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Can Your Electronic Billing System Be Optimized?


Change HealthCare recently released a statistic that of 9% of the $3 trillion in claims that are submitted annually result in denials. That amounts to $270 billion dollars in claims that providers are now required to address through resubmitting claims, calling payers, appealing, outsourcing/insourcing to designated teams, while still maintaining a handle on the day to day operations of the patient financial services areas. This made me think; Is there more we can do to optimize our electronic billing systems?

With increased innovation in recent years through direct software systems, Electronic Health Records and other improved technology, we would hope to expect far less disconnects throughout the process. However, providers are still losing approximately 3.3% of their net patient service revenue due to denials while they actively slice, dice and analyze their receivables and appeal hundreds of thousands of denials to minimize the loss of revenue. As payors continue to scrutinize our claims and place more emphasis on outpatient high volume, lower dollar claims, it is important to drill deeper into the “life of a claim” to address where the disconnects can occur and have action plans to address and correct the root causes.

  • What else can be done to modify billing system technology that has been the foundation of our business offices for the past 30+ years?
  • Are there other process workflows that can be refined?
  • Is there more we can do to optimize our electronic billing systems before a claim is submitted to help mitigate and reduce the overall denials providers are faced with after service?

Let’s consider the different functional areas within the revenue cycle, the root causes as to why denials occur and technology opportunities to prevent them moving forward.


Collecting pertinent information in advance of service allows for a more efficient and patient centric experience. Identifying denial trends resulting from scheduled patients is key to understand process related issues. Trends to look for:

  • What percent of your denials pertain to patients who were scheduled in advance of service?
  • Is information being carried over from historical visits without being properly validated?
  • Are their denial themes for recurring patients that may warrant a process change in the collection of demographic and insurance information?

Insurance Eligibility and Verification

Automated eligibility at time of service is fully integrated now; therefore, coverage denials should be minimal. Areas to target:

  • Are there services areas that are not performing eligibility at the time of service? Are process changes required?
  • Are denials received for insurance that has expired, was not in effect at the time of service or the patient can’t be identified as insured? Explore when the eligibility is conducted and gauge on whether shortfalls occur at scheduling versus at the time of service.
  • Is the service not covered through the patient’s benefit plan? Retrieve the real-time verification for these types of denials to identify the disconnect and determine if the patient’s benefits were truly vetted before the service was rendered.
  • How many of the non-covered services were deemed not to be medically necessary by the payer? Explore whether the proper Advanced Beneficiary Notice (ABN) was completed for Medicare patients and if the patient was advised beforehand that the service was not covered by their plan. Is the claim scrubber flagging these claims?
  • Are denials received for lack of authorization? Electronic billing systems can expand edits to flag these scenarios by payor, prior to submission, allowing for a better opportunity for resolution. Target the service areas and payers that consistently have high denial rates.
  • Are services authorized and still denied? Create another layer of EDI edits to identify these situations in advance to allow for upfront identification prior to submission.


Now that ICD-10 implementation is behind us, are there still coding denials that require further analysis?

  • Are claims denied for lack of modifiers? Are proper claim edits to identify these situations built into the claim scrubber?
  • Are HCPCS codes denied as outdated? Can your claim scrubber identify these situations prior to submission?

Claim Submission

Can additional we enhance our technology more to prevent re-work and denials?

  • As payors refine their contract language to require more aggressive timely filing requirements, denials due to timely filing is a top denial for many providers. Often the claim is submitted timely initially, however additional information that is needed to process the claim is not provided timely. Utilize historical denial trends to identify technology solutions to identify timely filing denials in advance. Create processes and track claims that are denied for additional information required. Ensure these initial denials are addressed within seven to ten days of receipt to minimize the risk of timely filing denials.
  • Claims that deny for lacking information should be reviewed for additional opportunities to modify the claim scrubber edits.

Additional items to consider:

  • Continue to evaluate the effectiveness of your process improvement / denials management program by ensuring that the changes you are making are not resulting in other disconnects or denials.
  • Concurrently look for ongoing opportunities to flag or edit your EDI claim scrubber to address disconnects upfront.
  • Work collaboratively with your EDI partners to continue to enhance innovation into the billing function.

Enhancing existing electronic billing technology will not resolve all denial issues, however there is a tremendous opportunity to streamline workflows to identify disconnects in advance, allowing providers the ability to be more efficient and realize more revenue.

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