The number of Americans with insurance has risen in the past seven years, but they’re also shouldering a larger portion of their healthcare bills. This has created new challenges for healthcare organizations. By proactively addressing these challenges, organizations can maximize reimbursement today, allowing them to invest in the future.
A Shift in Health Insurance Coverage
Health Insurance in 2010
Health Insurance in 2016
While there are fewer uninsured patients, more patients are paying a larger portion of their healthcare bills.
People with insurance who have high deductible plans
Deductibles of more than $1,000 for those with employer-based insurance
People with insurance who are underinsured
3 Ways to Maximize Insurance Reimbursement
In order to maximize insurance revenues, healthcare systems need to be vigilant to uncover every opportunity to accurately capture charges and reduce denials. Areas of opportunity include:
Charging, Documentation and Coding
Medical Necessity and Authorization Denials
Alternative Payment Models
- Review charging and coding practices -- particularly around clinic visit/physician services which are often decentralized.
- Ensure charge preference lists are updated and tools are available to help capture common visit details.
- Establish processes for maintaining the Charge Description Master and completing daily charge reconciliation
- Create audit processes, feedback loops and training to identify and address issues.
- Study denial trends by service, provider and payer.
- Create workflows and communication channels between clinical and financial teams to review results and collaborate on solutions.
- Focus on creating connections between the right people and the right systems that support real-time responses to add-on visits and last-minute order changes. This will help secure authorizations and complete financial clearance while also addressing the patient’s care needs.
- Understand current and future strategies around risk-based contracts and other alternative payment models.
- Ensure revenue cycle processes are aligned to support new payment models.
- For example, under capitation models such as Comprehensive Primary Care Plus (CPC+), approaches should be established to reconcile prospective payments to services delivered later.
By developing effective patient communication strategies and taking a proactive approach to capturing charges and reducing denials, healthcare organizations can collect payments more efficiently to sustain growth.