Automation of Copay Management to Tackle Hidden Financial Risks:
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Introduction
Credit balances are a concealed financial burden in the healthcare industry, typically accounting for 1% to 5% of total gross accounts receivable. To put that into perspective, if a healthcare organization has $100 million in receivables, a 3% credit balance translates to a staggering $3 million of potential revenue sitting idle, waiting to be refunded or reconciled.
What is messier is that mismanaged credit balances can open the door to serious legal and compliance troubles. Under the Affordable Care Act, Medicare and Medicaid overpayments must be reported and refunded within 60 days. Failing to address these balances can result in penalties, including charges of fraud under the False Claims Act.
Such challenges were becoming all too real for one of the leading Urology Healthcare Facilities in the US. Copayments made in advance were not properly reflected in the billing system, resulting in inaccurate outstanding balances and growing patient dissatisfaction.
Recognizing the need for a solution, the facility turned to Nalashaa for help. The mission: to automate the process of updating copay information on newly created claims, ensuring that credit balances never materialize in the first place
The Need for Automation
Managing credit balances isn't just a matter of bookkeeping—it's a resource-intensive process that demands constant vigilance, driving up operational costs without directly contributing to revenue. With just one staff member processing and updating around 350-400 claims daily, the task becomes overwhelmingly tedious and repetitive. Without automation, there’s a risk that copayments could be mis-recorded or missed entirely, resulting in excess credits on a patient’s account. Thus, it was imperative to create a reliable process to accurately reflect the financial status of each patient’s account.
Streamlining Claim Management through Automation
The client provided a daily report containing all the claims and their associated copay amounts. The team at Nalashaa developed a Copay bot that used the data in the report, to open each claim individually, and update the copay amount in the respective records. When a claim is created for a service, the system would automatically apply the recorded copay, reducing the outstanding balance, making it easier for the billing team to reconcile the amount accurately when the ERA/EOB was received for the claim.
Benefits
Nalashaa embarked on a journey to integrate client’s D365 platform with DocuSign, leveraging the robust capabilities of both systems by developing a comprehensive solution:
Improved Accuracy in copay mapping
The Copay bot achieved a 100% success rate, needing just 10 seconds to update each claim compared to the one minute it would take a human to perform the same task.
Productivity Improvement
Reduction in administrative tasks allowed the billing team to focus on more critical responsibilities.
Cost Savings
The reduction in manual labor and the efficiency gains translate into cost savings, as fewer resources are needed to manage the same volume of work.
Improved Compliance
The automated process ensures that copays are consistently and correctly applied, aiding in compliance with healthcare regulations and reducing the risk of penalties.
Technology Stack
