Availity Blog

Availity Blog

Actionable insights for medical business professionals

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.

In a recent blog post, Can “Big Data” help address the challenges of risk adjustment,” we looked at why risk adjustment is critical to the successful implementation of value-based payment models. But risk adjustment models rely on timely and accurate provider data, and many health plans don’t have the systems and processes in place to efficiently capture the right data points, relying instead on manual, labor-intensive processes. As a result, health plans face the following challenges related to organizational efficiency and provider network satisfaction.

Much has been written about “Big Data” and its potential for helping companies turn information it collects into critical business insights. Amazon’s product recommendation feature is one example of big data at work, but companies are also using it as a tool for many strategic decisions, including pricing, staffing, and product development. As the health care industry transitions from fee-based to value-based care models, big data holds a lot of promise for health plans and providers who are looking for better ways to measure value and assess risk within patient populations. One important area is risk adjustment.

Healthcare providers know all too well how consumerism is affecting their bottom line. As high-deductible plans become more common and patients are responsible for a larger portion of their healthcare costs, hospitals and physician practices are finding it more difficult to collect the full portion of the patient responsibility.

In a previous blog, “Learn How a Settlement Recovery Service Can Help You and Your Organization”, we introduced several types of settlements. One of the types mentioned was a “product anti-competition” settlement, which relates to products with allegedly inflated prices that were purchased either directly or indirectly from certain companies. The Polyurethane Foam Antitrust Litigation Class Action Settlement, also known as the Poly Foam Settlement, is an example of this type of settlement. At $151 million, the settlement fund is both substantial and rare, and organizations potentially affected by alleged overpayments may want to consider filing a claim.

The Affordable Care Act (ACA) requires health insurance companies to spend a minimum amount of premiums collected from members on specific categories of activities that are intended to benefit those members. This is known as the Medical Loss Ratio (MLR). Each year, health plans are required to report their MLR for the preceding year; in the event they do not meet the mandated ratio, those health plans must issue rebates to their customers. The MLR requirement is intended to provide greater transparency and accountability around the expenditures made by health insurers and to help bring down the costs of health care.