Private Hospitals: How to maximise private health claims

Private hospitals: Why it pays to get private health claims right first time

Claims leakage: It’s a term that can cause more than just financial loss for private hospitals, it can also result in a serious amount of administration grief – years after a claim was first sent through.

Why? Effectively, private health funds are under an incredible amount of competitive stress. One of the most effective ways to ensure they maximise revenue is by preventing claims leakage on their side of the fence. Their answer? Regular back audits on hospital claims.

In a nutshell, if a past or current claim isn’t 100% accurate, the health fund will query it with the private hospital. This is particularly so with the larger funds, as they have the resources to uncover procedural code contradictions, any likelihood of overservicing, non-alignment with Medical Benefits Scheme (MBS) and Australian Classification of Health Interventions (ACHI) codes, or just plain lack of knowledge or experience during the hospital coding/auditing process.

To confuse things further, there are no broad set of rules when it comes to insurance contracts between private hospitals and health funds; each can be as varied as the hospital offerings themselves.

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Doctors are at the sharp end of the equation

Private health funds can have up to two years to query a claim.

And it’s hardly surprising that, if claims are rejected two years after submission, they can seriously affect the funding and revenue – along with financial planning of a hospital.

If a claim is rejected, the additional auditing by the HIS can be time consuming and costly – as it requires thorough consultation with the Doctor who signed off on the MBS code prior to any procedure/s. (If the doctor has since left, that can complicate things even more.)

Consequently, doctors come under considerable administrative pressure to get their procedural scope 100% correct from the outset. Considering patients may develop additional complications, or have unknown morbidities, the situation can lead to under or overclaiming by the doctor in question – which of course will need their explanation.

The solution is ‘certainty’

Due to the increased attention that leakage has acquired from both sides of the claims spectrum, coding and auditing have become highly specialised fields.

Dedicated HIS teams are now common in all private hospitals to avoid revenue loss associated with inaccurate coding and incomplete documentation. However, despite all the specialised procedures and ongoing training associated with coding and auditing, mistakes still get made – particularly if traditional spreadsheets are being populated manually and data is being kept without good governance procedures in separate departments.

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The resulting mistakes can cost any hospital considerable amounts of money. This is where Clinical Coding Auditing Software can provide the oversight and visibility to correcting and coding accuracy.

With Code Focus, for instance, all MBS AND ACHI claims are 100% aligned – so it automatically flags whether an episode can be claimed or not.

The platform also educates Health Information teams and clinicians as they work – showing and explaining any mistakes they have made, what should be done and why. Any vital information which may be missing is highlighted as well and consequential queries are streamlined and recorded within the case history.

The software is also real time, so any changes to the MBS are identified to all users immediately; the platform also integrates and updates with other hospital reporting and procedural software (avoiding human error with data entry); and raw data can be collated for accurate, streamlined reporting and administration.

Simply put, Code Focus offers a key management tool that assists every department.

Ensure quality of coded data

First time right approach saves time and money

In conclusion, the only way private hospitals can confidently claim from health funds is to take a ‘first time right’ approach.

It simply saves considerable time, money and administrative problems down the track.

With Code Focus’ educational feedback loop, configurable real-time auditing, management status tracking and reporting insights, one would have to question the cost effectiveness of not running an automated system.

For a no-obligation demonstration of how Code Focus can answer your unique coding and auditing problems, contact Callum Haggerty at Data Agility.

Book a demo today.

Find out how Code Focus can help optimise your health information management.


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