Availity Blog

Availity Blog

Actionable insights for medical business professionals

Availity Access gives viewers a glimpse into the people behind our products. It features commentary on challenges facing the healthcare industry and how Availity can help providers and health plans better share patient information. In this first episode, we discuss why the risk adjustment process is difficult for health plans and how digital tools can help streamline it.

Health plans are increasingly under pressure to maintain accurate provider directories, or they risk regulatory fines and potential third-party lawsuits. Given these regulatory and market pressures, healthcare providers are likely to see a lot more requests for up-to-date demographic data from your partner health plans.

It is not an overstatement to say the healthcare industry has experienced unprecedented change since the Affordable Care Act (ACA) was passed in 2010. Healthcare has fundamentally evolved in how it is delivered and how payers are reimbursed for the care they give patients.

“Sudden” changes in the information we have and how we use it are usually not all that sudden, and it’s almost impossible to predict their effects. Whether it’s pinpoint accuracy in location data or efficient sharing of health care information, improved technology, changing attitudes about the technology, and government pressure often lead to unexpected consequences.

As long as there’s been medical insurance claims there’s been a tug-of-war between payers and providers. Payers want clean claims and providers want to get paid promptly. Meanwhile, “dirty claims” — those with errors — are causing billions of dollars in added expenses for the healthcare industry because payers and providers have to retain extra resources to manage the rework and manual processes, among other factors. Experts agree that both payers and providers are at fault for the “calamity of claims” that exists today.

Providers submit millions of claims to payers every day. Most are adjudicated promptly and for the full contracted amount, but a fraction of these claims are denied. However, the American Medical Association (AMA) reports that between 1.38% and 5.07% of claims are denied by payers on first submission.

In two recent blog posts, we talked about the promise “Big Data” holds for risk adjustment and some of the challenges health plans face with existing systems and processes. In the final blog of this series, we look at how the Member Assessment application, part of Availity’s Revenue Program Management (RPM) solution, helped one large health plan improve the risk adjustment process.

Payers need information about the population of members in their health plans to predict and track healthcare costs, and to comply with regulatory requirements for risk adjustment and quality assessment. The latter is particularly important for members in Medicare Advantage, Medicaid managed care and Affordable Care

The administrative employees of critical access hospitals typically wear many hats. With extremely tight margins and few alternative funding sources, smaller institutions must keep staffing at a minimum to effectively manage cash flow. So, it’s not surprising when the person who checks patients in at the registration desk is the same person who handles administrative responsibilities for the emergency department.

Healthcare providers are in the middle of enormous change. Declining reimbursement, the transition from fee-for-service to value-based payment models, and consumerism are all influencing the way providers get paid, how much they get paid—even whether they get paid at all. While it’s difficult to stop in the middle of managing these changes to evaluate existing revenue cycle processes, it’s an important step in ensuring your organization is positioned for success.