Bundled claims, combining all services related to a treatment or condition into a single payment, are becoming increasingly common. These payments can include the services of multiple providers at once, which means that many providers could be taking on financial risk from a single payment, especially if a patient is unable to pay. Bundled payments contain allowed amounts, which the health care provider is paid by the insurance company, as well as disallowed amounts which an insurance company refuses to pay. These amounts are based on the average cost of the group of services contained within a bundle. If disallowed amounts are positive, because the provider’s cost of care is more than the average, the provider loses money, because a patient doesn’t have to pay for those costs. If disallowed amounts are negative, because the provider’s fees are less than average, the provider earns additional revenue. Standardizing prices on the average group cost helps providers save money because the number of unnecessary procedures performed is reduced and, consequently, necessary resources are saved. Providers, therefore, should strive to minimize disallowed amounts whenever possible.
In order to minimize disallowed payments, it is essential to understand the most efficient ways in which to handle bundled claims. There are four critical areas of expertise: understanding the bundling claims process, continually checking eligibility, automating tasks, and working as a group. Each of these are part of a greater whole that is aimed at maximizing profit for providers, while also slowing cost increases to patients. Providers cannot continue to function without revenue, but patients cannot obtain care if costs are too high; as a result, minimizing disallowed payments is a delicate balancing act for everyone involved.
Understanding the bundling claims process is important because a well thought out plan for completing that process eliminates the vast majority of disallowed charges. Bundled claims should first be validated, using patient identifiers and business logic. Next, any services or claims that aren’t part of the bundle should be removed and processed individually. At the same time, providers should check bundles for policies which require particular attention or any unusual outliers. When submitting claims, services should all be included within one bill for payment, and different bundles should be submitted at different times. This strategy removes any obvious issues that could generate disallowed amounts, staggers submissions, so there is a constant revenue flow, and simplifies administration because bundles are easier to handle than are many different, separate claims. There is always a chance that unexpected disallowed amounts can be included within a bundle, but following this strategy should cushion the impact of any problems which unexpected costs could cause.
Continually checking eligibility is vital while a bundled claim is being processed. A provider’s staff should continuously double-check to make sure that all the services in a bundle are still covered by a payer. This may seem like unnecessary, additional work at first, but more than 30% of claim denials in the United States occur because of mistakes made during these checks. Including services that are not covered by a provider, finding out something is ineligible for coverage, or incorrect registration for claims processing are among the most common mistakes. These can all be mitigated by better staff training, however, and the more vigilant these checks are, the fewer denials there will be.
Automating tasks can give providers a significant efficiency boost. Many medical billers don’t have time for proper training because they are just too busy and have to learn on the job. The number of people who need health care is growing rapidly, and handling claims quickly is essential, so formal training sometimes is lacking, particularly with respect to new payment models such as bundled claims. Since some staff members may lack formal training, they could do things in slightly different ways that might become inefficient over time. Fortunately, there are often many areas where repetitive or everyday tasks can be automated, so they can be executed in a standard way much more quickly than they can be done manually. This ensures that critical information gets where it needs to go without delays and that neither time nor money is lost as a result of mistakes, confusion, or inefficiency.
It takes a group effort to process bundled claims well and to make health care value-based, instead of volume-based. In order to keep health care costs from going too high, while maintaining a high standard of care, it’s always helpful to connect with other healthcare providers and professionals. Sharing data, analyzing what works, and changing what doesn’t work, can help providers, payers, and patients. If providers learn through these connections that they are charging more than the average amount for services in a bundle, for example, they can evaluate what to do before losing money on the bundle. Connecting with other healthcare entities is an excellent preventative measure which can help to avoid disallowed amounts.
eReceivables can help healthcare providers navigate the tricky process of reducing disallowed amounts from bundled payments. Providers can follow the tips above to get started, but having an experienced partner to improve efficiency is always a great help, and this ensures that providers will have the opportunity to excel. To quickly become an excelling provider, contact eReceivables today.