A holistic, end-to-end approach to managing provider data
Organizing, maintaining, and managing an ever-changing sea of provider data has become a major undertaking. Many healthcare payer organizations are faced with a wide array of systems, constantly evolving regulations and compliance requirements, and complex agreements. These administrative challenges can lead to costly inefficiencies and missed opportunities.
Exela’s Provider Data Management service is designed to relieve healthcare payers of this burden by introducing operational best practices, leveraging powerful technology, and strengthening existing workforces with trained exerts. Our solution enables strategic forward-looking management of provider data to improve accuracy, decrease compliance issues, and encourage a better relationship with your providers.
30+
years of Experience
Accurate
Validation
Simplifies
the Process
Seamless Source Integration and Interoperability
Match, reconcile, and combine data from many sources into one reliable database and get easy-to-understand context for all data points with Exela’s advanced automated system. Interoperability with claims processing and adjudication platforms ensures data is readily available where it’s needed most.
Proactive Compliance
With over 30 years in the industry, Exela builds regulatory compliance into every process. Our data management system is designed to deliver transparency through audit trails and next-level reporting features to ensure that your organization is prepared to meet current and future regulatory expectations.
Provider Data Maintenance and Changes
Exela’s Provider Data Management systems simplify the process of updating stored provider data, and allows for easy tracking of all updates for full transparency.
Provider Enrollment and Validation
Enroll new providers using their profile, W9, contract information between the provider and the group (PPG), or contract information checklist. Exela partners with a number of businesses and organizations to ensure accurate validation of provider information, including NPI number, stat license, address, DEA number, demographic information, and UPIN.
Nearly a decade ago, Harvard economist, David Cutler, famously called out Duke University Hospital for employing 1,300 persons to administer billing for only 900 beds. Apparently, that’s what it took in light of the many disparate requirements imposed by multiple payers (patients, insurance companies, the government) in every transaction. Nearly a decade later, healthcare automation offers efficient alternatives in billing as well as many other business processes.
Automated claims processing
As a threshold matter, automating healthcare solutions requires effective health information management. Health information management holds significant promise with regard to eliminating delays and denials in the claims process, which impact payers, providers, patients, and public health in general. Effective health information management not only directly addresses known issues in the claims workflow, but it is also a crucial first step in automating points along that workflow for optimal use of human capital, ROI optimization, and enhancing employee- and patient/consumer-experience.
To wit:
- For every process a payer or provider automates, there’s less need for manual intervention.
- Automated processing enables full visibility throughout the process.
- Intelligent data analytics tools help ensure efficient compliance efforts and enhance data privacy, routing related documents for the most efficient and appropriate reconciliation.
- Predictive analytics tools help providers and payers plan for uncertainties, including appeals and resubmissions.
By way of example, Exela’s deployment of our custom, self-service, rule-based healthcare solutions saved a top 10 payer an impressive 35% in the cost of processing claims and amounted to a 50% reduction in cycle time and a 20% reduction in resubmission rates. In addition, increased transparency for payers, providers, and members vastly improved employee- and patient/member-experience and reduced the demand for customer-service interactions. You can learn more in this case study.
Reducing the number of persons dedicated to the process, reducing time spent, and errors associated with, manual keying.
Unifying payment data from multiple channels such as paper checks, debit transactions, collection procedures, etc.
Enabling an improved patient communication strategy.
Introducing other valuable efficiencies into the billing process such as HIPAA-compliant lockbox solutions.
In fact, we at Exela know how valuable such steps can be because we’ve seen it first-hand in solutions we’ve provided to our customers. For example, in the case of a major academic health system whose outdated payment operations had been mired in manual, error- and loss-prone processes, we deployed our Patient Financial Services suite to streamline information ingestion, facilitate communications, and optimize workflows, with the result being a 25% reduction in full-time employees needed for these operations and a 30% increase in collector efficiency. You can read more about it in this case study.
In addition to streamlining claims by avoiding denial of payment through improved coding, delivery of clean claims, and facilitating all related inter-stakeholder communications, automation can optimize revenue integrity through, among other things, data mining for the purpose of predictive analytics and revenue forecasting, all in the service of identifying and recovering all amounts in the most effective and efficient manner. For example, when a large healthcare system wanted a way to maximize reimbursement under their many payer contracts (all of which had different requirements, terms, and conditions), Exela deployment of its healthcare automation solutions resulted in 99.6% accurate reimbursement and identified 98.4% of underpayments and calculated predicted reimbursement under all payer contracts. “We look forward to continuing our relationship with Exela for years to come,” commented the customer in this case. “The contingency, success fee based engagement has provided an extremely positive, financial bottom line return, while requiring minimal staff time on our part...”
In addition, our medical lockbox solutions support providers in managing (and reducing the costs associated with managing) a high volume of receivables payments. And our newly-launched Real Time Payments solution can streamline the collection of remainders from patients using secure messaging and convenient payment options (via text message with payment options).
Automating accounts payable
It’s not just the core businesses of stakeholders that benefit from automation. For example, another of Exela’s customers, a national urgent care provider, had been processing more than 50,000 vendor invoices per month, resulting in lost documents and delayed payments to vendors, before turning to Exela to fully automate its burdensome paper-based workflow. In addition to streamlining payment to vendors and lowering the incidence of defaults and discrepancies, the user-friendly interface equipped the provider with the tools needed to readily address discrepancies if they arose and permitted the provider’s vendors to check invoice status online.
In the case of a major pharmaceutical company with a global footprint and driven by constant research and development, Exela was able to harmonize, digitize, and automate the more than 50,000 incoming invoices from 40 different business areas in 19 different countries through a custom-tailored combination of digitization services, data extraction, reporting, and remittance.
Automation Enrollment
Open enrollment is a payer-specific issue, and it’s always challenging. With ever increasing pressure to outperform the previous year’s results, there’s always a need for process innovation to meet increasing demands. Pressures are compounded by a short enrollment timeframe and employees who find the process confusing. The result is numerous queries and insufficient enrollment documentation. A large insurance company customer of Exela had been struggling with this scenario to the point that its satisfaction scores with providers and members were being severely impacted. Exela designed a universal intake and workflow solution to manage all the various modes of communication between the payer and the employees/potential members. In less than 90 days, Exela delivered 240,000 enrollment installations a month at a quality of 99.5% with significant cost savings in the form of reduced call volume and reduced pending items. Customer satisfaction soared.
Benefits to patients
The administrative complexity of the U.S. system also burdens patients, whether they are deciphering bewildering bills or shuttling records between providers. Three-quarters of consumers report being confused by medical bills and explanations of benefits. A Kaiser Family Foundation survey of people newly enrolled in the health insurance marketplace found that many were not confident in their understanding of the definitions of basic terms and concepts such as “premium,” “deductible,” or “provider network.” Insurers and employers spend an estimated $4.8 billion annually to assist consumers with low health insurance literacy, according to McKinsey.
For the full story on how technology can solve costly inefficiencies in the health industry, be sure to check out our Q4 Edition of PluggedIN: Tell Us Where It Hurts: How Tech Can Heal Healthcare.
One of the top challenges facing the healthcare industry and the revenue cycle is the medical billing system. The medical billing system encounters many obstacles due to the changes that occurred (and continue to occur) during the COVID-19 pandemic as well as the complexity of the billing system itself. Along with increasing regulations and standards, healthcare providers need to find ways to streamline the billing system. Because the billing system is repetitive in nature, it makes the perfect process to implement digital transformation.
Business automation in the medical billing system increases efficiency, speeds up payment posting, and improves the revenue cycle. The medical billing system is often the first element to be automated in the revenue cycle, usually because providers may be using an outdated billing system or notice higher claims denials. Employing automation in the billing system helps providers to enhance the process, avoid surprise bills, and focus more on patient care while reducing spending.
Complex Processing of the Billing System
Rather than being handled by a single department, the medical billing process requires input from multiple departments including the billing department, administrative department, and clinicians. With so many seemingly unlinked departments working together, there's bound to be room for error, slow processes, and inefficiencies.
Also, healthcare providers don't typically receive payment upfront. They first work with payers for reimbursement before deciding if they need to bill a patient and, if so, for how much. Healthcare providers need to consider a patient's copay, medical coverage, and insurance eligibility. At the same time, providers need to confirm that claims are accurate with the proper medical codes to avoid denied claims.
Business Process Automation Improves the Revenue Cycle
When it comes to enhancing the revenue cycle, the medical billing system needs to be taken into consideration and healthcare providers need to consider how business process automation fits into their overall digital transformation and revenue goals. According to a 2021 CAQH report, transitioning to fully electronic transactions could save the healthcare industry 48% of annual spending. There are various customizable digital solutions that healthcare providers can rely on to make repetitive tasks more efficient, free up resources, and ultimately, reduce spending.
Fewer Denied Claims
Currently, healthcare providers report that claim denial rates are between 6% and 13%. A denied claim is lost revenue and many claims are denied due to minor errors. With business automation such as Exela’s Lockbox, healthcare providers would see fewer denied claims.
Exela’s Lockbox improves the first pass rate of claim submissions by identifying and flagging medical coding and billing errors before the claim is submitted. By increasing the number of clean claims submitted, healthcare providers receive reimbursement more quickly.
Along the same line, once a claim is denied, it requires the provider to decide if the denial needs to be appealed, the claim needs to be adjusted, or the patient needs to be billed. Business automation solutions such as Exela’s Lockbox increases the recovery rate on denied claims thanks to a tool that presents the original claim along with all the related information in a single view. This makes it easier for the billing department to decide the next steps to recoup the payment.
Mitigate Human Error
As long as there are manual processes in place, claims will always be prone to human error. With claims being denied based on the smallest inaccuracy, healthcare providers can easily lose revenue due to human error. Automation ensures accuracy, removing another obstacle toward streamlining the revenue cycle.
Digital Document Management
Paper systems are inefficient, tedious, and risk documents being lost. Healthcare providers are choosing to transition to digital documents and digital archives to store all pertinent data and information. Exela’s Lockbox converts paper EOBs into EDI 835 remittance files while also providing full support for paper and electronic payments.
Providers can also access information such as EOBs and other data through Lockbox’s secure web portal. With a simple search, a provider can find exactly what they're looking for rather than manually sifting through paper files.
Increase Speed of Payment Posting
Due to the different departments being involved in the medical billing system along with any outdated system that's currently in use, the path toward payment is going to be inefficient and significantly slower. By using automation tools, healthcare providers reduce the time it takes for payments to post, giving them faster access to deposited funds.
Let Business Automation Improve the Revenue Cycle
While the medical billing system is a great place to start for digital transformation in healthcare, healthcare providers can find a myriad of business automation processes that can enhance their revenue cycle, and encourage them to save money while increasing patient care.
There's no one-size-fits-all when it comes to a solution, which is why healthcare providers should determine what needs to be prioritized in their own organization. Whether healthcare providers start automating the medical billing system or automate a different facet of a healthcare process, it's high time that the industry embraces digital transformation.
Digital transformation in healthcare continues to be a key topic in many healthcare leaders' minds. Healthcare providers of every size face the same challenge of improving patient care and engagement while managing costs. However, many obstacles create complications including limited staffing, outdated systems, payer contract complexities, and more. By embracing digital transformation, healthcare providers can begin to tackle these obstacles and accomplish their goals for the future.
Digital transformation in healthcare affects many aspects of the business from freeing up resources that can be devoted toward patient care and increasing patient engagement to improving operational and financial efficiencies. With AI, automation, and technological advancements, the healthcare industry stands to gain improved processes, quicker payments, and fewer claims denials.
Digital Transformation in Healthcare Starting with Automated Claims Processing
Claims management and processing is a major operation in need of digital transformation in healthcare. This is often a thorn in healthcare providers' sides because of its complexity. Claim denial rates are between 6% and 13%, which eats away revenue.
These statistics highlight the importance of submitting clean claims right from the start. However, this is easier said than done especially when relying on manual processing and outdated systems. Many healthcare claims are being denied for simple reasons such as a spelling error, incorrect coding, missing patient identify information. Given that healthcare organizations' resources are stretched thin, it makes sense that claims processing would be vulnerable to human error.
Once again, digital transformation in healthcare can step in and smooth the process. Exela is a leading claims processing provider with a solution that enhances claim processing by unifying data from all incoming communication channels, performing pre-submission checks to create clean claims, and intelligently routing correspondence for optimal processing using automated decisioning. Exela’s Healthcare Claims Processing solution reduces denials and resubmissions by applying business rules to produce clean claims prior to submission. Using automation and artificial intelligence, Exela increases transaction processing rates and accuracy while reducing manual processing and rework.
Take Complex Claim Processing Further
According to a 2021 CAQH report, only 21% of medical administrative transactions are digital while the rest are paper. Exela leverages exclusive vendor contracts with leading health plans for complex paper claims processing.
Embrace digital transformation further with Exela's PCH Global solution, a powerful digital platform that not only provides a single point of access for claims management but provides a central bridge between all parties including the provider, payer, and patient.
PCH Global promotes clean claim submissions by identifying certain-to-denied claims, thereby improving first-pass rates. Its iterative feedback loop technology helps the system continuously learn and improve to identify errors enabling proactive claims management with system flexibility as your contracts change.
Finally, the system automatically tracks and records any addition, deletion, or modification to transactions along with user reference and timestamps providing clear audit trails and ensuring full compliance.
Digital Transformation of Remittance Payments
The 2021 CAQH report determines that the healthcare industry could save 48% of annual spending by transitioning to fully electronic transactions. Manual processing significantly slows down operations especially when human errors are taken into consideration. Automation streamlines this process reducing errors, posting payments quicker, and improving overall efficiency making it a terrific place for digital transformation in healthcare.
Exela's Medical Lockbox simplifies the healthcare payment process by digitizing and automating manual, paper processing tasks. Using a state-of-the-art scanning platform and intelligent OCR/data capture technology, Exela’s Medical Lockbox solution converts paper EOBs from any source into 835, electronic remittance files, payment reconciliation and posting to the healthcare organization's medical billing system. By streamlining the payment path, Exela’s Medical Lockbox solution reduces the time it takes for payments to post and allows quicker access to deposited funds. Submitting secondary claims or patient billing, depending on the patient’s coverage, makes the payment cycle faster from Primary, Secondary, Tertiary or Patient payments.
Not only does Exela's Medical Lockbox streamlines payment processing, but it also features a web-based denial management tool designed to increase the recovery rate on denied claims. This web-based management tool presents the original claim and all related remittance information in a single view simplifying the process for users to adjust the claim, bill the patient, or appeal the denial. Insights are gleaned through reimbursement metrics presented within Exela’s Medical Lockbox’s configurable reporting function. These insights are valuable with billing system audits and contracts negotiations.
Automated Contract Management
Healthcare payer contracts vary greatly, each having different policies, regulations, and parameters. The contracts of each insurance company are often revised and updated annually so healthcare organizations need to renegotiate several payer agreements every year.
Keeping track of the current contracts and any annual updates is an enormous task that burdens healthcare resources. Without a handle on contract management, healthcare organizations are vulnerable to underpayments which affect their bottom line. Contracts and underpayment management are yet another place where digital transformation in healthcare is needed.
Exela’s Revenue Integrity solution automates the contract management process, document scanning, indexing, profiling, loading and maintaining all third-party payer agreements. Agreement terms are tracked and providers are presented with notifications of important dates as well as amendments and updates. Instead of using limited resources to keep track of contracts, automation is ready to step in.
Exela’s Revenue Integrity solution also offers predictive contract modeling that provides accurate reimbursement calculations for current and future contractual agreements. By providing multiple scenarios and utilizing the most recent one-year patient data set, the platform presents the net dollar and percentage increase or decrease.
This solution also identifies retrospective, current and prospective underpayments from all contractually obligated third-party payers.
Summary
Digital transformation in healthcare opens many doors and it’s time providers embrace the opportunities available to them. AI and other technologies are ready to streamline antiquated processes, increasing efficiency and accuracy while freeing up personal time.
The application of a robotic process automation solution provides significant results for a large health insurance organization.
Challenge
The decommissioning of databases that supply information to the insurance provider’s national corporate data centers required data migration and resulted in the need for multiple database searches across dozens of disparate data centers. This caused offsite direct data capture productivity to drop by approximately 30%. The customer required productivity improvements and the avoidance of errors associated with manual migration.
Solution
Exela utilized robotic process automation (RPA) for direct data capture deployment to connect disparate data systems. This solution automates the extraction of all provider information from the customer’s system into a unified spreadsheet for easy lookup. A software bot was deployed to update new provider information daily. All information was uploaded into a single view within the Exela RPA Design Studio interface.
Benefits
60% volume direct data capture edit utilized RPA
35% productivity gain (from 15 claims per hour to 20+)
