In-House vs. Outsourced?

Transcription

1 WHITE PAPER In-House vs. Outsourced? Best Practices in Injury Claims Revenue Cycle Management

2 2 In-House vs. Outsourced? Table of Contents Executive Summary 3 What an Injury Claims Specialist Provides 4 How an Injury Specialty Firm Achieves These Goals 4 Legal Expertise Makes the Difference 5 Benefits of Partnering With an Injury Claims Specialist 6 Reducing Hassles, Increasing Revenue 6 About RevClaims: 7

3 RevClaims 3 In-House vs. Outsourced? Best Practices in Injury Claims Revenue Cycle Management Executive Summary Hospitals and health systems encounter many challenges when handling injury and third-party liability claims. Managing injury claims is a very complex undertaking, requiring coordination between multiple non-standard payers, and posing numerous compliance risks adding to the complexity is a constantly changing state regulatory framework and determining potential coverages around atfault status. Typically, injury claims account for 5% or less of a health system s total claims. Due to its diminutive proportion to other accounts, hospitals allocate fewer resources in pursuit of recovery. Further, many health systems rely on cumbersome manual systems to process these claims because the information needed for billing is not known or presented at the time of treatment. However, if managed well, injury claims produce exceptionally high reimbursement rates (often even 100%), which helps offset declining reimbursement rates in other areas caused by health reform. Managing these claims requires a legal and insurance skill-set far different than what is needed for processing typical inpatient claims and most health systems don t have expertise in this area. A hospital revenue cycle management (RCM) department doesn t have the time or training to file and release liens or to review letters of protection and settlements. This often results in lost revenue and higher accounts receivable days. Partnering with an injury claims specialty firm doesn t take work away from a provider s core RCM team. Instead, it actually allows the hospital staff more time to devote to standard inpatient billing. There are two main reasons why injury specialists can help dramatically increase provider revenue while lowering accounts receivable (AR) days. First, they possess the necessary triad of skills legal expertise, familiarity with third-party liability insurance, and healthcare RCM strengths. And the best specialty firms have proven software platforms that automate and expedite injury claims management.

4 4 In-House vs. Outsourced? What an Injury Claims Specialist Provides Because of its single focus, an injury claims specialty firm can help hospitals and health systems expertly manage, process and recover claims from third-party liability and workers compensation with simplicity, speed, and success. An Injury Claims Specialist can significantly improve a provider s bottom line by getting claims paid faster and maximizing reimbursement with no financial risk nor headaches for the provider s core RCM team and IT staff. It takes a special team to swiftly identify, resolve, and recover payment for these types of claims. To adequately and adeptly handle injury claims, a team must include attorneys who handle the various legal interests involved with such claims, alongside insurance professionals who understand the intricacies of third-party reimbursement and workers compensation. To ensure success, the team must be anchored by healthcare RCM and IT veterans who have worked with and for hospitals and health systems of all sizes nationwide. 46% RevClaims was able to increase a community hospital s collection totals by 46% Motor vehicle accidents are only one component of injury claims billing. An Injury Claims Specialist must also have experience in dealing with claims involving burns, slips, falls and other catastrophic injuries. An injury specialist must also be adept at managing relationships by serving as the liaison between the provider and the patient. A specialty firm needs to reassure patients that the filing and payment of any insurance benefits will be handled swiftly and correctly. Working with an outside partner also reduces the provider s financial and compliance risks. The Injury Claims Specialist assumes all legal and regulatory risk on behalf of the provider, and is typically paid on a contingency basis. If the provider doesn t get paid, neither does the claims partner. How an Injury Specialty Firm Achieves These Goals An injury claims partner uses a highly accurate technology platform augmented by a team of legal and insurance experts to work every accident claim from start to finish. Managing injury claims requires flexibility and excellent communication. A superior firm will tailor its services to meet the unique culture and requirements of each provider. Attorney-driven teams are the key to success. Lawyers and paralegals, who are well versed in injury claims, know the nuances of every relevant state and federal law. Their knowledge is aided by insurance experts who know how to expedite third-party claims and by RCM professionals who are familiar with every type of healthcare claim and IT system.

5 RevClaims 5 With an attorney managing each case, the provider can be confident that every challenge, dispute, or appeal will be handled effectively and efficiently. A superior partner will provide a technology platform that delivers exceptional ease of use. The provider can turn over existing claim information in any format, knowing that the partner s technology is equipped to manage that data seamlessly. To achieve the best results, the technology platform must also provide these capabilities for its provider clients: Easy integration into the provider s IT infrastructure Technology that is fully HIPAA-compliant and accessible only to the provider Electronic billing pathways to the more than 2,500 injury claims payers, including every major auto insurer and workers compensation carrier Electronic 837 file upload with e-certified delivery from the provider clearing house An easy-to-use online portal so that RCM team members have 24/7, real-time access to claim activity Ability to normalize and correct bad data before claim submission, resulting in far fewer errors and fewer incomplete or denied claims Support for ipad apps offering a real-time questionnaire and search engine to assist with collecting claim information at patient registration Legal Expertise Makes the Difference Partnering with a superior injury claims firm gives you unparalleled access to experienced attorneys who: Establish the pace for handling claims by guiding paralegals and liability claim experts interactions with liability parties and insurance providers increasing recovery and reducing AR days Offer critical analysis in the legal nuances of insurance and workers compensation law Manage the filing of appropriate statutory liens and impairments of liens Help ensure that clients are compliant with Medicare MSP rules, Medicaid payer of last resort regulations, and network agreements regarding third-party liability Negotiate higher settlements with insurance adjusters and plaintiff attorneys to maximize reimbursement Oversee the appeal process to ensure proper and/or greater reimbursement for workers compensation claims

6 6 In-House vs. Outsourced? Benefits of Partnering With an Injury Claims Specialist Providers turn to qualified injury claims partners because they deliver results in the form of faster claim payments with maximum reimbursements and no financial/compliance risks or headaches for the provider s core RCM and IT teams. A superior outsourcer should be able to deliver benefits like these: A thorough, start to finish approach, including lien filing and enforcement, litigation, review of managed care contracts, and more Reduction in the provider s current number of claim denials and accounts receivable days for injury claims Increased revenue in the first 90 days Charge reimbursement average greater than 80% in lien states and greater than 30% in non-lien states No regulatory penalties because outsourcer is 100% compliant with Medicare Secondary Payer (MSP) rules, Medicaid payer of last resort regulations, and network agreements regarding thirdparty liability 20% Through modifying or implementing new procedures, RevClaims was able to identify 20% more third party liability accounts for a community hospital in a non-lien state Contingency-based compensation; if the provider doesn t get paid, the Injury Claims Specialist team doesn t get paid No fee for returned accounts to be billed to health insurance Reducing Hassles, Increasing Revenue Injury claims are usually a big headache for most providers core RCM team. These claims can be incredibly time-consuming and require both legal and third-party liability expertise that the hospital RCM team doesn t always possess. You don t expect a primary care physician to have the specialized expertise of a neurosurgeon. Similarly, you can t expect a staff that s devoted to conventional healthcare RCM to handle injury claims, like experts who do it every day. Effective injury claims management requires both a powerful technology platform and a team of legal and insurance specialists to manage the claims. The platform and processes can integrate seamlessly with a health system s existing staff and software.

7 RevClaims 7 Transitioning injury claims to an outside specialty firm doesn t take work away from the provider s RCM team. The outside partner frees them from the frustration of managing claims that require specialized training and gives them more time to productively manage conventional claims. The bottom line is that Injury Claims Specialists can boost provider revenue while reducing AR days. Injury claims that are managed well get reimbursed at very high rates. In this era of declining reimbursement from government payers, greater reimbursement from injury claims is a revenue stream too important to ignore by any provider. About RevClaims: Headquartered in Jackson, Mississippi, RevClaims is a recognized leader in injury claims outsourcing. The company s attorneys, paralegals and liability claims specialists work with healthcare providers nationwide to speed claims and increase revenue arising from motor vehicle accidents, slips and falls, burns, catastrophic injuries and workers compensation cases.

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