The Power of a Rules Engine

According to the Center for Medicare and Medicaid Services (CMS) only about 70% of claims are paid at the first submission. The other 30% are: · Denied (20%) · Lost or ignored (10%) What is more interesting is that 60% of these claims are never resubmitted to payers. This translates to the fact that medical practices never collect on 18% of their claims. One more scary fact for providers is that the Medical Group Management Association (MGMA) estimates that providers are underpaid by an average of between 7% and 11%. Including this and doing the math, means that 18% figure goes up to an average of 25% of money not being collected that has been earned by treating patients. That's a total of $125 billion of revenue left unrealized by healthcare providers. Revenue Cycle Management Practices- Rules Engines One way to collect this money is by improving, upgrading and otherwise automating your revenue cycle management system. New technologies like EHR and practice management systems can be used to do this. One of the most effective actions to take and one that speaks directly to the statistics related above is to implement a potent rules engine. One that will not only check for the proper coding but automatically identify the claims most likely to be denied. The top software solutions contain intelligent engines that adapt to changing rules by updating them. This helps keep you ahead of the latest claim denial trends. That's because the software gathers information on claim denial activity from all of the practices in the vendor's network. Other impacts of powerful rules engine software include: · A higher first pass resolution rate: Since more potential denials are stopped prior to the claims being submitted, you have a better chance of getting paid off of the initial submission. This could improve a national average first pass resolution rate of 70% to a much healthier 97% immediately. · Faster collections: This also improves the average time it takes practices to get paid. Plus, it keeps practices from leaving revenues on the table. · Staff efficiencies: No production staff likes to deal with reworks. Not only are they often laborious but they keep the employees away from producing fresh revenue billings. A good rules engine makes the process more efficient for everyone. So, installing powerful rules engine software could be one of the best investments you make in your practice. You can also contact a medical biller who already has this type of software in place. Sue (Sunni) Patterson, CMBA, Co-Founder Sunni started in the healthcare industry as a senior medical claims processor with a major insurance payer and since then has partnered with RMK123.com ( http://www.rmk123.com ), a top medical billing and revenue management firm. Sunni leveraged this to create Medical Bill & Claim Resolution (MBCR) [http://www.medicalbillandclaimresolution.com], a medical bill patient advocate firm assisting individuals with interpreting their medical and hospital bills, disputing erroneous charges and resolving/understanding insurance claim decisions. Sunni holds the specialist Certified Medical Billing Advocate (CMBA) designation. Article Source: https://EzineArticles.com/expert/Sue_Patterson/1240315 Article Source: http://EzineArticles.com/7245333