years of rising out-of-pocket costs and frustrating transactions with insurance companies, health care consumers are demanding better options and more accountability. Providers are burdened by regulations, health IT implementations, increasing patient loads and insurance-related processes. Many insurance companies struggled to make a profit in the individual market.

To make it through the looming challenges, health care organizations need to keep a sharp focus on optimizing operations and administrative systems.

Rejected claims are a significant drag on bottom lines and productivity. Hospitals, clinics and private physician offices lose money by failing to capture reimbursements for services rendered and by spending extra staff time correcting and resubmitting claims. The California Nurses Association found in 2011 that the state’s insurers denied 26 percent of all claims the previous year. Similarly, the National Health Insurer Report Card shows top insurers deny claims at rates ranging from 11 to 27 percent.

The Academy of Family Physicians recommends that providers ensure that no more than 2 percent of their claims are denied, but the industry average is closer to 10 percent. Insurance experts agree that most of these denials are not due to coding errors or issues of patient eligibility. Rather, many claims are denied simply due to inaccurate or incomplete patient information: basic demographics, Social Security numbers and insurance plan numbers. Offices are often too short-staffed to resubmit claims, or fail to do so within the allowed time frame — essentially leaving money on the table. Even when claims are successfully resubmitted, the additional time and work protracts the revenue cycle, disrupts cash flow and cuts into profits.

In a pressure-cooker environment that leaves little margin for error, providers can deliver better customer service and reduce rejected claims by improving administrative processes. Automated intake procedures, digital data capture and identity verification are an essential first step. The Council for Affordable Quality Healthcare (CAQH) has estimated that full adoption of electronic transactions (reducing manual administrative processes) could save U.S. health care billions of dollars per year and millions of hours each week.

Capturing accurate patient data and porting it efficiently into digital records systems goes a long way toward producing clean claims and avoiding rejections. Advanced ID scanning and verification solutions increase the speed and accuracy of data entry, cutting down the amount of time patients spend waiting in line and filling out redundant forms. Front desk staff has more time to focus on caring for the patient and providing a better overall customer experience.

Automated patient registration processes using self-service kiosks or desktop or mobile card scanners can be integrated with EHR systems and other databases to ensure that patient data is up to date and verified. Scan-and-verify solutions significantly reduce errors in patient records and claims submissions while saving hundreds of keystrokes per intake. Submitting claims electronically significantly reduces the time between a patient’s appointment and the insurance company’s receipt of claim for that service. However, the efficiency of electronic processing is totally dependent on the accuracy and completeness of data initially fed into the system. Many practices are deploying ID scanning, verification and auto-fill technologies to quickly capture and integrate high quality demographic and insurance data from each patient.

Identity verification solutions also tackle the scourge of identity theft and insurance fraud, issues that may be compounded during the ACA repeal-and-replace transition. There will likely be some degree of upheaval as insurance providers join or leave the new system. Employers and individuals may change insurance plans more frequently as they navigate new options and obstacles. Providers will have to focus resources on responding to regulatory and funding changes. If they can handle the administration of patient accounts more efficiently, the overall transition burden will be eased.

A confluence of factors is reshaping health care into a more consumer-driven industry. Early federal reform proposals recommend shifting funding to health care savings accounts in order to give individuals more choice and control regarding insurance plans. As patients pay more out of pocket, they are more likely to choose providers based on price and value. The quality of their care and their experience as a customer will become more influential, compelling providers to control costs and optimize services. Leading providers are adopting best practices from other consumer-driven businesses, including cloud platforms and services that automate, record and analyze patient data. Analytics-driven solutions can help providers improve treatment, comply with regulations, integrate with third-party systems, manage revenue and assess risks.

Health care is inherently a dynamic, complex and high-stakes industry. As high profile, controversial government reform agendas put the industry on the hot seat yet again, health care administrators have to prepare for an uncertain future. As exigencies bear down from many directions, sustaining cash flow and maximizing revenue are fundamental to thriving through transition. Manual processes, patient data errors and high rates of rejected claims can be addressed with readily available technology solutions. Building stronger operational foundations today will enable your organization to develop the capabilities and resilience you’ll need for tomorrow’s challenges.

About the author: Bruce Ackerman is executive vice president of global sales for Acuant, a leading provider of data capture and verification solutions.