Providers also need to offer clear, rational explanations of how much patients/guarantors owe, and the options available to pay that debt according to multiple studies. Those that can meet this standard are the ones who will succeed.

Larger deductibles and coinsurance costs also create a risk that patients will delay seeking care until their condition becomes unbearable or even forgo it entirely to avoid the unplanned expense. This approach is the polar opposite of value care, which relies on preventive care and early interventions to deliver better long-term health outcomes while reducing costs. This discrepancy must be resolved if we are ever to achieve true value care.

2. Advanced analytics will become a larger factor in denial management

One area where providers can have more direct impact on improving reimbursement is managing denials. At any given time, as much as 40 percent of a provider’s accounts receivable (A/R) portfolios are facing denials. This is an issue because, typically, only two-thirds of denials are recoverable. On the plus side, 90 percent are preventable, especially if you can attain a very granular root cause understanding of why claims are being denied.

Advanced analytics can offer that view, enabling providers to solve upstream issues so they can avoid most denials entirely. Providers can then take this information and use it to develop best practices that can be taught systematically to patient access staff, clinicians, coders and others. Getting to the deeper, root cause level of denials also often uncovers other important information that leads to continuous enhancements of systems of records and related software and subsystems such as EDI Claim Scrubbers.

Being proactive with good policies and procedures is a good start, but payer fee schedules, reimbursement guidelines and regulations are constantly evolving. With advanced analytics, providers can gain visibility into denials that question the clinical, medical necessity or missing information aspects of services rendered, giving them stronger footing to reach a mutual understanding with health plans more quickly. Providers can use deep and comprehensive longitudinal analytics to confirm they are meeting the terms of their contract and demonstrate why they should be reimbursed at the rates they negotiated with payers and in a timely manner. Both sides also gain insights that enable them to deliver more meaningful value to their patients/members.

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