A recent report from Kaufman, Hall, and Associates on behalf of the American Hospital Association
shows that in 2021, hospitals could lose over $120 Billion in revenue. If the situation remains
under control for a more significant part of the year, the minimum value of revenue loss would still
stand a little over $50 Billion. In these dire financial conditions, all health systems, big and
small, are doing their best to ensure that they stay afloat with a steady revenue cycle and regular
cash flow.
However, many health systems have accused insurance companies of “revenue grab,” which has worsened
their finances and revenue cycle. Downcoding and delayed payments are some of the most common
grounds of accusations in recent times. However, the insurance panels have reiterated that they take
time to check through the details of the claims to make sure that the health systems do not charge
above the reasonable level. Considering both arguments, the health systems need to take sufficient
measures to ensure that their cash flow is vital.
Healthcare BPO can act as great supporting pillars for healthcare organizations to manage their
revenue cycle and overall finances. Read on to know the current issues bothering the organizations
and how BPO services can help them.
Common Issues of Revenue Grab in 2021
Downcoding remains one of the most common issues that the providers are facing this year, leading to
severe losses of revenue.
After the claim submission, providers from some reputed healthcare systems have complained that
their complex patient visits have been downcoded to a lesser and more simplified form.
In a recent press statement, an independent clinician Dr. Will Sawyer accused Anthem of downcoding
all his claims repeatedly, leading to decreased cash flow in his practice.
According to his statement given to Medscape, the most frequent instances of downcoding occurs when
his billing team submits a claim with appropriate codes for 30-39 minutes of moderate
decision-making patient visits. He often finds they have been changed to 20-29 minute low
decision-making visits when the claims are reimbursed.
This leads to a loss of $18 per claim. For every claim that is downcoded, the clinic faces a
considerable loss of revenue every month, which affects the bottom line of the practice.
According to another report from Kaiser Health News, the leading health insurance panels like
UnitedHealth and Anthem have been delaying payments for the claims submitted.
This is also another cause of concern for the providers as they feel that the billing cycle keeps on
mounting without satisfactory results due to this delay.
However, the health insurance companies have also come up with their statements as to why the delay
and downcoding have taken place.
The insurance panels cited the most common and obvious reasons are related to the constantly
changing medical billing ecosystem due to the pandemic.
What are the payers saying?
Payer networks like Anthem and UnitedHealth have explained why they have been altering the coding of
the claims or delaying the payments, for that matter.
Apart from the apparent alterations due to changing situations of the pandemic, the health insurance
companies have witnessed changes in pricings of the health systems.
While some of those changes are absolutely necessary for the regulation of the business, some have
been unfairly priced or wrongly billed to garner more profit.
According to the health insurance companies, the well-being of the patients is their primary
concern. Hence they must look out for minute discrepancies to ensure that the patients are fairly
charged.
In some cases, adjusting to the new reimbursement rules has been challenging for many organizations,
which has led to unnecessary delays in the release of payments.
Pre-authorization still remains to
be one of the most contended issues of reimbursement between payers and providers.
Payers maintain that pre-authorization is the only way to guard patients against unnecessary medical
procedures and keep their hard-earned money safe.
On the other hand, providers feel that too many rules and regulations regarding the
pre-authorization system continue to hamper their revenue cycle management and affect the clinical
outcomes of their patients.
Healthcare BPO working on Medical Billing
Properly valued timely reimbursements are incredibly crucial for the health systems to manage their
finances and upgrade their care systems.
Though revenue grab has been an issue cropping up time and again, both sides have had significant
arguments regarding the reimbursement problems.
For health systems to ensure their reimbursements on time, the billing system needs to be of top
quality, which is often not the case with a limited in-house team.
Healthcare BPO companies are experienced in handling the changing landscape of the American medical
billing system.
Given the issues of revenue grabbing, healthcare BPO companies make sure that the appeal processing
is smooth, and you get your reimbursements by submitting clean claims in the first instance itself.
Most of the denials or rejections come from the insurance companies regarding incomplete paper
proofs or documentation errors. Healthcare BPO companies make sure that your claims are properly
supplemented with the required documents.
If the insurance companies return the claims, healthcare BPO companies have dedicated teams with AR
calling support.
If the claims processing leads to an appeal filing, the professionals will take care of the
processing of the step-by-step appeal and help you compose the proper letter to ensure that all
points are thoroughly checked.
Overall, healthcare BPO companies act as a support team of experienced professionals, making the
billing system error-free and more compact.
If you are looking for comprehensive support in your revenue cycle management, get in touch with a
leading experienced healthcare BPO company to
evaluate your finances and chalk out the most suitable plan for you.
We hope this blog helped you understand how revenue grab issues can decrease cash flow, and you can
use healthcare BPO companies to help you. For any queries, please drop a comment below. Please
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