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Posted on: October 28-2014 | By : Harish Rijhwani | In: Healthcare Informatics | No Comments

Providers often face challenges with minimizing rejected claims, improving cash flow and reducing accounts receivable delays. All they need is to streamline the accurate collection of patient insurance and eligibility information. Implementing regulations such as ICD9-10, Accountable Care, Bundle Payments and Meaningful Use will initially add to these challenges. The resulting changes can potentially cause loss of accounts receivable (AR) at point of service. Along with quality of care, AR is one of the key areas which hospitals work towards improving continuously.

 

To resolve issues associated with AR, it is important to identify the various touch points that can be cause bottlenecks in claim processing, thereby in AR.

 

To guard against hold ups from patient admission to claim settlement, let’s see the five common reasons for AR delays prior to claim submission:

Touch Point

Possible cause of delay

Front Desk
  • Invalid or incorrect patient information captured
  • Incomplete insurance details
  • Reason for visit not captured
Case Management
  • Final diagnosis code not entered at the time of discharge
  • Discharge disposition is not clearly documented
Charge Capture
  • Duplicate charges entered
  • Surgical charge entered but no procedure performed on the patient
Hospital Information Management (HIM)
  • Chart not received by the medical coders
  • Account cannot be finalized because documentation is not sufficient
Billing and Claim Submission
  • Date is invalid or does not match
  • Contract errors
  • Insurance coverage issues

 

Payers have certain mandates, failing to meet which can cause delays post claim submission, the most common ones being:

Type of delay Reason
Claim Denied
  • Service is not covered when patient is under age 50
  • Service not required due to Medical Necessity
Claim put on hold due to additional information required  
  • Missing Physician Order
  • Missing Discharge Summary
  • Consent form requirements not fulfilled
Bad Debt   Payment not received from Patient

Obviously, some of these issues are caused by human error and cannot be solved easily. One solution could be real-time tracking of key elements related to AR from patient’s admission to discharge.

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Harish Rijhwani


Harish C. Rijhwani is a Delivery Manager at Syntel with 14+ years of experience in Healthcare...

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