financial success. Payors must ensure that these processes go smoothly and that any possible error is flagged and addressed. Some members will always come and go, but to lose one single source of revenue because a payor uses inefficient and flawed manual methods should not be tolerated. As the numbers under the ACA grow, so must the use of automated controls so that payors realize maximum revenue under healthcare reform. As a comparison, incorrect data is the leading cause of failed or late payments in the banking industry. Since payments can account for 30 to 40 percent of net banking revenue, they need Millions of “free agent” members are up for renewal this year, and many payors are discovering shortcomings in their processes as unsatisfied members sign on with another payor. continuous assurance that key information for each transaction is accurate, consistent, and reliable. Just like banks and corporations, healthcare billing organizations face increasing pressure to transform payments processing systems, in order to: • Achieve cost reductions • Implement straight-through processing (STP) • Address new financial standards • Improve customer service • Comply with regulations Because each payment transaction requires numerous exchanges of data between systems inside and outside your company, opportunities for errors are high, and payment visibility is low. Undetected anomalies may cause billers to send invoices to the wrong address, bill procedures to the wrong patient, or not bill them at all, and as inconsistencies build, determining the root cause of an error can be cumbersome. Without complete visibility into this process, much can slip through the cracks. Automated controls enable billers to validate and track payment transactions across complex processes and audit those transactions in real time, resulting in greater operational efficiencies and streamlined compliance efforts. Analytics: Better Data Drives Better Decisions In addition to better managing complex ACA member data as it flows through information systems, data integrity establishes a foundation that healthcare billers can build on to better predict which patients are more likely to pay, translating these 16 HBMA BILLING • MARCH.APRIL.2015 insights into programs and policies to better manage that reality. Data integrity can take many forms, including: • Define and model “good customers” • Predict future financial outcomes • Relate enrollee segments to claims • Score for payment risk • Rank individual members for medical and financial interventions • Identify high-risk new members to consider prevention or case management • Identify high-value members for enhanced service/retention • Identify payment risk for early supervision • Relate enrollee segments to claims • Aggregate and explain payment risk While some consider this step a thing of the future for healthcare, smart companies will consider ways to integrate data quality and analytics into their data management best practices to see improved results and better understand their customers. With accurate data at the core of your company’s endeavors, rich insights and data-driven decisions will create opportunities for better business moving forward. Whether it is high-deductible plans or patients not paying their premiums, the burden of collecting payment is falling more and more to billing companies. By using effective data controls and analytics, you can work more efficiently and better understand the challenges and opportunities hidden within your company’s rich operational data. Keeping visibility and data governance at the core, not only will companies rise to the occasion to meet ACA requirements while keeping business running smoothly, but they’ll be able to look forward at ways to improve processes as business evolves. ■ Sumit Nijhawan is CEO and president of Infogix, where he is responsible for leading company strategy, operations, and customer partnerships.
Billing_MarApr15
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