Electronic Health Records (EHRs) have revolutionized healthcare delivery. From just 16% adoption in hospitals back a decade ago to over 96% this decade, EHRs have become the backbone of modern medical practice.
According to one survey, the most common EHR platform is EPIC Systems at 41 percent of the market share, followed by Oracle Cerner at 21.8 percent, and MEDITECH at 11.9 percent. These EHR systems have transformed how clinicians access patient data, manage workflows, and deliver care.
Today’s sophisticated EHR systems offer impressive capabilities: seamless interdisciplinary communication, comprehensive patient histories, customizable clinical workflows, powerful analytics, and integrated e-prescribing. These features have made EHRs indispensable for healthcare providers focused on delivering exceptional patient care in an increasingly complex medical landscape.
But here’s what most hospitals and healthcare systems don’t realize: while your EHR excels at clinical-care and standard revenue-cycle tasks, an expert in complex claims management can help get the most out of your hospital’s revenue recovery efforts working alongside your EHR system.
What Is an Electronic Health Record (EHR) System?
EHR systems represent the digital evolution of traditional patient charts. These comprehensive platforms capture and organize essential patient information—from basic demographics and medical histories to diagnostic results, vaccination records, clinical notes, lab findings, imaging data, and vital signs.
While EHRs and electronic medical records (EMRs) are often used synonymously, EMRs typically offer expanded functionality spanning billing operations, telehealth connectivity, and coordinated care management.
For today’s healthcare systems, EHRs function as the digital backbone of patient data management, serving as centralized repositories for all clinical information.
The Complex Claims Challenge
Most EHR systems include basic revenue cycle management features—insurance verification, standard claims processing, patient billing, and coding support. These work beautifully for routine commercial claims, but managing complex claims might work better when coupled with a complex claims expert.
Complex claims—including motor vehicle accident (MVA), Veterans Administration (VA), workers’ compensation (WC), and out-of-state (OOS) Medicaid—require specialized handling that standard EHR workflows aren’t necessarily designed to manage. Instances where a dedicated RCM expert might make a difference include:
MVA Errors: MVA claims can sometimes get misdirected to the wrong insurance carrier
Out-of-State Medicaid Losses: Some OOS Medicaid claims never get filed at all due to enrollment complications, representing massive revenue losses
Workers’ Compensation Misdirection: Workers’ comp claims can get routed to incorrect carriers, creating payment delays and driving up administrative costs
VA Claims Denials: VA claims can face denials due to preventable issues like missed filing deadlines, coding errors, authorization problems, and carrier mix-ups
These bottlenecks add up—they can represent millions of dollars in recoverable revenue that healthcare providers leave on the table every year.
Where Human Expertise Meets EHR Technology: Complex Claims Excellence
1. Deep Regulatory Knowledge
Successfully managing complex claims requires expertise that some EHR systems might or might not be able to provide. Payer requirements and processing regulations change frequently—and not uniformly across states. Out-of-state Medicaid exemplifies this challenge perfectly: each state maintains its own unique regulations and enrollment requirements.
EHR systems don’t always offer comprehensive multistate, cookie-cutter support, forcing providers to invest significant time and resources building custom capabilities—if such options even exist within their chosen platform.
Experienced OOS Medicaid vendor partners like Aspirion understand payer differences across all 50 states.
2. Specialized Documentation Requirements
Complex claims demand detailed documentation that differs dramatically from standard commercial claims. VA claims require specific medical documentation formats, while workers’ compensation cases need entirely different supporting materials. Many commercial claims need only prior authorization, but complex claims often require comprehensive medical records with each submission.
EHR systems aren’t typically optimized for these varying documentation requirements. This is where the right complex claims partner becomes invaluable.
3. Advanced Denials Management
Complex claims face significantly higher denial rates than standard commercial claims due to their intricate nature involving multiple payers, specialized coding requirements, and varying reimbursement rules. While EHR systems provide basic denials management tools, they can sometimes lack the sophisticated capabilities needed to successfully overturn complex claim denials.
Consider fee schedules: most EHR systems default to Medicare fee schedules, which work fine for many claims but lead to denials or underpayments when other specialized fee schedules are required. A dedicated RCM partner can help prevent denial errors that typically drain revenue.
4. Multi-Payer Compliance Navigation
Each payer group operates under distinct rules and regulations, creating compliance challenges that generic EHR workflows might not be able to address. Workers’ compensation claims, for instance, require specific expertise to avoid authorization errors, missed filing deadlines, and coding mistakes.
When payers delay workers’ comp claims, billing the patient directly can create significant financial hardship and unnecessary stress. These compliance missteps don’t just affect revenue—they impact patient relationships and your hospital’s reputation.
The Strategic Solution: EHR-Expert Partnership
While complex claims may represent only a fraction of a health system’s total volume, they can account for millions in potential revenue. The solution isn’t replacing your EHR—it’s augmenting it with seasoned expertise.
The most successful hospitals and health systems recognize that maximizing complex claim reimbursements requires both robust EHR capabilities and specialized revenue cycle management expertise working in harmony.
This partnership approach delivers four key advantages: seamless integration, subject-matter expertise; proactive prevention, and true partnership
Ready to discover how Aspirion’s expert team of data scientists, attorneys, clinicians, and claims specialists can work in concert with your EHR system to dramatically impact your complex claims recovery? Our specialized approach to complex claims processing has helped hospitals recover millions in previously lost revenue. Connect with us today!
