15-20 years ago, the cash posting unit of a hospital was one of the larger units within the business office. Lots of man hours were needed each day to organize and manually post paper checks/remits from the wide variety of payers in the marketplace. Staff in these positions had to understand how the keystrokes they completed impacted the remaining accounts receivable after a payment was posted, along with the many differences in how each payer processed (and paid) on claims. Is this a full payment? Partial Payment? Denial? Does the remaining balance need to move to the next payer or to the patient? While the process was 100% manual, with the right team in place you could ensure the remaining accounts receivable was clean, allowing follow-up staff to focus their attention on accounts that truly needed follow-up. The key challenge was ensuring staff had adequate training and controls were in place to minimize human error.
Fast forward to today and most organizations are operating with a fraction of the staff, relying on enhancements in technology and automation to complete the daily cash posting process. Many hospitals are utilizing 3rd party tools/vendors to organize incoming electronic remits from payers that can be posted through an automated process into the Electronic Health Record (EHR). The promise of eliminating human error through automation has always been a key selling point to moving away from manual cash posting. Do the same job with less staff at a higher level of quality; sounds great! In a perfect world, a cash poster would simply import the electronic remit into the EHR and payments/adjustments would post automatically and accurately with little to no intervention. While this process can (and does) work very well for some organizations, the simplicity promised is not reality. There is now a new set of critical points in the process/configuration that can lead to less than optimal results:
- ANSI/CAS code usage by payer varies – While there are standards in place, there are numerous inconsistencies in the codes used across payers that indicate denials, contractual adjustments, etc. Usage for an individual can also change suddenly without warning. Cash posters need to be aware of the differences AND be on the lookout for changes so that configuration downstream can be adjusted.
- Paper EOB Interpretation – For payers that still provide paper EOBs, many hospitals use conversion tools that convert the paper EOB to the 835 format – but is the interpretation correct? While there are fewer and fewer payers out there that still provide paper EOBs, they do exist. Converting what is on the EOB has to not only be accurate, but also has to be evaluated periodically to ensure the payer hasn’t changed their format or usage of codes.
- EHR Configuration – One of the most important pieces of the process is the configuration within the EHR on how the electronic remits are interpreted and automated actions are performed on the account. Should certain ANSI/CAS codes be interpreted as contractual adjustment? Should certain codes hold the remaining balance with that payer because it is likely a denial? Should certain codes automate a non-contractual adjustment? When should the balance move to the next payer or to the patient?
- Process Monitoring and Adaptation – Lastly (and equally as important as the technical configuration), cash posters need to be able to identify and resolve errors in the automated process on an exception basis. The idea of simply hitting a button and everything working is unfortunately not the reality. Cash posters also need to be able to spot and escalate key themes/issues in #1-3 so that they can be addressed in the configuration and/or how they are “fixed” on an exception basis.
Missing the mark with any of the items above can lead to numerous issues and rework:
- Erroneous credits
- Inaccurate patient balances/statements
- Adjustments on denials that still have cash opportunity
- Inflated accounts receivable from inaccurate insurance balances requiring additional clean-up, but no additional cash value
- Staffing constraints leading to unposted cash or cash research backlogs
Are you experiencing any of the issues above with your cash posting process?
For more information related to the cash posting process or revenue cycle management, please contact Andrew at Ajacobsen@PinnacleHCA.com.