Are Out-of-Network Claims Causing Headaches? Consider Outsourcing Them to Build Advantage

Posted on in Growth Strategies

By: Beth Cox Hollingsworth, VGM Marketing

The challenges heaped on billing specialists in today’s regulatory environment are substantial. Reimbursement rates are changing, Medicare reviewers are regularly adjusting their criteria and billing specialists are called to understand and act on hundreds of details every single day. In this hurried environment, time is of the essence to ensure claims are submitted without error to support the cash flow that funds business and innovation.

With the extra pressure placed on one of the most fundamental functions of an HME business, conducting a value chain analysis of the billing process may be critical to identifying strengths, weaknesses and where your business has the opportunity to decrease inefficiencies. A value chain analysis is a tool used to analyze the internal business activities to determine the business’s activities that produce value to customers or to determine a cost advantage (or disadvantage) over the competition. For the purposes of this article on billing and reimbursement, we’ll focus on the concept of cost advantage.

In the image of Porter’s Value Chain Model below, we’re working out of the operations arrow as we address our billing and reimbursement needs. Billing and reimbursement is just one link in a long chain, so don’t forget the value of conducting an analysis on multiple processes in your business.

Analyze Billing Practices to Obtain a Cost Advantage

According to Strategic Management Insight, a business that chooses to compete through cost advantage seeks to perform internal business activities at a lower cost than competitors would do. Specifically, this can pinpoint to the time billing specialists spend on the billing process, from beginning to end. In our world, measuring the time expended on one claim can be daunting as it may include calls to the doctor’s office, intense review of details of the claim, and verification and follow-up conversations with third-party payers or contractors. As a labor-intensive activity, understanding the hours worked, wage rate and speed of the work being completed will shed light on where time and money is being spent inefficiently. Your billing software may be able to do this for you.

Analyze Time, Wage Rate and Duration of Claims Processing

Let’s walk through some examples. Perhaps your staff, although well-intentioned, are experiencing high error rates that cause claim rejections. (Let’s be honest, we know this is happening everywhere now.) By conducting a pinpointed analysis on the time spent working on claims and investigating more thoroughly into the ones that are rejected, you may be able to categorize error types. Does the error occur in the physician’s notes? Is the error caused by an unfocused staff person? Or perhaps your staff as a whole would benefit from billing and reimbursement training. If you’re able to take steps to decrease your error rates, thus decreasing the time invested in a claim, this will allow you to invest more in creating differentiation or diving into caretailing and cash sales opportunities.

Outsourcing May Free Up Time for Advantage-Building Activities

Or, perhaps you find your staff are spending hours on out-of-network claims or even turning them down all together. A value chain analysis can determine if outsourcing some or all out-of-network claims would free up time to focus on revenue or advantage-building activities. As the fine details of a claim matter now more than ever, outsourcing out-of-network claims to VGM’s HOMELINK can save time that would be spent calling the insurance company to get in-network, waiting for a predetermination of benefits and collecting a copay. It may also prevent your company from turning away customers.

Network management companies have become an attractive source for payers as they pursue efficient partnerships to meet the demands of their patients and health care reform. This is especially true as public and private insurance panels are narrowing, locking independent providers out. If you‘re not in-network or participating with a patient’s insurance company but HOMELINK is, an HME business can call  to have them coordinate the claim and billing to get in-network benefits for the patient. Out-of-the-box solutions to billing and reimbursement process can give you cost advantage, can free up funding for business growth or improvement of fundamentals and will be an important piece of your value chain analysis.

If outsourcing out-of-network claims will create cost advantage for you, contact HOMELINK’s Craig Douglas at [email protected]