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

 
ABILITY Network, which develops workflow technology for hospitals, home health agencies and other care settings, will acquire MD On-Line, maker of electronic data interchange and revenue cycle tools for payers and providers, for an undisclosed sum.
October 15, 2014
News
Optum, the health IT division of UnitedHealth, will acquire MedSynergies -- which makes practice management, revenue cycle, physician referral management and other ambulatory-focused technology -- for an undisclosed sum.
September 30, 2014
News
A Mississippi health system and three hospitals in Texas, Indiana and Alabama are illustrating how hospitals can thrive, even in a tough economic environment. One hospital increased its revenue by $8.2 million after improving clinical documentation. Another changed the way it collected for services and boosted revenue by $6.1 million.
August 27, 2014
News
By mining state Medicaid data and utilizing a population health platform, the Wyoming Department of Health was able to slash its Medicaid-related emergency room visits by 20 percent in a one-year period.
August 8, 2014
News
The revised compliance date for providers, payers and clearinghouses to transition to ICD-10 has been finalized by the Department of Health and Human Services. It's Oct. 1, 2015 -- just 14 months from today.
August 1, 2014
News
Even if the ICD-10 compliance date is farther away than it once was, it will arrive eventually. (For real, this time. We think.) And while you'd be forgiven for taking a foot off the proverbial gas, this is time that should be spent pushing ahead with preparedness plans.
June 27, 2014
News
When it comes to revenue cycle management, a recent poll of hospital chief financial officers shows 86 percent of respondents saying the "needs" of CFOs are currently more important than most clinical and patient care "wants."
June 18, 2014
News
Simply put, most revenue cycle management systems aren't suited for a future where providers are paid for quality, not volume. That, coupled with increasing hospital consolidation and the fact that the "the average system out there is quite old," means the entire concept of RCM is due for a shakeup.
June 12, 2014
News
The annual PayerView Report from health IT company athenahealth, released today, reveals the healthcare payer that has the best relationship with providers and the one that has the most problems.
May 30, 2014
News
The long and short of it is this: Old code deteriorates over time. It begs to be transported to new platforms. With that, though, comes challenges.
May 9, 2014
News
Truven Health Analytics has acquired Fortel Analytics, whose fraud detection technology will be deployed to comb data for suspicious patterns in healthcare insurance claims.
April 28, 2014
News
The American Health Information Management Association has called for the Department of Health and Human Services to announce Oct. 1, 2015, as the new implementation date for ICD-10 as soon as possible.
April 16, 2014
News
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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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