What You Should Know About Pending Claims and Their Impact on ROI

As the world of medical credentialing and privileging continues to grow, one thing we can count on is that provider enrollment is where the financial component of a health system resides. It may even be fair to say that when it comes to enrollment, poor provider data management is where a large portion of unnecessary cost is accrued. Keeping track of all variables that impact our bottom line is a must, which is why we’re eager to share our findings from this year’s Annual Report on Provider Enrollment, and what we uncovered regarding pending claims.

In our line of work, we’re all too familiar with terms we’d rather not hear about: claims that are on hold, have been denied, or have been written off. And yet, as much as we’d like to avoid them, they are a part of our day-to-day.

So, what are the three types of pending claims that financially affect a healthcare organization?

• On Hold – claims awaiting confirmation of enrollment from the payer
• Denied – claims that have been denied by the payer
• Written Off – claims that have been written off because of delays in enrollment timeframes which would make the claim ineligible to be paid

Any claims in these statuses negatively impact your organization's bottom line. But, they result in more than just dollars on hold or lost, they also cost you time.

Crunching the Numbers

In our 2020 Annual Report on Provider Enrollment, we uncovered exactly how much time and money pending claims are costing.

In terms of full-time employment (FTE) hours, we found:

• 18.9% spent >3 hours researching claims classified as on hold and/or denied
• 9.2% spent 2-3 hours researching claims classified as on hold and/or denied
• 10.6% spent 1-2 hours researching claims classified as on hold and/or denied

More than a third (38.3%) reported they did not know how much time was spent!

In terms of dollars on hold, we found:

• 31.3% of respondents had less than $500,000 on hold
• 16.98% of respondents had between $500,000 and $999,999 on hold
• 11.32% of respondents had between $1 million and $5 million on hold

A little less than half (42.7%) reported that they did not have access to the average amount of dollars on hold.

In terms of dollars written off, we found:

• 12.5% of respondents wrote off between $500,000 and $999,999
• 37.5% of respondents wrote off less than $500,000

When asked if their organization and/or enrollment department tracked the reasons why dollars are written off, 81.8% affirmed their organization does track the reason why, but the sample size for this question was only 11 individuals.

Some of the reasons dollars were written off include:

• Provider’s credentialing approval was delayed
• The office location where the patient received services was not enrolled
• Locum provider-enrollment was not notified within timeframe
• Provider was not enrolled at the location where services were provided

Improvement Opportunities

Clearly, there is opportunity to implement facility-wide changes that can improve these numbers. Staff and leadership need to understand how their work contributes to their organization's revenue. So, what are some actions employees can take?

• Identify a revenue cycle/billing service leader to be your source of information
• Request monthly, quarterly, annual reports
  • Try to obtain ad hoc access to data, to run reports on your own
• Create enrollment dashboards focused solely on financial data
• Work closely with your billing and revenue cycle teams for both hospital and professional billing
  • Collaborate with them on claims, holds, and denials

What’s Next

This year’s Annual Report on Provider Enrollment has made it clear that there is fragmentation in the processes related to provider enrollment, but there is also evidence that many organizations are taking steps to integrate their processes. This is mostly evident in the number of organizations that have integrated credentialing and provider enrollment. Nearly two-thirds (63.3%) of organizations without an internal health plan reported that they used the same department to perform both credentialing and enrollment.

The data above is but a sampling of what the 2020 Annual Report on Provider Enrollment taught us this year. Be sure to download the report today and get all the details you need, whether they be about pending claims, delegated credentialing, or enrollment operations priorities. Here at VerityStream, we’re dedicated to helping you with all your provider enrollment needs, and that starts with knowledge powered by data.