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Every year, hospitals are not reimbursed for billions of dollars in costs incurred while treating patients. Why – They never made it to the claim. Coupled with the pressure to reduce the provider’s cost and payors reimbursement, financial shortfalls force Hospital Administrators to face decisions that can severely affect the quality of care provided to patients. There are many technical and procedural reasons for missed charges. Most frequently, missed revenue is the result of: · - Use of multiple technology solutions across the patient care continuum · - Failed interfaces between HIS system modules · - Breakdowns in manual processes performed by staff Most of the hospitals employ nurse-auditors for manual review of patient claims. Unfortunately, with this approach hospitals often are able to review only high ticket items such as implants, supplies and high cost drugs.
Although significant improvement opportunities exist throughout most clinical services, ranging from cardiology to radiology, the emergency room to the laboratory, hospitals simply don’t have the resources required to audit each claim. As a result, it is estimated that hospitals lose an estimated average of 4-5% of gross charges resulting in approximately 1% of lost net revenue. |
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“An analysis of 1 million claims from 80 hospitals had an error rate ranging from 8 percent to 30 percent. A total of 80 percent of the hospitals reviewed had significant incidence of compliance or cash-flow problems.” -3M Health Information Systems “The amount the average hospital spends on reworking claims and managing denials averages $75–$125 per claim.” -3M Health Information Systems “Private companies that process health claims from its beneficiaries made nearly $20 billion in erroneous or questionable payments last year, an error rate of 9.3%. These were claims that were inadequately documented or improperly coded” -Medicare
“70% of all billing errors stem from an inaccurate Chargemaster.” |
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