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Leverage Revenue Cycle Management (RCM) Technology to Ensure First-Pass Resolution Rate (FPRR) Of 90% Or More – Part 2 (What Providers Need to Know, From a to X12)

Healthcare providers should track claims first-pass resolution rate to determine how to reduce accounts receivable (AR) days. The topic was introduced in the article, Reducing Accounts Receivable (AR) Days with Revenue Cycle Management Technology (How to ensure claims first pass resolution rate of 90% or more Part 1). Though this article and the aforementioned can stand alone, it may prove beneficial for providers to  read both guides, Part 1 and Part 2, of how to achieve a first-pass resolution rate of 90% or more.  



Achieve First-Pass Claim Rate of 90% Or More

Achieving medical claims first pass resolution rate of 90% or more requires not only Revenue Cycle Management technology but also support services. These services should facilitate medical billing efforts, providing full service resources for healthcare providers. Though providers can conduct electronic claim submissions directly to the payer, the stakes are too high to leave success to chance.  Thus, to attain the highest possible first-pass rate, providers should partner with a revenue cycle management company, like Health Recon Connect


Partner With a Revenue Cycle Management Company to Increase Claims First-Pass Rate

Revenue Cycle Management (RCM) companies have the software tools and human resources to help healthcare providers reduce accounts receivable (AR) days.  RCM businesses can leverage the provider’s electronic health records (EHR) system to create an electronic claim. RCM technology would then utilize software edits to make that claim “clean,” free of format and coding errors, by “scrubbing” the data to meet HIPAA EDI X12Nstandards. Overall, an effective RCM system drives efficient and standardized integration of provider, patient, payer and medical coding information to increase the first-pass resolution rate. 

Though RCM companies welcome the weight of enabling revenue growth, healthcare providers still have some work to do on their end, the front-end. Providers have to officially establish their business presence and those of their physicians, and other healthcare professionals, before seeing patients. This effort entails establishing unique identifiers, EINs and NPIs, and credentialing and contracting with payers, among other necessary processes. If providers are not aware of these front-end issues and/or do not manage them well, it hinders the ability to ensure a first-pass resolution rate of 90% or more, reduce AR days and improve revenue growth. 


What Providers Need to Know, From a to X12

The following terminology, and aspects of electronic claim submission, present the information providers need to know on some level. Healthcare professionals can leverage this knowledge, listed from A to X12, to mobilize claims first-pass resolution rate (FPRR) of 90% or more.  

  • Automated Workflow –  also known as workflow automation, stands as the foundation of RCM technology automating daily workflow processes, like patient scheduling, eligibility checks, claim and medical coding edits and analytics to just name a few, to make healthcare business more efficient.
  • Analytics –  data driven analysis of past and/or current healthcare information, like EDI transactions and identifiable claim errors, that can transform a low first-pass resolution rate to a high first-pass win towards revenue growth.
  • ASC X12/X12N – ASC X12N is thehealthcare subgroup of the Accredited Standard Committee X12 or ASC X12; ASC is a committee of the American National Standards Institute, ANSI. 
  • Adjudication –  the payer’s process of reviewing approved claims (those that have passed format and coding edits on the payer’s end) to determine how much of the balance due the provider will receive.
  • Benchmark Assessment –  an evaluation used to optimize business performance, leveraging applied analytics to determine how one healthcare provider compares to other healthcare businesses.
  • Common Claim Errors – claims are rejected and/or denied due to missing or invalid provider, patient, payer and medical coding information, including diagnostic, procedural, NDC code issues and even mathematical errors, among other mistakes.
  • Credentialing and contracting – different from EDI enrollment, providers should complete all three processes to avoid claim errors: credentialing for official authorization to conduct business, including reimbursement issues, contracting to get In-network with a particular insurance/health plan and to obtain their terms and conditions, and EDI enrollment to obtain approval to submit electronic claims.
  • Denied Claims – a claim that has been accepted and processed on the payer’s end but is denied for payment during the adjudication process, see front-end.
  • EMR vs. EHR  –  Electronic Medical Records and Electronic Health Records are essentially the same, they refer to patient records, but the EHR system is more technologically advanced and may integrate with revenue management technology better.
  • EDI – Electronic Data Interchange (EDI), business to business electronic communication, see HIPAA EDI X12N.
  • EDI Enrollment Agreement – An EDI enrollment agreement must be completed for every insurance company for which providers have conducted medical services and require reimbursement.
  • First-pass resolution rate – claims first pass resolution rate is the rate at which claims are accepted and approved, passing all claim and coding edits, by the payer on the first try or first electronic claim submission.
  • Front-end – prior to submitting claims, healthcare providers have work to do on the front-end of the revenue cycle, from credentialing and contracting to patient scheduling, eligibility/insurance verification checks, prior authorization, copays, and so on. If these front-end issues are not handled correctly, they could lead to front-end rejections, payer rejections and/or denials.
  • HIPAA – To safeguard protected health information (PHI), which includes patient and provider data, the U.S. government instituted the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  • HIPPA Administrative Simplification – see explanation and quick links here, including a list of unique identifiers.
  • HIPAA EDI Rule – HIPAA specified EDI X12N transactions and code set standards, see X12N.
  • ICD-10-CM (Clinical Modification) – International Classification of Diseases, diagnostic codes designated by the World Health Organization(WHO), see ICD10/11 information.
  • ICD-10-PCS (Procedural Coding System) – maintained by CMS Medicare, see code file.  
  • NPI – The National Provider Identifier (NPI) is required for credentialing, contracting, payer enrollment and HIPAA compliant EDI transactions, among other healthcare processes.
  • NPPES – Providers can create a 10-digit identifier on the National Plan and Provider Enumeration System(NPPES) and register that number on the NPPES Registry.  
  • PHI – Personal Health Information / Protected Health Information (PHI).
  • Prior Authorization – a common reason for claim denials when providers do not obtain approval for products and/or procedures prior to conducting services.
  • Rejected Claims – claims that fail to process due to missing or invalid data, invalid NPI, missing patient name and/or member ID, and so on, see HIPAA EDI X12N standards and front-end issues. An effective RCM system can detect medical coding and payer specific errors through software edits. Despite those efforts, however, claims can still be denied on the payer’s end.
  • Revenue Cycle – a series of healthcare related events that initiate and complete the payment process. This revenue cycle, from end-to-end, begins with a scheduled medical appointment and culminates in compensation for the services performed.
  • Revenue Cycle Management – making the revenue cycle process more efficient, using advanced technology to automate various healthcare and revenue cycle related processes.
  • Transaction Set / Codes transaction set or codes consisting of three digit IDs (837-claims, 835 Electronic Remittance Advice, and so on) that denote the type of electronic transactions providers can submit to other healthcare businesses.
  • Unique Identifiers standard HIPAA identifiers providers have to use throughout electronic claim data, Tax ID / EIN – Employer Identification Number and NPI.
  • Verification – Insurance verification or patient eligibility is an essential check providers should run before administering services to determine if they will receive reimbursement from the payer. 
  • Workflow automation – see Automated Workflow.
  • X12N  – X12 is the general set of standards for business-to-business Electronic Data Interchange (EDI) transactions, X12N relates specifically to healthcare exchanges. X12 also denotes the nonprofit organization, and professionals from a wide range of work industries, that help to institute X12 standards and are part of the ASC X12 committee.  

Deriise Dowell is an Atlanta based healthcare IT copywriter and advocate of efficient billing services, having served, empathetically, as an Enrollment Specialist and Technical Analyst for 11 years.

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