Automation Coupled With Machine Learning
Automation plays a vital role in improving operational efficiency for managed services providers, leading to steady growth and profitability. According to the HFMA's Pulse Survey, around 78% of providers already utilize automated solutions. The benefits of automated Revenue Cycle Management (RCM) include streamlining workflows, reducing manual errors, and speeding up the reimbursement process. These factors lead to faster payments and increased revenue. Additionally, automation allows for accurate patient payment estimations, tailored care plans based on patient data, and better tracking and analysis of payer performance. It also helps in contract management, minimizing administrative labor costs, and improves interoperability between different software solutions.
One critical problem is right in our faces, but it goes largely unnoticed. Variance reports only include a small part of the data on underpayment. Most of the challenges we face in the revenue cycle are not addressed in these reports. The payment variance report does cover a few items like stoploss, carveouts, annual escalators, bundling, and payment variance, but it also shows several false variances. However, despite the attention given to variances, they only represent a fraction of the underpayment issue.
Disputes can arise between providers themselves or between providers and payers. These disputes have distinct characteristics and require efficient handling due to the ongoing relationships between providers and payers. Additionally, managed care organizations have complicated the healthcare system, creating challenges for some providers. Understanding payer contracts is crucial for providers to ensure correct and timely reimbursement and prevent claim denials.
In the healthcare industry, healthcare providers and insurance companies frequently encounter claims for both underpayment and overpayment due to contracts or services provided. These claims get accumulated and grouped together for legal proceedings, often leading to addressing thousands of claims in a single action. If informal resolution fails, the disputes are usually escalated to court or arbitration. Parties involved typically aim for a settlement through mediation, but in some cases, trials and appeals become necessary for resolution. To avoid such undesirable situations, it is crucial to act swiftly. Time is of the essence, and our dedicated staff is ready to handle most cases on a contingency basis.