By Frank Forte

After decades of reluctant adoption, the healthcare industry has embraced a dramatic technological transformation over the past 15 years. In 2008, a mere 9% of hospitals and 17% of office-based physicians were using electronic health records (EHR) systems. By 2021, those numbers had skyrocketed to 96% and 78%, respectively.

This digital revolution has streamlined many facets of healthcare delivery and billing. Yet formidable challenges remain, particularly in the revenue cycle, which has become increasingly complex. As EHR systems have become nearly ubiquitous and interoperability initiatives gain momentum, some healthcare providers may believe their revenue cycle challenges are solved. But the reality is more nuanced, especially regarding complex claims and denials management.
While EHR systems easily manage routine tasks and standard commercial claims processing, they often struggle to navigate scenarios that involve multiple payers, intricate coding requirements, varying reimbursement rules, and increasing denial rates. These challenges are compounded when dealing with specialized claims outside typical commercial insurance processing, such as for military payers.

The scope of these challenges is considerable. For example, roughly 60% of workers' compensation claims are being initially sent to the wrong insurers, causing significant processing delays and increased administrative costs. Veterans Administration (VA) claims face similar complications, with about 13% being denied based on various technical issues, including timely filing violations, coding errors, authorization problems, carrier selection mistakes, and eligibility verification failures. Perhaps most alarming is that between 25% and 33% of out-of-state Medicaid claims are never filed due to enrollment complications. Financially vulnerable Americans deserve better.

These statistics reflect a deeper problem: The growing complexity of healthcare billing and reimbursement has overwhelmed the capabilities of standard systems and processes. Each specialized claim type has its rules, requirements, and potential pitfalls. Providers require special expertise in handling such claims to manage the revenue cycle more reliably and efficiently.

Specialized expertise enables collaboration
For claims processing to work and serve all stakeholders, collaboration across the healthcare ecosystem is essential to success. The complexity of modern healthcare revenue cycle management demands a multifaceted approach that draws on the strengths of various stakeholders, including hospitals, payers, third-party administrators, and specialized service providers.

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