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Maximizing Reimbursement for Complex Billing Scenarios (Part 2 of 3)

December 17, 2024

Part 2: The Power of Patient Engagement to Improve Reimbursement in DME and Remote Monitoring

Efficient billing and revenue cycle management (RCM) is the lifeline of healthcare providers, enabling them to maintain financial sustainability while managing complex billing scenarios. The increasing complexity of healthcare billing in telehealth, durable medical equipment (DME), medical device, and remote monitoring services makes technology a necessary ally.

In this post, the second in our series on “Maximizing Reimbursement for Complex Billing Scenarios,” we examine how the patient experience plays a crucial role in many of today’s billing challenges. Understanding and improving the patient journey can significantly impact billing outcomes, financial health, and sustainability.

If you missed the first blog in this series, Navigating Complex Reimbursement Pathways for DME and Remote Monitoring, you can access it here.

The Evolving Patient Experience

Today’s patients are consumers who expect convenience, transparency, and personalized interactions. By integrating patient engagement tools with billing systems, we can ensure that patients receive timely and accurate information about their expected out-of-pocket expenses, are notified when they need to update or complete their demographic or insurance information, and are informed of any remaining balances they may owe. This transparency boosts satisfaction and reduces payment delays.

Critical points in the patient experience include:

  • Facilitating access to care (including completing prior authorization, qualification, benefit coverage, and insurance discovery tasks)
  • Capturing patient communication preferences
  • Accurately calculating out-of-pocket estimates before services are provided
  • Establishing multi-channel patient follow-up
  • Providing invoices that are easy to understand and access
  • Presenting clean financial payment options
  • Making it straightforward to access and share results with other providers

The evolving patient experience requires an RCM strategy that prioritizes communication. It ensures that clinical or financial interactions are seamless and optimized for the patient and the provider.

Let’s walk through a typical patient journey—from before the visit, through the clinical process, and the post-visit experience. There are many steps along the way where patients might have questions, so it is essential to keep them informed. Coordination is crucial when DME or a medical device such as a remote health monitor is within the care plan, since the provider of these equipment and services may not be the therapeutic provider.

Since RCM systems are not directly involved in patient care, they must be tightly integrated with the ordering, inventory, scheduling, and logistics systems. This will ensure smooth communication with patients throughout their experience.

  1. The process starts with accurately identifying the patient and capturing their demographic information.
  2. Confirming insurance details and verifying eligibility is crucial for keeping everything on track.
  3. Performing benefit verification—especially when preparing accurate patient estimates—helps avoid surprises for both the patient and the provider and makes all downstream steps much easier. In DME and medical device, it is essential to verify eligibility and benefits before any equipment or device is shipped.

  4. Next, providers (and their teams) must document referrals, pre-certifications, clinical and familial history, and evidence of medical necessity, while also requesting prior authorizations, and ensuring they can provide payors with any required medical history and clinical notes.
  5. Ensuring the claim meets benefit maximums and handles ‘same and similar’ considerations also helps avoid claim rejections.
  6. Then comes the financial conversations, like collecting payments at the time of ordering or at the place of service or managing any prior balances.
  7. Post-visit touchpoints are important for following through on clinical and financial responsibilities.

All these communications can be triggered by RCM systems and sent directly to the patient. For example, this can be an SMS outreach after a scheduling or an order intake step. The patient portal can provide direct visibility and payment options to the patients.

The Importance of Patient and Provider Communications

Portals Support a Better Patient and Provider Experience

  • 24-hour, convenient access to results, statements, and bill payment capabilities
  • Present accurate expected patient financial responsibility amounts and enable pre-payments before services or products are dispensed
  • Automatically apply patient payments in real-time
  • Provide online access to view pricing, fix errors, and upload documents

Patient and provider portals have become crucial parts of modern healthcare. Combined with a multi-channel communication strategy, they give patients and referring physicians 24/7 access to valuable information—including test results, statements, and bill payment options—all in one place. Text messages can be sent to patients, prompting them to view their expected patient responsibility and make pre-payments online before dispensing products or devices. This makes life easier for patients and helps streamline the entire billing process.

By integrating closely with RCM systems, portals enable patients to manage their financial responsibilities more efficiently—or even allow providers to help. Estimates are calculated, and payments are processed in real-time, which helps reduce errors and boosts patient satisfaction.

Plus, physicians can:

  • Securely access pricing information
  • Correct billing errors
  • Upload documents

This seamless, self-service approach improves efficiency, speeds reimbursement, and reduces front-end denials. It also
keeps the clinical and financial aspects of healthcare well-connected.

The key to enabling this vital communication and collaboration is having a robust, comprehensive Application Programming Interface (API) layer as part of your RCM system infrastructure. APIs let two systems talk to each other in real time over the Internet. XiFin’s API suite allows our Patient and Provider Portals to play a direct role in the billing process. It also gives our customers the flexibility to integrate their own systems into the RCM process.

Applying AI to Improve Patient Experience

1. AI Uncovers Insurance Information

Deciphering health plan insurance cards is one of the most challenging tasks in billing. There is no standard format. Many cards have incomplete payor information or just images instead of text, making extracting the information required for a successful claim difficult. Ensuring that the RCM system captures the correct payor name and information is the first step in maximizing reimbursement and preventing unnecessary delays in the billing process.

Artificial Intelligence plays a pivotal role in simplifying insurance verification. We have built AI solutions that can work with minimal input, such as a Subscriber ID, to identify the correct payor and plan. By mapping payor eligibility responses to the correct payor, AI can fill in gaps that traditional methods miss. Minimal input from the patient can complete the process, speeding up eligibility verification and claim submission while ensuring the patient’s experience is smooth and seamless.

Our AI models are designed to work with whatever data we can collect. The models determine the appropriate insurance company to contact for an eligibility check. Once we receive a successful eligibility response, another AI model maps the returned information to the correct payor ID. This happens instantly, and a confirmation is displayed to the patient. We then take this payor information and use it to calculate a patient estimated out-of-pocket responsibility.

Machine Learning Models trained on recently adjudicated claims can overcome these challenges and provide accurate:

  • Estimated Copay
  • Estimated Coinsurance
  • Risk of coverage limitations

2. Patient Estimation: Eligibility Alone is Insufficient

Patient estimation based solely on eligibility information often falls short. This is where AI (specifically machine learning) can help. Training AI models on recently adjudicated claims can generate more accurate estimates for copays, coinsurance, and coverage risks. These models account for complex and varying payor rules, ensuring that the estimated costs align more closely with the final adjudicated claims. This helps improve the accuracy of financial discussions up front.

Today’s patients expect transparency in billing and the ability to manage their financial responsibility obligations easily. Integrated patient portals provide a seamless solution, including:

  • Real-Time Cost Estimation: Using RCM-integrated portals, providers can give patients accurate cost estimates detailing their financial responsibility. This clarity leads to fewer disputes and more timely payments.
  • Self-Service Capabilities: Portals enable patients to make payments, review billing statements, and resolve issues independently, freeing up administrative resources and improving patient satisfaction.
  • Transparency and Accessibility: Portals provide access to patient demographic, payor, and billing information, which helps maintain patient satisfaction and increase the likelihood of on-time payments.

Our final post in this series covers why a programmatic approach to prior authorizations is essential. To explore these topics further, watch our on-demand webinar, Maximizing Reimbursement for Complex Billing Scenarios: The Power of Purpose-Built Billing and Financial Analytics Solutions.

 

Medical Device - Remote Patient Monitoring

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