Payers

Payers Feature Story

Their Fair Share

An academic medical group recovers $1.7 million with an automated contract-management solution.

When it comes to physician reimbursement, payers do not always abide by contract terms. Verifying payment accuracy for medical services, however, is a complicated venture, requiring medical groups to analyze the complex payment policies and countless variables that affect reimbursement.

 

Autonomous Information Handling

New technology replicates information handling intelligence into small applications, benefiting a multihospital system in Michigan.

Healthcare is an information-rich environment, and while information systems help manage the deluge of data, the technology is still highly dependent upon labor-intensive processes. For each patient encounter, consider the staffing resources that are consumed to input, locate, access, distribute, analyze and store information. A vast amount of information is stored in multiple systems, but the intelligence of how to handle this information — getting the right information into the right hands at the right time — largely resides within the heads of the staffing resources that use the systems.

 

Strategic Placement

Addressing the data explosion in healthcare requires a sound strategy for turning data into information.

There is a data explosion occurring in healthcare. Frost & Sullivan's "2004 Healthcare Storage Report" predicts that by 2010, medical centers will need to be equipped to hold almost 1 billion terabytes of data, or the equivalent of 2 trillion file cabinets worth of information.

   

Scrubbing Reimbursement Rates Clean

A private practice Radiology group integrates a claims editing application with its practice management solution, increasing accuracy and improving cash flow.

Like many medical practices, St. Paul Radiology, of St. Paul, Minn., found managing the complexities and pressures of securing reimbursement a considerable challenge. According to the most recent PayerView statistics available, denial rates for the state's Medicare agencies ranged from 4.3 percent to 14.9 percent. Among national payers, Cigna topped the list at 5.9 percent while Champus/Tricare had the eighth-highest rate with 12.3 percent. Unfortunately for us, our own rate was even higher. Of course, in Radiology, denials and delays are even more of an issue than in most specialties, especially in a practice of our size. In our field, just a few thousand claims may represent hundreds of thousands of dollars in reimbursement. Five years ago, we took a comprehensive look at our explanation of benefits (EOB) data and its impact on our healthcare business, and we saw plenty of room for improvement.

 

Reclaiming Lost Revenue

An FQHC-qualified community clinic faces down the complexities of the claims editing and submission process.

Neighborhood Healthcare, a large group of community clinics in California’s San Diego and Riverside counties, serves a population that is largely below the poverty line. We primarily offer outpatient medical services as well as dental and behavioral care, but we also operate a hospitalist program that provides some inpatient care.

   

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