The Patient Revenue Cycle
The Patient Revenue Cycle (PRC) management is core to every healthcare system (Rosario, 2018). Automation of the management process has been a trendy topic featuring modern technologies in claim submission and processing. As a result, there has been a rise in the adoption of software of revenue cycle management software by health centers whose benefits have been handy owing to its efficiency and time effectiveness.
However, the rise in automation subject’s various health centers to probable electronic faults and errors committed by either machine or the humans operating those particular machines. Due to the embedded nature of the claim submission and processing between the hospital systems and the insurer systems, delays caused by such electronically related errors are resolved through resubmissions, which results in an apparent disruption of the hospital’s cash flow. For instance, electronic claims submission systems are subject to a wide range of errors that, once upon digital screening, could lead to rejections of claims hence resulting in a ripple effect in delayed hospital revenues.
There are numerous types of electronic submission errors made especially made during the early phases of the patient revenue cycle, and some of the most common are discussed as follows. The first common type of electronic error in claim submission is incomplete client claim profiles featuring a lack of essential claim processing information. This error is usually prone at the initial phase in the revenue, which involves front office staff’s appointment setting and capturing patient demos. Some electronic submission systems might lack comprehensive or updated the claim screening systems aligned with the insurer’s policy and conditions compliance checks. As a result, the lack of crucial information or inaccurate information provision leads to automatic claim rejections at the insurer’s end.
To minimize the possibility of occurrence of this error, the hospital can invest in actualizing the following recommendations. Firstly, the hospital should aim at an error-free front desk by acquiring modern software that is efficient enough to capture patient demographic data and insurance information. Moreover, the hospital can develop and instill policies and invest in training of its front desk staff on their roles as this could lead to a loss in the battle of getting paid by the insurer.
The second common type of electronic error in claim submission is the wrong capturing of claim codes. Every claim is associated with a code as guided by ICD-10, a medical coding language that links every application to specific treatments and procedures. The wrong code capturing error usually occurs in phase two of the revenue cycle, which entails capturing charges and accompanying claims’ submission. Therefore, improper capturing of the claim code would lead to inconsistencies, which are immediately flagged out during the screening stages of the submitted applications by the insurer’s system leading to numerous automatic claim rejections.
To avoid claim code-related errors, hospitals should invest in minimizing manual inputs of the codes. Instead, their systems should avail provisions for choices of pre-coded choices from which the staff can select relevant to the patient’s appointment or reported medical case. Moreover, keeping the system up-to-date with the changes in the insurer’s claim codes is key to avoiding situations of rejection at first submission. Besides, reviewing the details of the claim to be submitted by more than one person is key to minimizing the possibility of such claim code-related errors.
The other standard error with the electronic claim submission is the client’s illegibility to the insurance claim (Providers, 2019). This error occurs in the second phase, where all the verification of the client’s eligibility to certain services owing to their cover terms and status with the insurer should be done. Those hospitals that submit claims without verifying patients’ eligibility to the services with the insurer end up in denial, and therefore the contrary should happen before submission.
Compatibility errors are another common type of electronic claim submission error. The claim submission process’s automation has attracted many technology companies featuring different approaches to revenue cycle management and claim submission processes. As a result, different technologies feature different communication formats and transfer of data, which always needs to be compatible to communicate to allow the method of claim processing. This error occurs at the initial phase of setting up appointments and capturing the client demos. Therefore, the health center must ensure that they have a system in place that is certified and compliant to the insurer’s system requirements to avoid inconveniences caused by systems incompatibilities.
Buying systems from the right and certified system vendors are key to ensuring compatibility between the systems is maintained, which crucial for two systems to operate (Kumar, 2019). For instance, this ensures that all the attachments required to access eligibility, especially in the client identification process, are in the right format compatible with the insurer’s system or else lead to automatic claim rejection on the first submission.
Another common type of electronic submission error is system errors. System errors are prone to both sides that the insurer and the claiming party occur just before or after submission. They include power outages leading to the eventual loss of data before processing a claim, hence the need for resubmission. It can also be a result of a computer virus, which could corrupt the data, thus leading to an eventual need for resubmission of the claims. However, system errors can be resolved and prevented to ensure efficiency and reliability by providing the right information technology infrastructure, and personnel is present to address such related errors.
The electronic submission system is a revolution in the insurance industry, which features a range of advantages and shortcomings. Some of the deficiencies are in form errors, as highlighted above. However, most of these errors are manageable hence maintaining its reliability to sustainable cash flows in hospitals.