Unlocking 835 Remittance Files for Increased Revenue

Accessing and understanding the data trapped in 835 EDI remittance files can have a significant impact on the financial health of hospitals and providers of all sizes. Plus, unlocking key data elements such as claim header and service line data offers immediate value and can provide hospitals with a competitive advantage, such as a reduction in denials of 3-5%… which has the potential to increase revenues by $5-10 million. By identifying denied service lines, the hospital is able to fix an incorrectly billed CPT-4, for instance, to ensure not only correct payments for existing claims, but also future claims.

OTHER OPPORTUNITIES FOR REVENUE BOOSTS

Improving revenue cycle management (RCM) enhances the efficiency, quality, and financial performance of hospitals, including:

  • Resolution of denied claims. Whether measuring denials by payer, DRG, procedure code, adjustment reason code, or other cause, the data just needs to be unlocked, transformed, and analyzed to quickly determine the real drivers for denied claims.
  • Reconciliation of outbound claims with inbound remittances. Automated tracking correlates 837 claims submitted with paid or denied 835 claims.
  • Crossover/Coordination-of-Benefit Claims. Identify complex claims with multiple payers.
  • 4010 v. 5010. Accommodate ICD-10 coding structure. The need to interpret and report on 835s, whether in 4010 or 5010 format, is more critical than ever.
  • Provider level adjustments. Those neither at a claim level nor service line level still impact actual payment to a provider and need to be considered.

By accessing and employing 835 EDI files for RCM, a self-service data prep platform can be used to manage cash flow, see revenue across service lines, and drill down to claims. Analysts can look at aging by accounts, payer, age, patient type, service line, or procedure in a more dynamic environment. They can identify gaps in processes, or denials by service line, and determine where corrections are needed in order to recapture potential lost revenue. The platform allows for distribution of information to all users, via the web, in a secure environment.

For more advanced analytic users, a self-service data prep platform provides a web-based interface to interact directly with the sourced report. Given that the platform can store the sourced reports, users can search across time periods to create trend analyses. And annotations can be added on any piece of data on the report or in any section of the report.

With access to basic analytic views, each end-user can create his/her own filter from which to sort and view data. The analytic module interacts with data trends by service line, age, patient type, payer, patient name, and more as requested. Trends are displayed by medication, patient, unit, and nurse to uncover medication errors. Labor distribution can be viewed by hours, salary, pay rates, overtime, and more in order to improve the client use of staff. And the more graphical-oriented user can aggregate views into dashboards.

With self-service data prep, users can make better decisions and solve business problems by simplifying access to information in 835 remittance files. Within two weeks, individuals can be up and running, creating and sharing basic reports. And with an ROI that’s typically measured in days, not months, healthcare providers can realize savings almost immediately.