Claims Processing

Claims processing involves both healthcare payers and providers, and relies heavily on the use of IT systems to submit, receive and either approve or deny payment. Disrupted processing can subject providers to cost increases associated with inefficiency and outstanding balances. Hospital billing departments use billing and revenue cycle management systems to get claims processed and paid in the most timely and efficient manner possible.

RELATED STORIES: 
AMA calls on nation's health insurers to fix claims process
Emdeon acquires Chapin, better addressing hospital-based claims and payment recovery

 
Speaking at HIMSS15 on Thursday, Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services, said providers will need to evolve in order to benefit from value-based reimbursement, and "will need technology to help them get there."
April 17, 2015
News
The Office of Inspector General is once again calling out CMS for failing to adequately address fraud vulnerabilities in electronic health records.
April 1, 2015
News
Predictive analytics has helped some revenue cycle departments identify problem claims before they're denied.
April 1, 2015
News
In what looks like it might be becoming a trend, another health plan has been targeted with a "sophisticated cyberattack," with hackers gaining access to the financial and medical information of 11 million members.
March 18, 2015
News
Centers for Medicare & Medicaid Services' first Chief Data Officer Niall Brennan talks about his first few months as CDO, and offers advice for providers looking to tap into their own data to drive efficiency and improve care.
March 9, 2015
News
In a letter this week to the Centers for Medicare & Medicaid Services, more than 100 medical societies aired "a number of concerns that do not appear to be addressed" as the ICD-10 deadline looms.
March 6, 2015
News
The oral arguments the U.S. Supreme Court heard Wednesday in King vs. Burwell did not address any health IT provisions of the Affordable Care Act, but the ruling could have far-reaching effects on the future of American healthcare.
March 5, 2015
News
Oral arguments begin today in yet another Supreme Court case that could threaten the existence of the Affordable Care Act, challenging the legality of one of its key components.
March 4, 2015
News
After Mike Simms, vice president of revenue cycle for Greensboro, N.C.-based Cone Health, signed on with one RCM vendor, he quickly found himself wishing he'd followed his hunch the first time around.
March 3, 2015
News
"CMS is ready for ICD-10," said outgoing Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner this week, pointing to 660 providers and billing companies that submitted some 15,000 test claims.
February 27, 2015
News
Most physician practices are now convinced that the ICD-10 transition will finally happen on Oct. 1, 2015. But just 21 percent say they're on track with their preparations for the switchover.
February 24, 2015
News
For physicians in small practices, it turns out the cost of moving from ICD-9 to ICD-10 is much less than anticipated, according to a new study released today by the Professional Association of Health Care Office Management.
February 10, 2015
News
Join this presentation to hear how organizations have used Hadoop and data analytics to reduce readmissions, and how your organization can build the data infrastructure necessary to thrive during this time of disruptive change.
March 2, 2015
Resource
Do Not Protect
http://www.himssmediawebinars.com/registration/webinar/harnessing-hadoop-drive-better-outcomes-healthcare?affiliatedata=HITNwebsite
Learn about key trends and important changes in health spending accounts and health plan administration, and find out how health plans and TPAs scope and implement the right solutions for themselves and their customers.
October 27, 2014
Resource
Do Not Protect
http://www.himssmediawebinars.com/registration/webinar/why-account-based-plans-are-critical-consumer-loyalty?affiliatedata=HITNwebsite
For health insurers, data integrity and visibility are key to successful integration with the Federal Marketplace. However, complex processes and trivial errors can lead to data gaps that impact revenue, profitability and member satisfaction. Adopting a standarized approach to data integrity early in the process is critical to succesfully adapting to the technologies and processes of the Affordable Care Act.
March 11, 2014
Resource
sites/default/files/resource-media/pdf/pri-0086-healthcarebrochure-revenue-ver3_28329.pdf
Protect
Seeking to improve daily workflow and decrease A/R days, Roanoke, Virginia-based Carilion Clinic discovered that through tight integration with its Epic HIS, SSI’s ClickON® Technology solutions could help the health system achieve its goals. With SSI, Carilion Clinic now boasts an impressive 47-52 A/R day range for hospital billing and 25-30 days for professional billing.
July 8, 2013
Resource
sites/default/files/resource-media/pdf/carilion_case_study_final.pdf
Protect
At the precipice of the 5010 conversion, Hendersonville, North Carolina-based Pardee Hospital embarked on a change of billing vendors. With guidance from SSI’s acclaimed customer support, the nationally recognized, not-for-profit community hospital thrived during the transition and continues to benefit from ClaimSmart Suite®, SSI’s fourth generation Revenue Cycle Management solution.
July 8, 2013
Resource
sites/default/files/resource-media/pdf/pardee_case_study_final.pdf
Protect
The multimillion-dollar question is: Are you covering who you think you’re covering? This white paper gives insights into the scope of eligibility fraud among commercial managed care organizations, state employee health plans, and state and federal agencies. It also addresses why it is important to incorporate multiple, diverse data sources into your analysis to spot inconsistencies and anomalies. Lastly, read about five real-world case studies of eligibility fraud detection in action.
April 2, 2013
Resource
sites/default/files/resource-media/pdf/before_claims_fraud.pdf
Protect
Atlantic Health System is leading the way in connecting healthcare providers with one another and with patients to help improve care coordination and patient engagement. Increasing levels of clinical connectivity in parallel with improved financial connectivity are driving better care and better financial outcomes. Read Atlantic Health’s story to learn about the incremental steps taken to establish the Jersey Health Connect HIO and about revenue cycle process improvements to improve financial performance via a relationship with RelayHealth.
February 27, 2013
Resource
sites/default/files/resource-media/pdf/1470_atlantic_health_case_study_v8.pdf
Protect
Specialty medicine practices rarely employ a dedicated information technology resource. Durham Nephrology is no exception. The Durham practice navigated the uncharted waters of attesting to <a href="/directory/meaningful-use" target="_blank" class="directory-item-link">Meaningful Use</a> under <a href="/directory/health-information-technology-economic-and-clinical-health-hitech-act" target="_blank" class="directory-item-link">the HITECH Act</a> of 2009 without the benefit of an IT expert or outside consultant. They implemented an <a href="/directory/electronic-health-record-ehr" target="_blank" class="directory-item-link">EHR</a> system in 2003 and believed that an EHR was the only long-term, effective way to organize patient charts and clinical notes. Read this story to find out this resourceful team achieved their goals--and more.
September 4, 2012
Resource
sites/default/files/resource-media/pdf/pro100_proehr_durham_nephrology_associates_nephrology_nc_success_story_10_19_11.pdf
Protect
Every HIM initiative - especially clinical documentation - relies on a single common thread for success: the availability and integrity of the right data to drive the correct decisions and follow-on actions. Capturing accurate, complete quality clinical documentation is the most critical and fundamental component in providing quality care, and ultimately has the biggest connection to generating revenue. This white paper describes the risks associated with the lack of a core HIT strategy; identifies HIT strategies that can help manage the complex clinical documentation challenges associated with ICD-10, RAC and ACOs; and provides an overview of existing and emerging technologies that have significant impact on addressing these challenges.
August 2, 2012
Resource
sites/default/files/resource-media/pdf/white_paper-perfect_storm.pdf
Protect
This paper examines why health care reform is causing a shift to a consumer-driven business model and the role analytics plays in helping organizations make the transformation successfully. Read this white paper to gain insight on how health insurance plans can come out ahead with advanced customer intelligence and engagement strategies.
March 1, 2012
Resource
sites/default/files/resource-media/pdf/sas_faqa.pdf
Protect
Curtailing the massive drain caused by waste, abuse and fraud in healthcare has never been more impor¬tant. New payment models are on the horizon, including <a href="/directory/bundled-payments" target="_blank" class="directory-item-link">bundled payments</a>, and greater emphasis is being placed on payment for outcomes. Given the magnitude and visibility of the problem, insurers need to avail themselves of advanced and effective means to reduce wasteful, abusive and fraudulent medical spend¬ing in the most efficient way possible. This demands a more holistic approach across the payment continuum, using technologies that not only address issues from multiple angles but also facilitate cross-organization partnership. Read more now.
December 12, 2011
Resource
sites/default/files/resource-media/pdf/mckesson_paymentpolicyoptimization.pdf
Protect
Hundreds of initiatives for care episodes are already underway in the U.S., relying on myriad combinations of provider types, legacy systems, and techniques. No single system on the market has the perfect solution across all areas. Bundling payments can reduce the cost of care by significantly reducing duplicative services, refocusing practice on collaboration across providers and rewarding quality outcomes. Learn more about automating major care process components by encompassing episode identification and definition as well as payment determination and timing.
June 10, 2011
Resource
sites/default/files/resource-media/pdf/mckesson_care_episodes.pdf
Protect
Payers' involvement in patient care, and their access to clinical data, has remained limited. They have traditionally relied on claims data to build care management applications and cost reduction programs.
February 24, 2015
Blog
Payers' involvement in patient care, and their access to clinical data, has remained limited. They have traditionally relied on claims data to build care management applications and cost reduction programs.
February 24, 2015
Blog
For hospitals looking to protect their revenue streams, verifying compliance of financial connectivity software is a good way to start preparing for ICD-10 conversion. But preparation for a successful transition involves more -- including education, testing and process improvement. So, with seven months to go, here are six tips to help with the transition.
March 10, 2014
Blog
This past week I had the pleasure of traveling, along with MedTech Media Editorial Director Rich Pizzi, to Amelia Island, Fla. for the inaugural HIMSS Leaders & Innovators conference.
November 22, 2011
Blog
Most healthcare organizations have modified or customized their billing applications. While these customizations are fine for their intended purposes, they pose rather large obstacles to the ICD-10 code conversion process.
March 1, 2011
Blog
ICD-10 is a multi-headed beast. As such, there are many faces to the new code sets; some are well known while others, often just as important, are not so understood.
August 6, 2010
Blog
It's no secret that the government mandated dynamic duo - that being HIPAA 5010 and ICD-10 - requires changes enormous in both number and scope. What's not as well understood is all the challenges they present.
April 8, 2010
Blog
In this table, we've combined the meaningful use objectives for both eligible professionals and hospitals for the Stage 1 adoption year, the required EHR technology criteria to accomplish those objectives and what criteria the government will use to measure meaningful use.
February 4, 2010
Blog
Recently, clinicians have asked me "why should I implement my organization's preferred EHR when I've found a less expensive vendor that promises meaningful use?"
November 10, 2009
Blog
Clinical Groupware is a departure from the client-server and physician-centric EHR technology of the past 25 years, a fixed database technology that never really became popular.
February 9, 2009
Blog
EngagePoint today announced that it has been awarded the prime contract for the implementation of a comprehensive automated solution to support human services programs for the Missouri Department of Social Services, Family Support Division and MO HealthNet.
July 2, 2013
Press Release
EngagePoint today announced that it has been awarded the prime contract for the implementation of a comprehensive automated solution to support human services programs for the Missouri Department of Social Services, Family Support Division and MO HealthNet.
June 28, 2013
Press Release
M*Modal, a leading provider of clinical documentation and Speech Understanding solutions, today announced an expanded relationship with Erlanger Health System to deliver exclusive outsourced transcription and front-end speech recognition technologies. Erlanger has selected M*Modal Fluency Flex to bring greater choice, efficiency and cost savings in creating reports and documenting patient records.
June 26, 2013
Press Release
Technology could be the prescription for improving treatment outcomes, while reducing costs, for children suffering from chronic illnesses such as asthma and diabetes, according to a new report released on Tuesday (June 18) by the Verizon Foundation and Boston Children's Hospital.
June 18, 2013
Press Release
Healthation a leading provider of core administrative systems for legacy and emerging healthcare payers and administrators, will be used to support the operations of New Mexico Health Connections, one of the Consumer Operated and Oriented Plans (CO-OPs) established as result of the Affordable Care Act (ACA).
June 12, 2013
Press Release
Wellsoft Corporation has announced that Continuum Health Partners (CHP), based in New York City, has selected Wellsoft’s Emergency Department Information System (EDIS) to support its goal of improved patient care in their four Emergency Departments located in the boroughs of Manhattan and Brooklyn.
May 16, 2013
Press Release
he U.S. Department of Veterans Affairs (VA) has awarded Harris Corporation (NYSE:HRS), an international communications and information technology company, a $5.3 million contract to provide remediation to the VA’s Health Administration Center (HAC) Cache System to address new medical coding standards. This is a two-year contract with three optional tasks.
October 27, 2011
Press Release
DST Health Solutions, LLC, today introduced a new Integrated Care Management Suite of solutions that empowers health plans with flexible and comprehensive solutions to help reduce medical and administrative costs while improving clinical outcomes. Offering a 360-degree view of all members, the DST Health Solutions Integrated Care Management (ICM) Suite provides insight to properly manage populations, effectively utilize benefits and provide education for optimal self-management. The cornerstones of the ICM Suite are DSTHS CareAnalyzer® for member identification and CareConnect for care management. The ICM Suite leverages The Johns Hopkins Adjusted Clinical Groups (ACG) predictive model, which identifies members with the greatest opportunity to improve health outcomes, and identifies gaps in care.
September 13, 2011
Press Release
OptumInsight (formerly Ingenix) has collaborated with InstaMed, the leading Healthcare Payments Network, to offer CareTracker Payment Connect, a new feature for the CareTracker practice management system from OptumInsight, to help physicians give their patients more options to pay their bills electronically, and reduce administrative costs.
June 20, 2011
Press Release
CapSite announces the release of the 2011 U.S. Patient Access Study. The study represents the latest in a series of CapSite strategic industry reports focused on the Revenue Cycle Management (RCM) market.
June 15, 2011
Press Release
Health 2.0, IMPAQ International (IMPAQ) and NORC at the University of Chicago (NORC) are proud to announce the launch of the Medicare Claims Data Developer Challenge, which will solicit entries to develop an online dashboard for comparative effectiveness, health services and health policy research.
June 2, 2011
Press Release
Geisinger Health System, widely recognized for its implementation of innovative care models, is among the first healthcare organizations in the nation to deploy advanced technology that combines a Computer-Assisted Coding application with Natural Language Comprehension (NLC) in order to improve clinical documentation and coding accuracy.
May 25, 2011
Press Release