Four Easy Ways to Lose Revenue

Times are busy. We are all doing more with less these days. Sometimes we don’t put processes in place to make sure functions continue when our focus is elsewhere.  Here are four easy ways you could be losing revenue:

1. Member Experience and Claims Payment: Not storing all diagnostic codes for your provider and facility claims. Similar to working edits, if you have not reviewed your claims system to determine if it is accepting all diagnostic codes that come in on an electronic provider or facility claim, you don’t know if you are capturing everything you need. If your system is dropping diagnostic codes, you could be dropping appropriate reimbursement for impacted members. John Gorman, Founder and Executive Chairman at Gorman Health Group (GHG), recently commented on the importance of the member experience in a new article stating, “Now more than ever, it’s clear to us health plans and their stakeholders will thrive or die based on the member experience they provide.”
2. Reconciliation: Not working Prescription Drug Events (PDEs), enrollment edits, or risk adjustment and encounter data claims and enrollment edits. Payments for Part C and Part D are based on information from the services members receive. If you don’t have a good process in place to ensure all edits are resolved, you are more than likely leaving money on the table.
3. Hospice and Claims: Not having a tie between your claims system and hospice determinations. Hospice services are a carve-out for Medicare Advantage (MA).  Typically, hospice providers don’t bill for hospice-related services. Other providers may bill you for Medicare-covered non-hospice-related services. If your system is paying for those services, you are paying too much.
   
4. Medicare Secondary Payer (MSP): Not managing your MSP members. MSP impacts both premium received and the payment of claims. If you don’t have processes in place to validate each MSP designated member, and either correct discrepancies with the Coordination of Benefits Contractor (COBC) or set up your system to pay secondary, that mismatch is costing your plan money.

In busy times, it can be difficult to monitor everything. Establishing procedures and controls in order to manage these processes without interruption is critical to the success of your organization. Our multi-disciplinary team of consultants knows how to set up the right controls to keep your department running in an efficient, productive, and compliant manner.

For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas.

During this year’s information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn’t. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth.

Specifically, attendees can expect from my presentation practical strategies for combining productivity and compliance in your Operations Department while gaining real-world examples of the holistic management of compliant Operations departments.

The preferred room rate expires on Monday, March 28, 2016. Register now >>

Resources

If you haven’t had the chance to review all of the sessions we have slotted for the Gorman Health Group 2016 Forum, download the conference brochure >>

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