Few people outside the healthcare industry have any idea how complex the claims approval process can be – or how significant the claims payment issue is overall for medical clinics, especially the smaller ones. At Timmaron Group, we’ve even heard numbers that suggest some 80% of claims submitted by clinics nationwide are rejected the first time, whether it’s by CMS or private insurers. Even after submitting a second and third time, the rejection rate can still be as high as 70%. For small rural clinics, it gets even worse – some say 90-95% of their claims are initially rejected! One large clinic-oriented health system we have spoken with has 900,000 unpaid claims backed up, some as old as 24 months.
The root causes of the problem reside in three areas: the front office, the back office, and the claims submission department itself. The big missing piece, especially in small rural clinics, is simply a lack of proper training. Front office personnel (often just a lone receptionist or admin) get little training in proper patient in-take – that is, asking the right questions and documenting that in-take. The back office has to get patient-visit notes into the electronic health record, and that is often not done properly because of staff shortages or the overwhelming workload of the doctor or doctors in the clinic. Again, proper training can be lacking here as well. Thirdly, claims pile up for the personnel responsible for actually filing the claims, and once again, training is a major unmet need – to ensure proper data and coding are used. The result is far-too-often a downward spiral, with these small clinics continuing to suffer and lose more revenue with every new patient.
While most doctors understand general business, they are much more focused on healing their patients.
At Timmaron Group, we have a solution. It’s based on our 25 years of experience in data and AI, and our long experience with the Deming Model. It involves observing and documenting the processes of the clinic, in the front office, the back office, and the claims submission department. Then, we write an LLM (large language model) against the workflow of the clinic that allows us to provide a clear, ongoing solution. That level of expertise, of course, just doesn’t exist in small clinics. But we understand and use AI extensively, and we know the need for an entire revenue management model – which actually involves more than just getting claims paid.
If you’re in the medical clinic business and would like to know more, we’d be happy to book a call with you. Start with an email to hi@timmarongroup.com.
