Rest assured. LTPAC Clinical executives can know rather easily.

What keeps you up at night? When I ran SNFs, many things would intrusively leap onto the stage of my dreams, stealing the limelight. Their discordant presence would dash the quiet and restful performance currently playing, causing me to start into a sudden and unwelcome wakefulness. It was one thing to steal the limelight, it was another to completely take over the show and lock the stage door to my more sedate and slumber-inducing dreams. Stifling a cry, I would sit bolt upright in bed, beads of sweat on my furrowed brow. One of those frequent limelight-stealing imps was a nagging doubt about my facility’s compliance.

Compliant to what? Federal and State regulations? Fire and safety? The Fair Labor Standards Act? Safe Harbor? HIPAA? Corporate standards and objectives? The list goes on and on, each list member competing animatedly for my attention. “No sleep tonight,” I’d groan. But times have changed and so has technology potentially barring the stage doors to unsolicited dream disturbers.

In the days before automated data mining and business intelligence (BI)-generated dashboards and reporting, I would have to make a mental note to investigate if and how compliant we were, recognizing that the research alone would take quite a lot of time, assuming no interruptions (silly me), sorting through charts, files, and printouts. But today WITH BI at a manager’s fingertips, those with compliance concerns, including clinical managers, have ready access to critical Key Performance Indicators (KPIs). With Business Intelligence, clinical managers can conveniently view a variety of KPIs which they can make their own. (I’ll get to that shortly.)

Let’s take a look at some of the KPIs clinicians can view to discover in measurable terms if their areas of concern are compliant. With regular input either directly from the data which resides within their clinical application automatically “pumped” into the data warehouse or keyed in directly, clinicians have access to frequently refreshed information. This information can include such KPIs as in-house-acquired or community-acquired pressure ulcers with the number of residents with pressure ulcers at what stages and at what percent of the average daily census over a month’s period of time or trended over a 12-month period.

Restraints? Weight loss? Anti-psychotic use? Infections? Readmissions? Falls/Accidents? Sentinel events, such as dehydration or fecal impaction? Indwelling catheters? Pain management? Hour per patient/resident day compared to state standards and to budget? Overtime usage? And more. If the data exists, the information can be viewed in the BI dashboard.

Now, I referred earlier to managers making KPIs their own. How about comparing the KPIs against benchmarks the clinical team has created based on regulations and company/facility-established standards, usually set to exceed the regulatory requirements? It’s all in one dashboard. No longer do clinicians have to wait for reports to be researched, compiled, published, and distributed. Log in and find out. No more uncertainty. Just discover. Take action. Get results.

With BI, this potentially sleep-disruptive concern can be put to rest. It’s called peace of mind. Take a dose of BI every day and sleep well.

With a Claims Management Solution - The gift that keeps on paying

Admittedly, the reimbursement process is complicated. Not only must billers identify who is to pay the bill, they have to know how to bill the payer and get paid as quickly as possible. This is especially the case when billing third party payers, such as Medicare, Medicaid, Managed Care, and private insurances. Each has its own requirements as far as coding, bill timing, and claims processing quirks are concerned which seem to change frequently. If billers are having to prepare, process, track, and follow up with claims manually using spreadsheets, phone calls, emails, letters, logs, and on and on, it is no wonder that billers are stressed and overwhelmed, that dollars are left on the table and claims are lost or misplaced. Reimbursement, or revenue cycle management, does not have to be complicated, however. In fact, it can be relatively simple with an automated claims management solution through a claims clearinghouse. But, buyers beware. Let’s take a closer look.

Keeping it simple – clearinghouse musts

Let’s assume that the strengths of automating claims management are a given. Specific clearinghouse features can considerably contribute to claims management simplicity. To help simplify and accelerate converting revenue to cash, a clearinghouse, like primeCLAIMS, should be able to do the following:

• In the event a claim is rejected, the clearinghouse should be able to isolate specific claims, not reject the entire batch of claims.
• The solution should give billers the ability to edit, scrub, monitor, and manage claims throughout the process.
• The clearinghouse must be able to stay on top of the almost daily changes to submission requirements, even the most obscure.

Visibility and control – an AR manager’s dream

Visibility and control with an enterprise-class claims solution also contributes to process simplification. With one log-in:

• Billers can connect directly to all Medicare payers via CMS-approved NSVs (Network Services Providers)
• Billers should have access to tools needed to manage claims, DDE, ADR status tracking, eligibility, secondary billing, and claims denied.
• AR managers can view each facility’s claims status and provide assistance where necessary.

Such simple tools to help speed cash flow with fewer rejections and cleaner claims. They also reduce costs by:

• Eliminating unnecessary paperwork
• Reducing transaction fees
• Reducing labor through elimination of such labor-intensive inefficiencies as:

• Log-ins to multiple systems to view all locations, determine eligibility, edit, and track all claims
• Manually compiling and submitting secondary payer claims

Simplicity in claims processing and managing also delivers peace of mind with:

• HIPAA checks
• Up to 10 years of data stored online

The bottom line

Using a clearinghouse to process, submit, and monitor claims yields numerous cost savings and improved cash flow. It’s much simpler and it just make cents.

In our more recent blogs, we have pushed the benefits of business intelligence (BI). We have especially emphasized its timeliness. With BI, you can know what’s happening practically in real time. Just open the dashboard and you see Key Performance Indicators (KPIs) important to you. But are you aware that you can be alerted via email when certain KPIs are significantly above or below targeted benchmarks?

Let’s say you and your management team have identified specific census benchmarks with given parameters which, when exceeded or fallen short of, the BI tool immediately sends you an emailed alert notifying you that certain regions and facilities are at risk. With that information in hand, you can immediately contact and troubleshoot the situation with the appropriate staff.

This is just as valid with labor KPIs. How about overtime? You are sitting in your office preparing for the next meeting when your email notifies you of an incoming message. You navigate to the message to see that it’s from the Business Intelligence tool alerting you which facilities have exceeded overtime parameters today.

Cash management? Near and dear to any executive’s heart is making sure that collections are keeping pace with targeted collection goals. Let’s say your team has identified that certain private-pay collection benchmarks are achieved by the 10^th. On that day, you receive an alert that specific facilities are falling short of their collection goals for private-pay with resident-specific contact and balance information. Because of this alert, your team can address the issues now.

Business Intelligence generated alerts not only deliver timely information, they also reinforce accountability. I don’t think it’s so much of matter of “Big Daddy” is watching. Rather, it’s an opportunity. When facilities are falling short of their goals, they may be distracted by other matters. Receiving an alert-generated call from your team can be helpful and supportive.

If you have a Business Intelligence tool like primeVIEW, that generates alerts, use them! It’s one more benefit available to help your team to effectively manage that which really matters.

That claims management has an impact on cash flow cannot be denied. But is your solution really working for you? First, let’s identify in what ways a claims management solution helps cash flow by converting into statements the questions found in our recent primeCLAIMS quiz, entitled, “Is Your Claims Clearinghouse a High Performer?”

Cash Flow

With your current solution you should be seeing cash flow improvements quarter over quarter. We suggest setting specific goals tied to claims-to-cash improvement and review progress at least quarterly. Contributing directly to cash flow improvement is measured improvement in your claims acceptance rate. The clearinghouse you choose should be able to help your AR team significantly reduce claims rejections conveniently. Occasionally, payers may request changes to the claims your team submits. A clearinghouse should help you turn those claims around quickly.

Take a close look at your clearinghouse and the middleware[1] it uses. We have learned from providers who use other clearinghouses that critically-needed application upgrades can take an unreasonably long period of time. Why? Because some clearinghouses do not own the middleware their application relies on and must wait for such changes. Owning the middleware certainly contributes to a quicker response to upgrade requests. 

We’ve mentioned this before, but with a clearinghouse experienced with post-acute payers and their claims processing technicalities providers are more likely to see improved claims processing and fewer frustrations. Such a clearinghouse is more responsive to LTC provider needs and in some cases the clearinghouse can anticipate needs and be ahead of the upgrade curve.

Productivity & Labor Savings

Considering turnover issues, the automated claims management solution needs to be intuitive - easy to learn and use for newly-hired and less-experienced billers. Further, with customized train-the-trainer programs and implementation, the clearinghouse helps providers to get new-hires up and running quickly while reducing orientation and training costs.   

The clearinghouse application must be robust with simplified reimbursement workflows and the users’ ability to manage claims submissions, denials, remits, DDE access, and HETS inquiries in a single portal. Further, being able to submit claims in batches reduces inefficient and costly steps. Should a payer reject a claim, the clearinghouse should be able to isolate the rejected claim and not reject the entire batch. Another example of possible key clearinghouse capabilities is the automatic identification and release of secondary claims. Secondary claims are a significant part of revenue to be collected yet are likely most at risk for non-payment.

Near and dear to any CFO’s heart are reports. Being able to view a dashboard of claims-related KPIs has proven valuable to provider management teams which can reinforce accountability throughout the entire claims management process.

Compliance

From a strategic standpoint, having a clearinghouse partner that keeps up with LTC-specific regulatory changes across the senior care continuum and communicates them to its provider partners is important. In primeCLAIMS, customers are able to view updates and notices in their dashboards – a convenient way to anticipate and prepare for changes.

Security

Being in total control of who has access to which features, functionalities, and reports gives providers the control they want over the claims flow process. Such security capabilities give corporate, region, and facility managers the flexibility they need to view all locations for which he or she is responsible in aggregate and individually.

Enterprise Effectiveness

Sometimes the term “enterprise class” is overused, but in the case of claims processing, this term is meaningful. With some clearinghouses, management can only view claims’ status one facility at a time. Being able to aggregate (at the corporate or region level) and drill down to specific facilities in one portal gives managers both a high-level and, if they choose, an in-depth view of pending, outstanding, and paid claims.

A clearinghouse should not only upgrade its application and best-practice recommendations based on regulatory and payer-specific changes, but also listen to current customer needs and requests to improve customer productivity. If the clearinghouse appears to be unresponsive or slow to respond, that should be a concern.

Conclusion

We recommend that you carefully evaluate your current claims management solution to see if it is effectively helping you move cash into the bank. It just makes cents.

[1] “Middleware is a general term for software that serves to "glue together" separate, often complex and already existing, programs. Some software components that are frequently connected with middleware include enterprise applications and Web services.” TechTarget, http://searchsoa.techtarget.com/definition/middleware, Margaret Rouse

Recognizing the value of Business Intelligence to monitor and manage your business is one thing. Doing something about it is another? What is the next step? Do you build it or buy it? Admitting we are biased towards “Buy it,” we will identify what appears to be “best practice” for most SMBs.

Build it?

While several larger provider organizations have elected to invest the time, resources, and money to build their own data warehouse and reporting systems, such an investment is far out of the financial reach and expertise for most SMBs. Here are some of the key reasons why not to build is the better decision:

Those who have their own IT departments think they can do it themselves – It’s just a matter of directing the IT manager to create reports, isn’t it? Actually, it’s not that simple. Because they think they know how, we have discovered that some well-intentioned companies will start by hiring a programmer to write reports. However, business intelligence is interactive and displays critical Key Performance Indicators (KPIs) not only as tables, but as graphs and charts as well, involving higher levels of reporting. The distinction is that BI dashboards provide greater versatility than a report generator. It uses a warehouse to aggregate data, no matter the source, and normalizes the data so that the data is interoperable – where data comes from disparate sources, yet must work together. In this way, trending information becomes easier. Business intelligence also enables the users to roll up and or drill down to critical information depending on their needs and permissions. What we have observed is that the one programmer becomes multiple programmers as the project falls further behind and the requirements expand.

Beyond the danger of scope creep and its unforeseen impact on the budget, there is the development time to consider. Programmers have to learn the various databases that serve as the data generators and repositories. This requires expertise in data warehouse technologies and best practices. Without going too deep, another complication is retrieving the data on a scheduled basis and combining it into useful information. And, in our observations, all of this can take up to eight months on average and, in some cases, years. Then there is the situation where the nature of an application’s database may change, requiring understanding and a working knowledge of the new database.

Assuming the developers have BI up and running, it doesn’t stop there. As competitive, regulatory, reimbursement, and new legislative pressures evolve, so must Business Intelligence. That means that the BI project never ends. Building and maintaining it requires retaining in-house specialists or engaging outside resources – an expensive proposition.

There are other non-development issues to consider, such as the actual go-live, the initial user training, and on-going support. Since LTC does experience high turnover even among members of the management and executive teams, training is a recurring issue and, more importantly, so is support.

Then there is the power of the aggregation of understanding what providers across the country need and want to view, what information is important to them, and how to turn their data into actionable information. That uniquely is found with those who have developed and maintained dashboards for years for providers across the country at affordable economies of scale.

Buy it

Let’s assume that if you were tempted to create your BI tool or you have started it and found it to be a big black hole that seems to suck in more time and funds that your worst fears anticipated, pause. It’s never too late to cut your losses and investigate what is already available. But, though we consider this to be the right direction, we recommend you do your homework before you buy. Beyond the usual promotional materials and even the demonstration, consider the following:

• Outsourcing BI can be less expensive in the short and long term. Investigate the monthly subscription fees and any one-off fees. Know what you are getting yourself into financially.
• Get an estimate of the time it takes to get the system up and running. In our experience, assuming we have the necessary information needed to create connections to the various data sources, we have been able to get customers fully up and running in a matter of weeks.
• How long has the vendor been developing and satisfactorily meeting the needs of its customers? Our primeVIEW has been evolving with long term care providers for years which brings up another issue. Is the BI vendor responsive to customer requests for new features in a timely manner? Responsiveness is critical to providers who must be prepared to deal with changing challenges and opportunities quickly.

Summary

We highly recommend that you seriously consider looking into procuring a BI system developed by specialists who understand LTPAC and BI technologies. It’s cost-effective, scalable, and they can offer suggestions, based on what other providers have done. LTPAC specialists, like primeVIEW, also listen to customer suggestions to further enhance business intelligence’s capabilities and anticipate providers’ information needs. Our customers acknowledge that such a strategy is affordable and highly effective in controlling costs, ensuring compliance, improving service quality, and improving cash flow without the distractions inherent in “do-it-yourself” BI development.