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Adapting to a New Reality


The growing need for payment automation and reconciliation

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It’s safe to say that healthcare already has one of, if not the most different and complex payment models of any industry. Think about it – you do not get paid the amount you bill; the actual value of your services is, in fact, determined by a third party; and payment for a single patient invoice may come from multiple parties through a combination of both electronic and paper payments.

The result is a claims process that’s exceedingly costly and incredibly error-prone. And it’s a process that’s getting exponentially more complex by the minute. Over the past several years, the receivables landscape has dramatically shifted. Employers continue to migrate to lower-cost, high-deductible plans, shifting a greater percentage of the payment burden from insurers onto individuals.

This means you now have a steady stream of both insurance payments and patient payments coming into your organization that you need to post to your practice management system. As the vast majority of insurers moved to electronic payment, the expectation was that this process would simplify, streamline and expedite the payment process. But although the number of insurance payments coming into your “lock box” service is decreasing, the number of patient payments is skyrocketing. Today, with most of healthcare providers, about 65% of the checks coming into their lock box are patient payments.

Given this new reality, and in order to facilitate payment, new legislation has been put into effect mandating that all payers offer Electronic Funds Transfers (EFTs) and Electronic Remittance Advice (ERAs) as payment options. Unfortunately, this raises new reconciliation challenges for providers since these two payment methods come through two distinctly different paths. EFTs (or ACHs) come through your bank, while ERAs come through a clearinghouse or directly from the payer. You’re going to have to be able to reconcile that information.

Faster claims; faster payments

More than ever before, healthcare providers are realizing the critical importance of accelerating claim submissions and payments, and maximizing workflow efficiencies, all while continuing to satisfy the healthcare needs of their patients. Payment automation and reconciliation solutions like SunTrust’s eClaim Revenue Gateway® offer a simple means to take all your highly labor-intensive paper payments and convert them into an electronic transaction that’s posted in your system, freeing up valuable staff resources and reducing human errors in the process. For your payments that are presented automatically, these systems conduct a full reconciliation.

The benefits of these types of automated solutions aren’t just payment-related. They also:

  • Help to quickly identify exceptions so that you can work with payers to mitigate them going forward (and in turn, reduce some of your hard costs).
  • Give you visibility into all of your payments so you can see trending, denials and whether or not payers are paying the appropriate allowable amounts.
  • Allow you to research information and pull it up within seconds (every single payment is indexed down to the service-line level). If you don’t have a document management system, this can provide a huge time savings.
  • Improve your workflow by serving as a self-service portal (eliminating bottlenecks by enabling any “permissioned” employees to access transactions).
  • Eliminate paper storage, retention and destruction costs.
  • Provide you with a scalable solution that can easily adapt as your organization grows.

The reporting mechanisms that some payment automation and reconciliation systems provide will let you know immediately where rejections are occurring (e.g., what procedures, what payers), giving you immediate visibility into those rejections rather than having to wait a month down the road to realize you haven’t been paid for certain transactions.

Mitigating risk

Since payment automation and reconciliation system providers hold themselves to the same level of HIPAA compliance as you, there are no privacy concerns. Your Protected Health Information (PHI) is just that, protected. And because the information is held by a third-party, it spares you from having to develop extensive internal risk management protocols. With any information that’s automated, you have tools, mechanisms and permissions built into a payment automation system to help mitigate the possibility of fraud, not only for HIPAA but other legislation that’s out there like PCI compliance.

These systems are also highly scalable, an important consideration in an industry where mergers and acquisitions are the order of the day. Most importantly, however, they allow you to reallocate your staff to the jobs that best utilize their skill sets, allowing your entire organization to spend more time focusing their efforts on patient care rather than administrative tasks.


This content is general in nature and does not constitute legal, tax, accounting, financial or investment advice. You are encouraged to consult with competent legal, tax, accounting, financial or investment professionals based on your specific circumstances. We do not make any warranties as to accuracy or completeness of this information, do not endorse any third-party companies, products, or services described here, and take no liability for your use of this information.

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