Implementing the right solution is key to getting paid faster and with less friction.
Healthcare B2B payment processes are complex and often pose challenges for provider organizations receiving the payment from a payer. Remittance advice that arrives separated from payments, complex billing codes and a historically inefficient revenue management cycle result in frustration for employees and significant financial strain for healthcare providers, to the tune of $25B in avoidable spend. Economic factors such as a tight healthcare labor market and continued inflation have presented challenges for providers, many of whom spend extra hours per week attending to administrative duties themselves.
While many providers have modernized their payments process and interact with automated systems or portals supplied by the payer, there is still room to improve processes to ensure a smooth outcome, particularly in cases where providers can consolidate multiple long-tail payers (i.e. receiving infrequent or small payments over a long period of time) into a single management platform. Building on automation adoption is key and leveraging emerging, user-friendly solutions can help providers retain time, revenue and staff that may have been lost to frustrating, inefficient processes.
Problem 1: Increased Transactions, Reduced Functionality
Electronic volume in the past year increased for the medical (30%) and dental (18%) industries and continues to account for the highest percentage of total volume for both industries, according to the 2022 Council for Affordable Quality Healthcare, Inc. (CAQH) Index Report. The increasing amount of electronic payments can quickly overwhelm a provider’s revenue management systems, many of which are not specifically designed for such tasks. Providers often rely on their EHR system to manage the administrative tasks associated with getting paid. However, “there are many built-in nuances to the software management systems that are used by providers,” Alasdair Catton-Chastain, Senior Manager, Provider Experience at Zelis states. “Sometimes, a provider may need additional functionality which is not included with their service pack. Other times, the system version is outdated, so it doesn’t support the ERA coming back in.” This patchwork of technology can contribute to frustrations with claims management rather than solve for them.
Problem 2: Manual Processing Errors
Paper or fax remittance advice or explanation of payments exacerbate the challenges created by a siloed revenue cycle management process, with claims payment being a major pain point in that process.
Healthcare providers may receive claims payment via EFT from the many of their payer partners. However, they need Electronic Remittance Advice (ERAs) to explain the payment, whether it was made electronically or by paper check. ERAs provide reasons why a reimbursement may have been adjusted and allows providers to automatically associate the payment with the original claim and the ERA itself in their systems.
But when explanation of payments and the payment itself are sent manually via mail, fax, or check, it requires manual processing and leaves room for human error or misinterpretation. Consequently, this can create headaches for providers and their patients when the billing office sends off a patient bill.
”Those types of mistakes don’t typically come out until audit time or the end of the year,” Catton-Chastain continues. “That makes it very difficult when there’s a deficit in account receivable versus what the system is saying should be there.”
Problem 3: Fragmented Payments Platforms
Providers normally enroll in electronic EFT and perhaps ERA with larger, high-volume payers to get paid quickly and in an automated fashion. However, these connections can be cumbersome and time-consuming to maintain across multiple payers. This still leaves most providers managing dozens of portals every day to track payments and ERAs, if partial or fully electronic payment remittance is an option. Where infrequent or small payments are typical, known as a “long-tail payer,” this is particularly cumbersome to maintain.
In a fragmented system, enrollment is another obstacles. “Providers also frequently change bank information, add new partners, or see patients with new insurance plans—meaning enrollment is a never-ending process,” Catton-Chastain adds. Oftentimes, a provider will have one or more staff members dedicated to just electronic payment management as they must enroll with each of their payers separately.
Solution 1: Automation
Providers can optimize the enrollment process through an aggregated payer EFT and ERA solution.
Enrollment is a key obstacle and time suck for providers when they want to accept electronic payments via ACH (similar to direct deposits). Ideally, a solution needs to allow a provider to enter their bank information just once, with the solution then using that information to enroll the provider in all of its payers’ ACH. When a payer new to the provider wants to reimburse the provider, the provider does not have to then newly enroll with that payer. In this way, when the provider changes bank information, adds new partners or offices, they only have to change the information in one place for all their payers.
Technology is also key to processing electronic claims payments the way providers want, whether it is through an ACH, virtual card, or check. Providers can receive electronic ERAs in a consolidated format, which allows them to better track payments, including what they billed, what the payer reimbursed, and why the payer reimbursed the amount they did.
Electronic solutions enable providers to get paid quicker and provide transparency into the payment process for improved reporting, tracking and patient billing. CAQH calculates a time savings opportunity of 15 minutes per transaction for medical claim status inquiries alone with a completely digital, automated process. Automating claim payments and remittance advice can save another four and seven minutes, respectively. With faster, more accurate payments, providers can focus on communicating financial responsibility to their patients—a major selling point in today’s consumer-driven environment.
Solution 2: Data Management
Electronic remittance advice contains highly detailed, complicated information that, when sent in paper form, must be transcribed fully and accurately for providers to send timely, correct bills to patients. Adoption of electronic remittance advice saw a 19 percent increase according to the 2022 CAQH Index Report, the largest in the industry. Receiving remittance advice electronically can improve the process and reduce the risk of over-billing patients, which has long-term consequences.
Time is of the essence in healthcare, especially as patients act more like the consumers they actually are across other industries. “The quicker you understand what you’ve been paid versus what you billed, the quicker you can put in a claim for secondary insurance or send out a bill to the patient for their responsibility,” Catton-Chastain says. And this is important to patient retention; fifty-six percent of patients said they likely would switch providers after a poor billing experience.
Solution 3: Streamlining Payment Processes
A truly digital claims management system can bring together payers and providers to not only streamline the management of claims but the technology behind electronic payment, remittance advice and other necessary functions.
A singular, seamless platform for ERA and claims payment is key to streamlining healthcare claims management and reducing the burden of working across multiple payers. A solution that enables providers to enroll and view claims from across their payer ecosystem allows them to access payments and information faster to better serve their patients. An integrated solution means ERA and other data translate to the proper systems and patient accounts.
Providers also have one place to communicate with payers in this multi-modal payment environment. For office staff, it also means less time on administrative tasks that do not add value to the overall patient experience.
A singular portal has the potential to increase the security of healthcare payments versus managing multiple portals with different credentials and security systems, and with bank information in dozens of different places. A secure solution can also integrate with existing IT and billing systems to save providers time and the extra cost of implementing more software.
A Single System Solution
A consolidated, secure solution that enables payment and remittance options that match providers’ workflows allows them to not only realize potential savings from automation but get paid quicker both by payers and their patients, increase security and streamline administrative work.
Consolidation of electronic claims data delivers the information providers need to measure financial performance alongside quality and outcomes. All the while, a single system reduces the administrative overhead of managing multiple portals and systems, especially in a more remote world. Implementing the right digital solution is key to overcoming the challenges of claims data access and management.