In the rapidly evolving healthcare landscape, "claims adjudication" is a term that carries significant weight. As a crucial link between healthcare providers, patients, and insurance companies, claims adjudication ensures that medical bills are accurate and that reimbursements are appropriately dispensed. With the confluence of modern technology and strategic approaches, the process of claims adjudication is undergoing a significant transformative phase.

The Necessity of Modernizing Claims Adjudication

Claims processing, in its traditional sense, has been fraught with challenges. One primary issue is the high volume of claims, which can be overwhelming and lead to errors and delays if not managed effectively. Coupled with this, manual claims processing methods can be time-consuming and susceptible to human error, resulting in incorrect payments or denied claims. Further, intricate healthcare regulations and continually changing coding standards compound the complexity, making it difficult to maintain accuracy and compliance. 

By modernizing claims adjudication, payers can not only streamline their workflow but also significantly enhance accuracy, speed, and customer satisfaction. With the current workforce shortage and rising inflation costs, it’s becoming necessary to optimize workflows wherever possible. 

Revamping Claim Adjustment with Technology and Outsourcing

Technology plays a pivotal role in transforming the claim adjustment process. Cutting-edge solutions like AI and machine learning can automate many routine tasks, significantly reducing human error. They can analyze vast amounts of data quickly and accurately, spotting anomalies that could indicate errors or potential fraud.

Moreover, digital platforms can integrate multiple data sources, providing a unified view of claim information. This integration enhances accuracy during the medical bill review process, resulting in more efficient claims adjudication.

In the midst of the ongoing workforce shortage, payers are finding it increasingly difficult to maintain an efficient and effective in-house team for claims adjudication. Staffing issues not only create bottlenecks in the claims processing pipeline but also stretch resources thin, leading to mistakes and inefficiencies. Outsourcing claims adjudication presents a viable solution to this challenge. 

By partnering with specialized service providers, payers can leverage the expertise of trained professionals who can effectively manage the complexities of claims adjudication. This not only alleviates the burden on in-house teams but also allows for increased focus on core business functions. 

Outsourcing also brings with it the benefits of advanced technology and automation capabilities that these specialized firms possess, enabling a faster, more accurate, and cost-effective adjudication process. As a result, outsourcing claims adjudication is increasingly emerging as the strategic choice for payers seeking efficiency, accuracy, and scalability.

Strategies to Implement 

For an optimized claims adjudication process, payers can incorporate a variety of strategies. Firstly, leveraging technology such as AI and machine learning can automate routine tasks, reducing manual errors and speeding up the process. We’ve already mentioned this so let’s move onto the next strategy. 

Secondly, regular audits can help ensure ongoing accuracy and compliance. These audits can identify systematic issues early, allowing for proactive resolution. Thirdly, investing in staff training is crucial. Well-trained staff can better navigate the complexities of healthcare regulations and coding changes, and apply appropriate processing rules by each line of business, resulting in more accurate claim processing. Alternatively, it may be worth looking into and prioritizing outsourcing. 

Lastly, a clear communication strategy can enhance transparency in the process. By keeping all stakeholders informed throughout the claims process, payers can foster trust and build stronger relationships with both healthcare providers and patients. In summary, a combination of technology, regular auditing, staff training, and clear communication can significantly optimize the claims adjudication process.

Enhance Your Claims Adjudication Workflow with Exela

With over 20 years of experience and over 24 million claims edited and adjudicated annually, Exela understands and overcomes the challenges and obstacles of claims adjudication. We combine experts with technology to deliver a streamlined Claims Adjudication solution that scales to your needs, improves turnaround times, and provides a skilled team. Our workforce management team forecasts the volume and monitors the availability of the resources based on your requirements, providing continuous learning, cross-skilling and upskilling of the workforce while recruiting and training resources. Regardless of the change in claims volume, you have the resources ready at your disposal.

With extensive training, we ensure that our team has a wide variety of claim-type expertise giving them experience in end-to-end payer services. To make sure your company meets compliance standards, we provide a dedicated subject matter expert team that continually monitors changes in regulations that impact claims processing rules. Any change in regulation or payer policies is updated on our training and reference materials and delivered to our teams.

To help streamline the adjudication process, we supply a custom-built automation solution that simplifies workflows by taking over repetitive manual processes. The software tracks data from various systems making it easier to review the data and facilitate accurate and quick decisions. With the combination of our proprietary technology and our expert team, you experience lower costs, faster delivery, and improved reliability and productivity.

Take a Step into a More Modern Process

The road to modernizing claims adjudication is not without its challenges. However, with the right blend of technology and strategy, payers can streamline their claims processing and enhance their claims adjustment capabilities. With Exela’s long-standing relationships with large commercial payers and over 1,000 specialists, we have the expertise, consistency, and ability to unfailingly adapt to industry changes. Let us help you experience a modernized claims adjudication process that will provide enhanced efficiency, accuracy, and cost savings. Learn about our Claims Adjudication services today!

The relationship between providers and payers has often been seen as fraught with tension and mistrust built between the two parties. However, this is a common misconception. Providers and payers continually work toward a more collaborative relationship, using technology as a way to enhance their collaboration. 

While there may be challenges between providers and payers, technology has smoothed the path, making it significantly easier for the parties to communicate and share data. Automated claims processing has proven to be an effective tool for both providers and payers to streamline processes, quicken outcomes, and enhance communication. Through this healthy collaboration, providers and payers can create a better experience for all stakeholders.

How Providers and Payers Interact 

Providers work one-on-one with patients building strong relationships with their patients, providing care and treatment, and ultimately submitting claims to payers for reimbursement of services. Payers can provide a different viewpoint, while considering patient care, they focus on financial risk management. By combining these two experiences, providers and payers work toward a common goal of providing quality care, enhancing patient engagement, and achieving revenue goals and reduced costs. 

The general interaction between provider and payer is a tale as old as time in modern America. When a patient wants to set up an appointment with a provider, the provider will confirm if they accept the patient's insurance along with confirming any pertinent benefits. Assuming the provider accepts the patient's insurance, the patient will then visit the provider, wherein the practitioner will detail notes regarding the patient's health and subsequent needs. This medical record is directed through coding, billing, and claim generation prior to sending to the payer. The payer receives the claim, reviews, accepts, suspends, or denies it. That’s the story in a nutshell. 

The relationship between provider and payer is constant, both entities looking to save costs while providing the best customer experience they can.

The Challenges on the Road to Collaboration 

Despite providers and payers having a collaborative relationship, there are still many challenges that they face including:

Difficulty sharing data and communicating -  Payers and providers need to have the technology available to share data and communicate easily. Without this technology, the entire process could be quite lengthy. Exela’s automated claims processing solution provides a mechanism for digital exchange of documents and communication, and identification and correction of certain-to-be-denied claims, simplifying the process to be smooth and efficient. 

Delays in communication - Traditional communication involves mail and telephone, both of which may cause delays in sharing information and can be difficult to track. On the other hand, a digital communication channel enables 24/7 contact and provides an auditable trail if either party needs to refer back to any previous communication. 

Inefficient manual work - Paper documents are still common in the healthcare world creating manual work and delayed processing. Going digital enables efficient and accurate processing, while enhancing user experiences.  

Automated Claims Processing Saves the Day 

The answer to helping payers and providers create a more seamless collaboration is technology, specifically automated claims processing. Exela's PCH Global solution enables claims processing, optimizing the claims submission process driving successful reimbursement outcomes. PCH Global performs eligibility checks, clinical validation, and automates claims editing and submission. For payers, PCH Global offers automation of the full claim cycle including enrollment, claim submissions, processing adjudications, and processing payments.

PCH Global provides direct digital communication between all parties resulting in reduced friction and streamlined processing. Exela's automated claims processing platform can reduce pended claims by more than 30%, reduce claims redetermination requests by 21%, and reduce clinical edit exceptions by 24%.  

By using PCH Global, providers and payers can easily communicate, manage claims, and collaborate to ensure that both parties are satisfied. It's time to create a beautiful alliance between payers and providers with automation leading the way.

Technology Paves the Way to Success

A successful collaboration can provide the best reimbursement outcomes for payers, providers, and patients. Communication is the first step to collaboration and automation can smooth out any bumps along the way. Automated claims processing such as Exela’s PCH Global can provide the leverage all parties need in order to overcome many of the challenges collaboration comes with. Make this collaboration a win-win with Exela’s PCH Global.

Revenue Cycle Management for healthcare organizations has never been more important. Put simply, this process involves optimizing revenue integrity by reviewing every administrative and clinical function contributing to the collection of revenue and applying best practices to ensure maximum reimbursement for healthcare services in a timely manner.

The healthcare revenue cycle is complicated and intricate, with many factors that impact who pays, how much they pay, and how they pay. Patients may have no health insurance and are billed directly. Others have Medicaid or Medicare. Many are covered through a private insurance plan, often offered through their employer, which could involve any of the numerous US insurance companies - and in some cases multiple companies in collaboration. Mix that with the wide range of visit types and procedures, as well as coverage terms like deductibles, copays, and coinsurance, and you’ve got an environment ripe for errors and missed opportunities.

Clearly, in today’s complex and fluid healthcare industry revenue cycle management is about much more than just billing and collecting payments. Fortunately, with the help of digital solutions and third-party administrators who specialize in healthcare billing, healthcare providers are able to manage the complexity of these billing cycles, maintain reliable cash flow and deliver high-quality care to their patients. 

The Goal of Revenue Integrity

According to the National Association of Healthcare Revenue Integrity (NAHRI), the goal of Revenue Integrity is “to prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.” In other words, identify missed income for healthcare providers, determine the cause, and find ways to mitigate the issue in order to prevent it from happening with future payments.

Today, technology plays a crucial role in assisting providers, payers, and consumers in communicating efficiently, which breaks silos and improves durable revenue cycle management strategies. There are several critical areas that healthcare managers could focus on to ensure their medical facility optimizes its revenue cycle.
 

Reducing Claims Denials

As per the Healthcare Financial Management Association, claim denials cost an average of $5 million per year to each healthcare provider. Just reducing this amount could save a lot! 

More than 20% of healthcare claims are routinely denied, with some providers experiencing up to a 40% denial rate. However, 90% of these denied claims could have been prevented. 

Organizations can recover this loss by utilizing analytics that can provide a deeper view and help dig into patterns to understand the reasons behind denials. Such insights can help health systems implement prevention plans and procedures for recovering the denials.

A significant portion of revenue leakage comes from inaccuracies and errors that lead to denied claims. Unfortunately, the process of correcting and resubmitting these claims can also be costly and time-consuming. That’s why it’s critical for healthcare providers to take steps to prevent their claims from being denied. One proven strategy to reduce denied claims is partnering with a claims processing company like Exela. Our Global PCH solution substantially reduces the number of denials by correcting errors before the claims are even submitted, allowing healthcare companies to confidently submit “clean claims,” which are more likely to be accepted by insurance companies on the first pass.

By leveraging automation technology, streamlining communication between providers and payers, and reducing the number of resubmissions, PCH is able to significantly accelerate the revenue cycle time.

To learn more about Exela’s PCH solution, and for an in-depth look at Revenue Integrity, download this recent edition of Exela’s quarterly publication PluggedIN. 

Fix Medical Coding Errors 

Clinical documentation has a tangible impact on the revenue cycle. Unfortunately, there are cases where bills are unpaid due to documentation errors or medical coding. Managing these discharged-not-final-billed (DNFB) cases is essential for hospitals to improve revenue cycle performance.

Medical coding is a complex process requiring proper coding and proper documentation. Medical coders require compliance with government regulations and private payer policies as well as education in medical terminology, diseases, anatomy, and physiology. Documentation comes from the physician who needs to accurately detail the treatment and care provided so medical coders know which codes and modifiers to use. Any error could cost the provider. 

Due to its complex nature, healthcare providers may choose to outsource their medical coding needs. LexiCode, our medical coding services, aids providers of all sizes, scaling to each organization’s needs with quality assurance and productivity monitoring. Partnering with LexiCode, providers experience timely medical coding resulting in steady cash flow.

Hone in on Revenue Integrity

A revenue integrity (RI) plan is an essential component of optimizing the revenue cycle. This includes accessing current workflows for inefficiencies, implementing improvements, and upgrading technology where it can help. Unfortunately, not all providers have the time and resources to create a proper RI plan.  

Exela enables healthcare providers to attain revenue integrity through integrated solutions and proprietary technology that address the entire revenue and reimbursement lifecycle. Our Revenue Integrity solution helps identify and recover underpayments, maximize reimbursement from third-party payers, and provides a streamlined RI process. 

Leveraging decades of experience with Exela and our cutting-edge technologies, we maximize reimbursements and dollars recovered, and reduce or eliminate related overhead, all while enhancing employee, provider, payer and patient satisfaction. To know more in detail, take a look at our PluggedIN focusing on Revenue Integrity. 

Digital transformation in healthcare continues to be a key topic in many healthcare leaders' minds. Healthcare providers of every size face the same challenge of improving patient care and engagement while managing costs. However, many obstacles create complications including limited staffing, outdated systems, payer contract complexities, and more. By embracing digital transformation, healthcare providers can begin to tackle these obstacles and accomplish their goals for the future.

Digital transformation in healthcare affects many aspects of the business from freeing up resources that can be devoted toward patient care and increasing patient engagement to improving operational and financial efficiencies. With AI, automation, and technological advancements, the healthcare industry stands to gain improved processes, quicker payments, and fewer claims denials.

Digital Transformation in Healthcare Starting with Automated Claims Processing

Claims management and processing is a major operation in need of digital transformation in healthcare. This is often a thorn in healthcare providers' sides because of its complexity. Claim denial rates are between 6% and 13%, which eats away revenue. 

These statistics highlight the importance of submitting clean claims right from the start. However, this is easier said than done especially when relying on manual processing and outdated systems. Many healthcare claims are being denied for simple reasons such as a spelling error, incorrect coding, missing patient identify information. Given that healthcare organizations' resources are stretched thin, it makes sense that claims processing would be vulnerable to human error.

Once again, digital transformation in healthcare can step in and smooth the process. Exela is a leading claims processing provider with a solution that enhances claim processing by unifying data from all incoming communication channels, performing pre-submission checks to create clean claims, and intelligently routing correspondence for optimal processing using automated decisioning. Exela’s Healthcare Claims Processing solution reduces denials and resubmissions by applying business rules to produce clean claims prior to submission. Using automation and artificial intelligence, Exela increases transaction processing rates and accuracy while reducing manual processing and rework.

Take Complex Claim Processing Further

According to a 2021 CAQH report, only 21% of medical administrative transactions are digital while the rest are paper. Exela leverages exclusive vendor contracts with leading health plans for complex paper claims processing.

Embrace digital transformation further with Exela's PCH Global solution, a powerful digital platform that not only provides a single point of access for claims management but provides a central bridge between all parties including the provider, payer, and patient. 

PCH Global promotes clean claim submissions by identifying certain-to-denied claims, thereby improving first-pass rates. Its iterative feedback loop technology helps the system continuously learn and improve to identify errors enabling proactive claims management with system flexibility as your contracts change. 

Finally, the system automatically tracks and records any addition, deletion, or modification to transactions along with user reference and timestamps providing clear audit trails and ensuring full compliance.

Digital Transformation of Remittance Payments

The 2021 CAQH report determines that the healthcare industry could save 48% of annual spending by transitioning to fully electronic transactions. Manual processing significantly slows down operations especially when human errors are taken into consideration. Automation streamlines this process reducing errors, posting payments quicker, and improving overall efficiency making it a terrific place for digital transformation in healthcare.

Exela's Medical Lockbox simplifies the healthcare payment process by digitizing and automating manual, paper processing tasks. Using a state-of-the-art scanning platform and intelligent OCR/data capture technology, Exela’s Medical Lockbox solution converts paper EOBs from any source into 835, electronic remittance files, payment reconciliation and posting to the healthcare organization's medical billing system. By streamlining the payment path, Exela’s Medical Lockbox solution reduces the time it takes for payments to post and allows quicker access to deposited funds. Submitting secondary claims or patient billing, depending on the patient’s coverage, makes the payment cycle faster from Primary, Secondary, Tertiary or Patient payments.

Not only does Exela's Medical Lockbox streamlines payment processing, but it also features a web-based denial management tool designed to increase the recovery rate on denied claims. This web-based management tool presents the original claim and all related remittance information in a single view simplifying the process for users to adjust the claim, bill the patient, or appeal the denial. Insights are gleaned through reimbursement metrics presented within Exela’s Medical Lockbox’s configurable reporting function. These insights are valuable with billing system audits and contracts negotiations.

Automated Contract Management

Healthcare payer contracts vary greatly, each having different policies, regulations, and parameters. The contracts of each insurance company are often revised and updated annually so healthcare organizations need to renegotiate several payer agreements every year.

Keeping track of the current contracts and any annual updates is an enormous task that burdens healthcare resources. Without a handle on contract management, healthcare organizations are vulnerable to underpayments which affect their bottom line. Contracts and underpayment management are yet another place where digital transformation in healthcare is needed.

Exela’s Revenue Integrity solution automates the contract management process, document scanning, indexing, profiling, loading and maintaining all third-party payer agreements. Agreement terms are tracked and providers are presented with notifications of important dates as well as amendments and updates. Instead of using limited resources to keep track of contracts, automation is ready to step in.

Exela’s Revenue Integrity solution also offers predictive contract modeling that provides accurate reimbursement calculations for current and future contractual agreements. By providing multiple scenarios and utilizing the most recent one-year patient data set, the platform presents the net dollar and percentage increase or decrease.

This solution also identifies retrospective, current and prospective underpayments from all contractually obligated third-party payers.

Summary

Digital transformation in healthcare opens many doors and it’s time providers embrace the opportunities available to them. AI and other technologies are ready to streamline antiquated processes, increasing efficiency and accuracy while freeing up personal time. 

The COVID-19 pandemic’s impacts have been felt across industries, but none more directly than healthcare. In many parts of the world, the healthcare system has been pushed to capacity - and that doesn’t just mean the doctors and medical staff. Non-medical support staff and operations have been stretched thin as well. Whether it's in a large hospital or small practice, claims processing and denials management play a critical role in maintaining the fiscal health of any healthcare organization.

Denials management is a necessary, and often overlooked, aspect of that process. It’s important here to note the difference between rejected claims and denied claims. A claim rejection means the claim was submitted to a payer with incorrect coding or missing data. Claim denials occur when a claim is repudiated by a payer after being processed. While denials are a natural part of the healthcare billing process, they can be costly, so most hospitals seek to avoid or reduce them.

One of the main goals of the denials management process is to uncover the root cause. The aim is to reduce the risk of future claim denials by modifying the process to prevent unnecessary denials and reduce the overall denial rate. A low denial rate indicates a healthy cash flow. Organizations with a high denial rate should take a look at the causes and make necessary corrections.

Hospitals forgo thousands of dollars annually in revenue through denied healthcare claims. A significant portion of claims are denied annually - the industry average is between 5% and 10%, meaning payers deny about one in every ten submitted claims. Unfortunately, an estimated 90% of these denials could be prevented with solid denial management policies and procedures.

Challenges of Claim Denials Management 

Here are some of the most common challenges that lead to high denial rates:

• Disconnected systems and processes - As businesses grow, new solutions are often developed or implemented as the need arises. This often leads to a broken, disjointed internal landscape made up of multiple processes, solutions, and systems that are either poorly integrated with one another or operate completely independently. This leads to massive inefficiencies, backlogs of denials, duplication of efforts, and increased costs. Bringing the entire system together into one streamlined process can significantly reduce the number of denials annually.
• Increasing complexity of claims processing - The health insurance landscape has, in many ways, been growing even more complicated than it was just several years ago. The growth of insurance marketplaces gave birth to an increasing number and variety of insurance plans. At the same time, there’s been a marked shift toward high deductible health plans, which place more of the financial responsibility on patients. When taken together, these two trends lead to an increased number of costlier claims errors and higher rates of denial.
• Lack of visibility - Many claims systems - particularly those built on manual processes or over a variety of disparate tools - don’t provide any insight into denials data. Without this visibility, revenue integrity teams are always playing catch-up, handling denials as they come, rather than identifying and addressing the root causes and preventing future denials.

Due to the costs associated with denied claims, many hospitals are understandably eager to minimize denials and the errors that often lead to them. Here are a few simple solutions that can help healthcare organizations reduce their claims denial rate.

Healthcare Business Automation

Manual processes always leave room for errors and often slow down the entire denials management process. Be it a small practice or a large hospital, manually entering and dealing with multiple payers is not easy.

However, nearly one third of healthcare providers still perform all of their denials management procedures manually on spreadsheets, according to a recent Healthcare Information and Management Systems Society survey.

Introducing business automation into such processes can offer transparency, reduce the chances for human error, and drastically increase the turnaround time, improving efficiency and cash flow. Automated denial management lowers the number of errors in the process while providing useful insights that can drive better decision making and more efficient allocation of resources in the future. 

Experienced and Trained Staff

Even with automated processes including automated denials management, having the right people involved makes a big difference. Missing or incorrect information is one of the leading causes of denied claims, and that can often be traced back to overworked or inexperienced staff. Staff members are often burdened by many administrative tasks and required to fill many different roles. They must also deal with constantly changing industry and regulatory trends and regulations, and not having the right staff can impact the revenue flow.

Automation and digitized processes can help ease the pressure on small teams by handling some of the more tedious and time consuming tasks. Some hospitals may also choose to partner with experienced medical coding services to bring in a supplementary workforce of qualified coders to help handle increased workloads.

Preventing Denied Claims 

As the old, appropriately medically-themed adage goes, “an ounce of prevention is worth a pound of cure.” For many organizations, the best way to bring down their annual denials-related costs is by preventing denials from occurring in the first place.

Exela’s PCH Global solution uses intelligent automation to identify “Certain to Deny” claims before they’re sent out. This allows for corrections to be made early in the process, increasing first-pass billing accuracy rates by an average of 24-31%, directly reducing the volume of denials.

PCH Global provides a complete claims cycle management solution through digitization and automation, offering greater visibility into the processes. Get in touch with us today to know more about automation in the healthcare industry. 

Nearly a decade ago, Harvard economist, David Cutler, famously called out Duke University Hospital for employing 1,300 persons to administer billing for only 900 beds. Apparently, that’s what it took in light of the many disparate requirements imposed by multiple payers (patients, insurance companies, the government) in every transaction. Nearly a decade later, healthcare automation offers efficient alternatives in billing as well as many other business processes.

Automated claims processing

As a threshold matter, automating healthcare solutions requires effective health information management. Health information management holds significant promise with regard to eliminating delays and denials in the claims process, which impact payers, providers, patients, and public health in general. Effective health information management not only directly addresses known issues in the claims workflow, but it is also a crucial first step in automating points along that workflow for optimal use of human capital, ROI optimization, and enhancing employee- and patient/consumer-experience. To wit:

• For every process a payer or provider automates, there’s less need for manual intervention.
• Automated processing enables full visibility throughout the process.
• Intelligent data analytics tools help ensure efficient compliance efforts and enhance data privacy, routing related documents for the most efficient and appropriate reconciliation.
• Predictive analytics tools help providers and payers plan for uncertainties, including appeals and resubmissions.

By way of example, Exela’s deployment of our custom, self-service, rule-based healthcare solutions saved a top 10 payer an impressive 35% in the cost of processing claims and amounted to a 50% reduction in cycle time and a 20% reduction in resubmission rates. In addition, increased transparency for payers, providers, and members vastly improved employee- and patient/member-experience and reduced the demand for customer-service interactions. You can learn more in this case study.

Automating payments

Automating billing can be a game-changer by:

• Reducing the number of persons dedicated to the process, reducing time spent, and errors associated with, manual keying.
• Unifying payment data from multiple channels such as paper checks, debit transactions, collection procedures, etc.
• Enabling an improved patient communication strategy.
• Introducing other valuable efficiencies into the billing process such as HIPAA-compliant lockbox solutions.

In fact, we at Exela know how valuable such steps can be because we’ve seen it first-hand in solutions we’ve provided to our customers. For example, in the case of a major academic health system whose outdated payment operations had been mired in manual, error- and loss-prone processes, we deployed our Patient Financial Services suite to streamline information ingestion, facilitate communications, and optimize workflows, with the result being a 25% reduction in full-time employees needed for these operations and a 30% increase in collector efficiency. You can read more about it in this case study.

In addition to streamlining claims by avoiding denial of payment through improved coding, delivery of clean claims, and facilitating all related inter-stakeholder communications, automation can optimize revenue integrity through, among other things, data mining for the purpose of predictive analytics and revenue forecasting, all in the service of identifying and recovering all amounts in the most effective and efficient manner. For example, when a large healthcare system wanted a way to maximize reimbursement under their many payer contracts (all of which had different requirements, terms, and conditions), Exela deployment of its healthcare automation solutions resulted in 99.6% accurate reimbursement and identified 98.4% of underpayments and calculated predicted reimbursement under all payer contracts. “We look forward to continuing our relationship with Exela for years to come,” commented the customer in this case. “The contingency, success fee based engagement has provided an extremely positive, financial bottom line return, while requiring minimal staff time on our part...”

In addition, our medical lockbox solutions support providers in managing (and reducing the costs associated with managing) a high volume of receivables payments. And our newly-launched Real Time Payments solution can streamline the collection of remainders from patients using secure messaging and convenient payment options (via text message with payment options).

Automating accounts payable

It’s not just the core businesses of stakeholders that benefit from automation. For example, another of Exela’s customers, a national urgent care provider, had been processing more than 50,000 vendor invoices per month, resulting in lost documents and delayed payments to vendors, before turning to Exela to fully automate its burdensome paper-based workflow. In addition to streamlining payment to vendors and lowering the incidence of defaults and discrepancies, the user-friendly interface equipped the provider with the tools needed to readily address discrepancies if they arose and permitted the provider’s vendors to check invoice status online.

In the case of a major pharmaceutical company with a global footprint and driven by constant research and development, Exela was able to harmonize, digitize, and automate the more than 50,000 incoming invoices from 40 different business areas in 19 different countries through a custom-tailored combination of digitization services, data extraction, reporting, and remittance.

Automation Enrollment

Open enrollment is a payer-specific issue, and it’s always challenging. With ever increasing pressure to outperform the previous year’s results, there’s always a need for process innovation to meet increasing demands. Pressures are compounded by a short enrollment timeframe and employees who find the process confusing. The result is numerous queries and insufficient enrollment documentation. A large insurance company customer of Exela had been struggling with this scenario to the point that its satisfaction scores with providers and members were being severely impacted. Exela designed a universal intake and workflow solution to manage all the various modes of communication between the payer and the employees/potential members. In less than 90 days, Exela delivered 240,000 enrollment installations a month at a quality of 99.5% with significant cost savings in the form of reduced call volume and reduced pending items. Customer satisfaction soared.

Benefits to patients

The administrative complexity of the U.S. system also burdens patients, whether they are deciphering bewildering bills or shuttling records between providers. Three-quarters of consumers report being confused by medical bills and explanations of benefits. A Kaiser Family Foundation survey of people newly enrolled in the health insurance marketplace found that many were not confident in their understanding of the definitions of basic terms and concepts such as “premium,” “deductible,” or “provider network.” Insurers and employers spend an estimated $4.8 billion annually to assist consumers with low health insurance literacy, according to McKinsey.

For the full story on how technology can solve costly inefficiencies in the health industry, be sure to check out our Q4 Edition of PluggedIN: Tell Us Where It Hurts: How Tech Can Heal Healthcare.

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Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511963/

https://www.streamlinehealth.net/HIM-blog/revenue-integrity-can-organization-best-achieve/

https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/promoting-an-overdue-digital-transformation-in-healthcare