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Managing Revenue Leakage in Healthcare

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Managing Revenue Leakage in Healthcare Article – Written By: Dr. Jesupelumi Adenihun 

Revenue leakage as any unnoticed or unintended loss of revenue from your company – Recvue. Revenue leakage in healthcare according to Srishti is the difference between the amount of payment that is entitled to the healthcare provider versus the amount of reimbursement received. 

For clarity, few terms would be defined below. 

  • Claim: this is a request for payment the healthcare provider tenders to the health insurer (e.g., HMO) for service rendered to the patient.
  • Denial: occurs when the insurer refuses to pay for an item or service. If this happens after a claim has been sent following delivery of service, it then becomes ‘claim denial’.
  • Revenue cycle (RC): A revenue cycle starts when a patient books an appointment and ends when all claims and payments have been collected by the healthcare provider. 
  • Accounts retrievable (AR): The amount of money owed to healthcare providers for services and care delivered to patients. 

To understand how revenue leakage can play out, the case of Mr. Tanso Justice, a 45year old architect would be considered. (The names or conditions inserted have no bearing to a real person and is solely being used for the purpose of learning).

Mr. Tanso Justice is married to a banker who has insurance covering for their family with JayPMog HMO. He developed abdominal pain which he initially ignored but the situation worsened and became associated with reduced appetite. Realizing his need to see the Doctor., he goes to their provider hospital (Leyden hospital) to get checked. 

On arrival, his details are captured, vitals checked and then proceeds to see the Doctor. In the consulting room, the Doctor asks Mr. Tanso asks some questions, examines him and prescribes analgesics and supplements alongside dietary advice. He requested that he get a blood test done and abdominal imaging. Although, at this stage, there is no clear diagnosis yet. The Doctor, in his bid to clear the patients at the waiting area, decided to fill in details of visit at the end of all the consultations.

However, after seeing Mr. Tanso, he realized he was fatigued and decided to go on a break after which he would return to fill in details of the consultations. On returning from his break, he missed certain details on the services he had rendered. He decided to leave out information he was not sure of and deduced the diagnosis for some cases from the prescriptions he sent to the pharmacy. 

Having carried out requested investigations, Mr. Tanso picked his medication and returned the following week with his results to see the Doctor. However, this time, the attendant at the front desk captured his name as Mr. Tanko Justice. The Doctor referred him to a specialist as he had an intestinal growth. During this consultation, all details are inputted immediately and a working diagnosis. Only that this time it is under the name ‘Mr. Tanko Justice’ as sent by the front desk. 

All this while, Mr. Tanso had made no payment out of pocket and as far as he was concerned, JayPMog HMO was doing a great job. His appointment to the specialist involved further questioning and examination although he could not view his last hospital visit as there was only one documented visit to his name – his first visit. The Consultant requests he get tested for certain tumor markers just to be sure. Mr. Tanso is booked for the above-mentioned test but a call could not be put through to the HMO at that time to confirm if the test was covered. The front desk attendant eventually assumed that this was also covered. A patient had presented with a similar condition from the same HMO and got approval. What she forgot was there are different plans and coverage with HMO.

He gets his test done, returns to the consultant who states there is no problem and gives him a long appointment. All this took place within the space of 3 weeks and the hospital raised claims which received few denials especially the test for the tumor markers. Mr. Tanso is called to pay for the investigation done but insists his HMO should cover that ‘little’ blood test he did in his words. The continuous back and forth on the phone only resulted in a lengthy conversation with no payment. 

From the case study presented above, leakage points can already be identified. And no matter how small they seem, they usually result to a large sum being lost over time. Modern healthcare conducted a research across hospitals in Florida and discovered 9% of claims raised are denied resulting in an annual revenue loss of $262 billion. Recent research even shows denial rates have risen to about 11.1% which will continue to be on the rise if not curbed. 

The image below by Effy healthcare highlights possible causes of revenue leakages and can also be used to relate with Mr. Tanso’s case. 

It is therefore highly imperative that healthcare organizations stay in the black and remain financially healthy. One of the ways of doing this is managing leakage. Failure to do so often results in huge and expensive losses. Some facilities even fold up when they can no longer be sustained. To address the issue of revenue leakage, the first step is to identify and quantify how much revenue is being lost. It would suffice to further identify areas operating effectively and those that need to be worked on.  

General improvement measures that can be taken include: 

  1. Automating manual processes. Going digital has been shown to reduce errors and save time. 
  2. Training staff on proper billing and coding. 
  3. Ensuring claims are sent in good time. The longer they take, the more likely they are to get denied. 
  4. All procedures should be confirmed from the insurer in a timely manner to confirm coverage before being done.
  5. Patients should be communicated with politely yet effectively when the insurer is not covering the cost of care.
  6. Claim denials should be treated promptly by the team involved when sent. 
  7. Team handling patient care should be constantly reminded of the need for proper documentation as this does a long way in receiving payments due. 
  8. As the need may rise, revenue management should be outsourced for proper revenue cycle management services.

Revenue leakage can be managed. It may be cumbersome attempting to solve all at once. But there are improvements that can be made from time to time in addressing the issues whether simple or complex. Healthcare is dynamic and as such requires the willingness to be dynamic in addressing the challenges.

 

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aYo Zambia launches Family Cover in response to ‘overwhelming’ demand

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aYo Zambia CEO, Andrew Nkolola

microinsurer aYo Zambia has has just launched Family Cover, which allows Zambians to get hospital and life cover for themselves as well as their direct and extended families without filling in a single form. The new product will also see all premiums collected (and claims paid) via the MTN Mobile Money (MoMo) platform. Until now, aYo has offered hospital and life cover to individuals only through two insurance products, ‘Send with Care’ and ‘Recharge with Care’. But a growing market demand for insurance for the whole family prompted the company to create the new Family Cover product, which allows policy holders to add up to seven people, including themselves.

“As of today, we have had over 3.5 million customers purchase cover to protect themselves for hospitalisation in the event of illness or injury, or loss of life,” said aYo Zambia CEO Andrew Nkolola. “But many of our customers have been asking us: ‘How will we safeguard our children and families if something happens to them? We don’t want benefits only when something happens to us.’ We realised it was a huge gap in the market and have responded accordingly.”

As with aYo’s existing products, Family Cover customers must maintain active Mobile Money (MoMo) accounts to pay premiums and claim. This will allow them to insure up to three other family members per benefit, for a total of seven people. Family Cover allows policyholders to add extended family as well as direct relatives between the ages of 1 and 69.

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Customers can enrol family members by dialling the USSD code *296* and selecting the Family cover option to enrol and manage cover. As with ‘Send with Care’ and ‘Recharge with Care’, valid Family Cover claims are paid directly to the claimant’s mobile money wallet without any hassles.

aYo was recognised as the Most Innovative Ecommerce Product in Zambia by the Institute of Finance and Economics in October, and followed that up in November with three awards at the Pensions and Insurance Authority Industry awards: Microinsurance product of the year, Best Customer Centric Experience, and Product and Service Innovation of the Year.

“The market perception of insurance in general is changing. Today, every Zambian consumer can purchase insurance on the go, using their mobile phones. Offerings like Family Cover provide a much-needed social safety net that helps vulnerable people and particularly people with low incomes to stay afloat when the unexpected happens,” said Nkolola.

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mPharma acquires majority stake in HealthPlus

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mPharma, Africa’s leading patient-centered technology-driven healthcare company, has acquired the majority stake in HealthPlus, the leading pharmacy chain in Nigeria. mPharma and the former investor, Alta Semper, have signed an agreement leading to the acquisition of a majority stake in the HealthPlus Group.

According to the Chief Executive Officer and Co-founder of mPharma, Gregory Rockson, the acquisition is in line with the company’s mission to build an Africa that is in good health by delivering life-changing healthcare services and drugs to improve health outcomes for patients. He stated that the acquisition of the HealthPlus Pharmacy chain by mPharma complements mPharma’s deep commitment to increasing patient access to affordable and quality healthcare in Nigeria.

“mPharma is deepening its long-standing commitment to Africa by reimagining primary healthcare in some of the most vulnerable communities on the continent. We continue to transform community pharmacies into primary care centers to provide affordable and accessible healthcare to all patients so they can live not just longer but healthier lives. We are optimistic about the future of healthcare for Nigerians through the acquisition of HealthPlus.”, said Rockson.

In her remarks on the acquisition, Afsane Jetha, Co-founder and CEO at Alta Semper Capital, said: “We are delighted about HealthPlus’ partnership with mPharma. We have a strong conviction in mPharma’s strategy of revolutionizing primary care across Africa and believe mPharma is the ideal steward for HealthPlus’s next chapter of growth. We believe mPharma’s vision is consistent with that of HealthPlus’s shareholders and employees, and we are enthusiastic to support the business through a relationship with mPharma going forward”.

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While mPharma plans to continue to keep and strengthen HealthPlus as Nigeria’s leading pharmacy brand in Nigeria, the acquisition will also provide expansion opportunities for mPharma within Nigeria and a platform to expand mPharma’s mutti pharmacy retail footprint across the continent through its fast-growing QualityRx program. Powered by mPharma’s proprietary Bloom software, HealthPlus will provide patients access to affordable primary care services within its pharmacies, in addition to affordable and quality medications it currently retails across 12 states in Nigeria. The HealthPlus pharmacy chain will also launch mutti®, mPharma’s health membership program, which will provide both existing and new customers with discounts, interest-free “heal-now-pay-later” plans, free health screenings, and other primary care services.

By combining HealthPlus pharmacies with mPharma’s growing portfolio of partner mutti pharmacies and GoodHealth shops (PPMVs),mPharma’s network will grow from 224 to over 320 health facilities in Nigeria and will provide care to more than 100,000 Nigerians each month.

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Chantel Cooper: The Epitome of Empathy and Care

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Chantel Cooper, CEO of The Children’s Hospital Trust (Image: Supplied)

Chantel joined the Children’s Hospital Trust in 2013 as the Head of Fundraising and Communication and was appointed as CEO in 2019. For her, 2020 was a year that reinforced the importance of the core purpose of the Trust and the difference the organisation wants to make in the lives of children. “Our cause is driven by the need to make a difference in the lives of sick and injured children. We are people who work together to save the lives of the children who matter. We all have a purpose!” she says.

Sharing excerpts from her journey, Chantel says:

“My purpose in life is to serve those who are most vulnerable: women and children. My career was driven by my passion to make a real difference in the lives of women and children. When I was 18 years old, I volunteered for an organisation that provided support for women who had been raped. While volunteering, I started working with women in rural areas in the Eastern Cape where we found opportunities to grow their businesses.

“My passion for women led me to Cape Town where I became Director of Rape Crisis Cape Town when I was 27 years old. After the birth of my two children, I moved to an organisation called St Joseph’s Home for chronically Ill Children. St Joseph’s is a step-down facility for tertiary hospitals like the Red Cross War Memorial Children’s Hospital. It was a profound move for me as I was able to work with children who inspired me.

“One of the most valuable lessons I learnt is the power of love. You can offer a child the best healthcare in the world, but what a child wants most is their parents to love them and be by their side. This is the value I most appreciate about the Red Cross War Memorial Children’s Hospital and my past experiences. This hospital believes in child-centered care and knows that a child heals when their parent or caregiver is by their side – even during the COVID-19 pandemic. All other hospitals had restricted access to patients, but the presence of a parent is imperative to their sick or injured child’s healing.”

Overcoming Adversities

“The COVID-19 pandemic taught our team that life can change in a blink of an eye and that we need to be prepared for all possibilities. The pandemic hit the world with such speed and velocity that we had no choice but to find a way to not only sail through the storm but also find ways to get out of the situation stronger than before.”

Chantel also states that 2020 provided the Children’s Hospital Trust with the opportunity to learn extraordinary lessons that they would not have normally had the opportunity to learn and some of these include:

  • The value of deep listening and the importance of demonstrating kindness.
  • Working in collaboration created the opportunity for meaningful impact for our beneficiaries.
  • Opportunities do exist during challenging times; positivity exposed the opportunities.
  • Adapting to change during uncertain times helped to build a resilient team.

“Our Trust team demonstrated ingenuity, compassion, resilience, commitment, and fortitude during a very difficult time. As a result, we surpassed our goals, and this enabled our organisation to reach more children and families. We are grateful for the contribution from every individual,” adds Chantel.

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“Walking through the corridors of a children’s hospital during a crisis gave perspective on the real value of care, kindness, and collaboration. While children were not the face of the COVID-19 pandemic, the Social Work Department experienced first-hand the profound impact the pandemic had on children’s health and well-being.

“Unemployment, food insecurity, child safety and schooling were common concerns for many patients and their parents who entered the doors of the Hospital. The Red Cross War Memorial Children’s Hospital values patient and family-centred care which includes care for the whole family from a holistic perspective.

“In response to the needs of the families, the Trust secured funding to enable the social workers to provide additional counselling services and material support such as the provision of food, hygiene, and home-schooling supplies to vulnerable families when children were discharged from the Hospital.” Read more on the Family Care Project here.

Redefining Excellence

The core to achieving our vision is upholding our values of Integrity, Accountability, Kindness, Dynamism, and Collaboration in every aspect of our work. The Trust has a sound financial record in administration and good governance. For the past 28 years, we have raised funds to address many pressing needs, but much has yet to be done. With the help of many donors, we continue to give hope and healing to our little ones who need it most.

The Trust raises funds for the upgrade and expansion of the Hospital’s buildings, the purchase of state-of-the-art medical equipment, and new medical treatment projects and funds the training of medical professionals across Africa – ensuring that the Hospital not only retains its world-class stature but is able to continue providing life-changing and life-saving care for children.

The Trust relies on donations to fund these needs. When you donate to the Trust, 100% of your donation goes towards funding projects that change children’s lives (and the lives of the people who love them). The operational costs of the Trust are funded from an endowment, so your generous contributions are never used to cover administration costs.

Donate to the Children’s Hospital Trust today! www.childrenshospitaltrust.org.za

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