Key Ways to Improve Access to Claims Data for a Smoother Revenue Cycle

Healthcare claims contain a wealth of information. Each service line on a claim paints a picture of a patient’s healthcare journey, including their quality of care as well as the cost of that care. Claims data is key to improving population outcomes, reducing total cost of care, and improving the overall experience for patients and providers.

However, providers oftentimes cite barriers to accessing claims data. Top challenges include data quality and completeness of claims data, while research has also shown that providers struggle to integrate claims data from multiple sources and convert claims data into more useful information.

The challenges of claims data access have prevented providers from gleaning key insights on their patients and care delivery, researchers found. Some providers have also said that a lack of timely, complete claims data has slowed their progression toward value-based care.

The challenges of claims data access have also impacted the business side of healthcare. Providers need to be able to quickly receive payments and reconcile accounts to keep the clinical side operating smoothly.

How claims data access impacts revenue cycle

Without complete access to claims data, providers may find it difficult to measure key financial performance indicators, which impacts their bottom lines. This can ultimately affect the reimbursement rates they negotiate with payer partners.

“Providers, particularly in-network providers for certain insurance companies, have agreed to accept a specific set of discounts on various procedures and certain guaranteed minimums from the insurance companies. They want to make sure that they're getting paid according to those agreements and that their network relationship is working out how they expected. But it can be a big area of contention at the end of each year,” explains Alasdair Catton-Chastain, Senior Manager, Provider Experience at Zelis.

“Tracking things like network discounts and if patients are accessing some kind of advantage network is important and that data is typically found on the remittance coming back from payers.”

Unfortunately, there is still a lot of paper involved with claims payment, according to Catton-Chastain.

Manual payments create obvious data collection challenges, from human error to data conversion difficulties. But even the technology payers and providers use can exacerbate existing claims data struggles. For example, many payers use their own portals to send electronic claims data to providers. However, that means providers are logging into dozens of different portals a day.

“They're having to manage passwords and usernames for each portal. Each one's going to look and feel slightly different. They're going to have to remember how they use the site and how they find the data that they need,” Catton-Chastain says.

On top of this challenge, some providers may not have the bandwidth within their offices to chase after all this information. Consequently, many offices only go after higher dollar or volume claims when there is an issue, leaving money on the table.

Ultimately, this impacts the patient billing cycle, which is arguably one of the biggest revenue cycle challenges for providers right now.

“Getting patient financial responsibility is where the majority of the lost dollars and write-offs occur,” states Catton-Chastain. “The quicker that providers can get better information, the better. They will have less appeals and better visibility into what is owed.”

As electronic claim payment adoption continues, providers should be cognizant of the solutions they implement to resolve claims data access obstacles.

“By removing the number of places that they have to go for the remittance, providers can make it a lot easier having an aggregator where you have multiple payers all in the same portal,” Catton-Chastain states. “It makes it much easier when you're looking for a remit because you can search by the payment details and the claim information rather than having to go out to the payer with a list for different things that you need.”

The benefits of electronic claims payment adoption

Implementing the right solution is key to overcoming the challenges of claims data access and healthcare revenue cycle management.

“Having the payment data in the same system and electronically is a big benefit,” says Catton-Chastain. “It should be part of the digital transformation providers are striving for. It’s going to reduce errors and reduce the amount of protected health information and privacy incidents they may have.”

A multi-modal solution allows providers to enroll in electronic claims payment across their payer partners. This not only streamlines the transition to electronic claims payment but grants providers access to a wealth of electronic claims information, including remittance advice, from their payer partners. These systems should also allow providers to access and download data in the right electronic format for their other billing or patient accounting systems (e.g., 835, CSV, or PDF).

Consolidation of electronic claims data delivers the information providers need to measure financial performance alongside quality and outcomes. Meanwhile, a single system reduces the administrative overhead of managing multiple portals and systems, especially in a more remote world.

“We saw a big increase during the COVID-19 pandemic of people going home to work remotely. A lot of cash posting teams did this and haven’t gone back. But with paper, working remotely is a massive challenge,” Catton-Chastain explains. “We saw a lot of checks piling up in offices.”

The shift to remote administrative work will be a major driver of electronic claims payment adoption. But providers will also reap the revenue cycle benefits of having timelier access to complete claims data, including faster reimbursement, streamlined billing, and more accurate financial tracking.

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Zelis harnesses data-driven insights and human expertise as scale to optimize every step of the healthcare payment cycle. We partner with more than 700 payers, including the top-5 national health plans, Blues plans, regional health plans, TPAs and self-insured employers, 1.5 million providers and millions of members, enabling the healthcare industry to pay for care, with care.