Proclaim Partners

Recent posts by Proclaim Partners

3 min read

Improve claims turnaround and business processes – a case study

By Proclaim Partners on Wed, Aug 13, 2014 @ 09:00 AM

istock_000017882928smallCMS Says Skilled Nursing Will Face Negative Margins By 2040,” so read the headline in last Wednesday’s AHCA/NCAL Gazette. In fact, it was the top story. Yep. It grabbed my attention really quick. Now granted, I may likely not be around by 2040, but judging by my parent’s longevity, I could. I’ve been affiliated with LTC since 1978 and it’s in my blood. I care. And, yes, to be frank, the article somewhat spooked me when I read the following, “By 2040, two-thirds of skilled nursing facilities will be operating in the red, signaling more consolidations, partnerships and accountable care organizations (ACOs) on the horizon, according to a recent memo issued by the Centers for Medicare & Medicaid Services’ (CMS) Office of the Actuary.”

Here are a couple of reasons why I am spooked. First of all, I have seen projections of the future, especially those going further out than 10 years, either flat out ignored or at least not effectively addressed. Perhaps, we hope the projections are wrong or that someone someday may do something about the issue at hand. It never ceases to amaze me that the future eventually becomes the present. Have you noticed that too? Rephrased, have you acknowledged that truism as well?

Secondly, I am spooked because I’ve noticed that when it comes to health care policy, government at the federal and state levels feels that it will have the answers. Their track record has not convinced me that government is or should be the problem solver. So what can LTC providers do today to meet the challenges the years leading up to 2040 will pose? Well, they can start today to embrace and implement available practices and technologies to build a solid financial footing by quickly collecting claims processed.

Ensign Services did just that. A recently-published ProClaim Partners case study revealed that Ensign Services faced several challenges:

  • Ensign Services needed to replace a legacy clinical and financial software application which included a basic claims submission automation feature.
  • The new software Ensign Services implemented met its EMR requirements, but lacked automated claims submission to Medicare. This also became the catalyst for consideration and conversation about clearinghouse services to all payers.
  • To compensate, Ensign Services selected a widely-used clearinghouse. The new clearinghouse was unwilling and unable to support Long Term Care-specific claims submission and management requirements.

To overcome these challenges, company executives arrived at the following conclusions:

  • Ensign Services needed a responsive and easy-to-use enterprise-class claims clearinghouse designed specifically for Long Term Care to help its clients meet their respective cash flow objectives, save money, reduce unnecessary claims processing and collections tasks, increase user satisfaction, and streamline business workflows.
  • Because of its relationship with Prime Care Technologies, Inc. for IT hosting services, Ensign Services investigated PCT’s affiliate, ProClaim Partners, LLC, and discovered that it could assist them in managing client claims.

The results? Since fully implementing the ProClaim Partners solution, Ensign Services has been able to:

  • Decrease claims turn-around time
  • Significantly improve claims management-related business processes
  • Reduce frustrations related to new client on-boarding
  • Experience quicker special requests and support issues response times

Is this THE answer to the spooky negative margins providers may experience by 2040? Not entirely. But as margins get tighter, a quicker turnaround of claims processed will be critical. The fact is it is critical today. Those providers who take steps today to improve cash flow through claims automation will not only have the advantage in the future, but also right now. At least with a better cash flow position, providers can focus on the factors influencing the bottom line.

At least those are my “thunks”.

Have you fully automated the claims management process? If so, what advantages are you seeing today?

Topics: Improved Business Processes claims management clearinghouse IT hosting services claims turnaround claims turn-around clinical and financial software claims processing EMR claims management process
2 min read

Update and Improve Medicare Claims Management

By Proclaim Partners on Thu, May 29, 2014 @ 08:00 AM

pcl_horn_playerI acknowledge that blogs are for the purpose of educating and earning your trust, but at times I think it’s alright to blow one’s own horn once in a while. After all no less a business guru than Kenneth H. Blanchard said, “If you don't blow your own horn, someone else will use it as a spittoon.” In the highly competitive world of claims clearinghouses, blowing our own horn is a must and doing it early is essential. Otherwise, the ensuing copycat cacophony will drown it out. So, here it is.

ProClaim Partners announces the release of its new integrated HETS/CLIP/DDE module as part of its automated claim processing clearinghouse software. For providers who bill Medicare this is a boon. It gives them access to Medicare eligibility and claims management tools through one portal. What is particularly noteworthy is that billers will be able to:

  • Browse claims data through the ProClaim Partners proprietary web user interface
  • Have a secure, high speed connection between the portal and the Centers for Medicare and Medicaid Services (CMS)
  • Enjoy an integrated implementation of the new HIPAA Eligibility Transaction System (HETS) for real-time eligibility determinations
  • Access Claims-in-Process (CLIP) which securely sweeps the CMS data during off hours for the latest claims activities.

The data seamlessly integrates into the ProClaim database and workflows. Together these functions will present the CMS data in a much more user-friendly, browser-based format than what billers have had through other tools. While CMS has recently delayed the sunset date for access to the older technology used for eligibility determination, the transition to HETS is still imminent. Why wait? With this new module providers don’t have to worry about a future sunset date.


For real-time Medicare eligibility determinations, ProClaim implements the new digital certificates (X.509), Simple Object Access Protocol (SOAP), and Multipurpose Internet Male Extension (MIME) standards within the ProClaim software service to provide web-based workflow and access to HETS. ProClaim makes instant programmatic determinations of eligibility against the CMS backend data store with minimum time and effort.

Claims in Process

The ProClaim Claims-in-Process (CLIP) function displays the current Medicare claims status, avoiding the need to navigate through the many legacy screens of the soon-to-be-phased-out eligibility inquiries into CWF using DDE for each individual claim. ProClaim’s CLIP accesses DDE during off hours to deliver programmed operator services. These services sweep the claims data off the DDE Mainframe and into the ProClaim database.

DDE Access

By design ProClaim minimizes DDE usage. However, under certain circumstances, claims administrators and billers may still need to access DDE. ProClaim provides a new and powerful DDE access solution as an integrated part of the software service. Now, providers have the choice of continuing to use 3rd party terminal emulation software for DDE access to the CMS Host or using the new ProClaim DDE access.

In summary, ProClaim Partners helps Long Term Care providers face a challenging environment converting claims to cash, especially when dealing with CMS/Medicare systems. In short, we’ve modernized and simplified the daily Medicare claims processing workload. The key benefits of using the system include:

  • Real time eligibility determination
  • Faster access to CWF data
  • Faster access to Claims in Process
  • Faster resolution of ADRs
  • Reduced training time for new claims administrators
  • Quicker collection of cash from claims

Tada! I have finished my horn solo. It’s nice to know that technology has caught up with the complex world of revenue cycle management.

Where are you in adopting new technologies to accelerate payments and improve cash flow?

Topics: automated claims management revenue cycle management web portal to manage claims HETS DDE CLIP
2 min read

Accurate Medicare claims submission & eligibility determination

By Proclaim Partners on Mon, Mar 10, 2014 @ 09:00 AM

Is it HETS or miss?

Man_Woman_Desk_Laptop_Clock_trimmedIn a recent issue of CMS’s Medicare Learning Network Matters News Flash, SE 1249, CMS reaffirmed its intention to replace the Common Working File (CWF) Medicare beneficiary health insurance eligibility queries with HIPAA Eligibility Transaction System (HETS). (You can refer to last year’s blog posting for more details.) However, CMS has opted to postpone (again) the CWF access termination – this time indefinitely, but with a caveat. While this announcement will not affect the use of DDE to submit claims or to correct claims and will not impact access to beneficiary eligibility information, providers “should immediately begin transitioning to the Medicare Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS).”

Succinctly put, “While termination was originally scheduled for April 2014, CMS is delaying the date. CMS will provide at least 90 days advanced notice of the new termination date.”

So, in other words, transition to HETS sooner than later or you are at risk of missing out. Borrowing from our earlier blog, at some point in time you will no longer be able to check on a resident’s Medicare eligibility through the Common Working File (CWF).  HETS is replacing CWF inquiries. In a way, CMS has made life much easier for billers, because with HETS you can check a beneficiary’s eligibility in real time. CMS has simplified the eligibility checking process so that through HETS you can submit your inquiry with a real-time 270 request and receive your 271 response, a Functional Acknowledgement (999), an Interchange Acknowledgement (TA1), or a proprietary error response over a secure connection. According to the guide, “The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.” This change will likely require you to change your billing processes.

Some of the information HETS will reveal to you will be in a format somewhat different from what you may be used to. Also, HETS will eventually be able to send Hospice information in the same format as the CWF. The HETS 270/271 Companion Guide gives you more insight into the eligibility information you will receive in the HETS 271 response.

ProClaim Partners offers direct access to HETS through its enterprise-class automated claims clearinghouse portal. Not only can you submit, monitor, and correct claims, if necessary, you can also determine a Medicare beneficiary’s eligibility. You can select exactly what information you want to see. There is no need to bounce between applications; your information regarding all things Medicare and other insurance payers is conveniently accessible in your own branded portal.

Question: If you are using HETS, how has this changed how you check a resident’s eligibility?

Topics: 270 Request HETS Medicare claims 271 Response Medicare Eligibility
1 min read

The 411 on Best Billing Practices

By Proclaim Partners on Fri, Aug 23, 2013 @ 10:00 AM

For some providers, billing can simply be a nightmare. Despite the countless years of experience in dealing with Medicare, insurance companies, and other claim problems, many still struggle with the complexities that go into billing. As a vital component in managing a business, it is crucial to learn some of the best billing practices which have been tested by professionals in the field.

  1. Eligibility verification – By pre-screening a resident/patient’s insurance a provider can know upfront what can be covered and what will not. This will decrease the number of denials a provider receives when filling claims.
  2. Admissions– Define a clear set of rules and follow them. These will help the patient and family to know up front how business will be conducted. Having a clear system of handling transactions allows you to save countless hours of financial reviews.
  3. Revenue cycle – Create a revenue cycle and live by it. This will help guarantee that you get paid in a timely manner. Map out each step in the billing cycle and educate all the employees involved on how to properly handle their individual roles. While an educated staff can develop these, many providers might consider it valuable to bring in an expert like an accountant to help develop this cycle.

These are just a few of the countless practices that experts have found to increase billing efficiency. For more information, contact the experts at ProClaim Partners, who can show you how to make sure your business stays productive and profitable.

Topics: Billing Practices
5 min read

Medicare Secondary Payer – 5 Steps to win the race to timely payments

By Proclaim Partners on Fri, Apr 12, 2013 @ 01:20 PM

Winning the raceWinning the race to collect your money on time is everything. However, Medicare Secondary Payer[1] (MSP) may cause nursing home billers to trip up in their efforts to get payments as quickly as possible. Tripped too often, and providers may find themselves not quite reaching the monthly collection goal finish line. Worse yet, they may find themselves going backwards due to fines imposed for “knowingly, willfully, and repeatedly providing inaccurate information related to the existence of other health insurance or coverage.” Perhaps it’s time to get in shape regarding MSPs.

But first, what is MSP and why is it so important?

Conditioning exercise – know the terms of the game. Let’s start with primary payers. Primary payers are those which have the primary responsibility for paying a claim. Sounds simple, right?  How does this apply to MSP? Medicare does not pay for services and items that other health insurance or coverage is primarily responsible for paying. In other words, Medicare is the secondary payer when it is not responsible for paying first; when it is not the beneficiary’s primary health insurance coverage. So, remember, only in the absence of other primary insurance or coverage does Medicare remain the primary payer.  Examples include accidents where the auto insurance would eclipse Medicare, workers compensation, a fall whether at home or on public property, etc.

Are there any exceptions to the MSP requirements? No and Yes.

First, no.  Federal law takes precedence over state laws and private contracts. It doesn’t matter what an insurance contract or state law may claim federal law always take precedence.

Second, yes. In the following situations, Medicare may make payment, assuming Medicare covers the services and you file a proper claim.

  • A Group Health Plan (GHP) denies payment for services because the beneficiary is not covered by the GHP;
  • A no-fault or liability insurer does not pay or denies the medical bill;
  • A Workers Compensation (WC)  program denies payment, as in situations where WC is not required to pay for a given medical condition; or
  • A WC Medicare Set-aside Arrangement (WCMSA) is exhausted.

Conditioning note: When submitting a claim to Medicare, include documentation from the other payer stating the claim was denied and/or benefits were exhausted.

OK. With this understanding, you should be in shape and in racing trim. Let’s discuss 5 tactics to completing the collection race in good time.

1. Contact the COBC (Coordination of Benefits Contractor).
You may contact the COBC to:

  • Verify Medicare’s primary/secondary status,
  • Report changes to a beneficiary’s health coverage,
  • Report a beneficiary’s accident/injury,
  • Report potential MSP situations, or
  • Ask questions regarding Medicare development letters and questionnaires

2. Know your responsibilities. 
As a Medicare provider you should obtain billing information prior to providing services.  You will need to:

  • Gather accurate MSP data to determine whether or not Medicare is the primary payer by asking Medicare beneficiaries (or their representatives) questions concerning the beneficiary’s MSP status.
  • Bill the primary payer before billing Medicare.
  • For Part A, submit any MSP information on your Medicare claim using proper condition and occurrence codes on the claim.
  • For Part B, submit an Explanation of Benefits (EOB) form from the primary payer on your claim with all appropriate MSP information. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process the MSP claim.

3. Gather accurate data from the MSP beneficiary.
You must determine whether Medicare is the primary or secondary payer for each inpatient admission prior to submitting a bill by asking Medicare beneficiaries about other coverage. You should also inquire through HETS (HIPAA Eligibility Transaction System).

The MSP Questionnaire
CMS developed an MSP questionnaire[2] for providers to use as a guide to help identify other payers that may be primary to Medicare. The questionnaire follows a logical step-by-step sequence of Yes/No questions involving whether or not:

  • The beneficiary is receiving Black Lung (BL) Benefits
  • The services are to be paid by a government research program
  • Department of Veterans Affairs (DVA) has authorized and agreed to pay for your care at this facility
  • The illness/injury was due to a work-related accident/condition
  • The illness/injury was due to a non-work-related accident
  • No-fault insurance is available
  • Liability insurance is available
  • The beneficiary is employed
  • The spouse is currently employed
  • The beneficiary has group health plan (GHP) coverage based on his or her own or a spouse's current employment
  • The beneficiary has GHP coverage based on own current employment: does the employer that sponsors or contributes to the GHP employ 20 or more employees or 100 or more employees?
  • The beneficiary has GHP coverage based on his or her spouse’s current employment: does the spouse’s employer that sponsors or contributes to the GHP employ 20 or more employees or 100 or more employees
  • The beneficiary is covered under the GHP of a family member other than his or her spouse whose employer that sponsors or contributes to the GHP employs 100 or more employees
  • The beneficiary has End Stage Renal Disease (ESRD) and has group health plan (GHP) coverage
  • The beneficiary has received a kidney transplant
  • The beneficiary has received maintenance dialysis treatments
  • The beneficiary is within the 30-month coordination period that starts MM/DD/CCYY
  • The beneficiary is entitled to Medicare on the basis of either ESRD and age or ESRD and disability
  • The initial entitlement to Medicare (including simultaneous or dual entitlement) was based on ESRD
  • The GHP is already primary based on age or disability entitlement

Race tactic: You should retain a copy of completed MSP questionnaires in your files or online for 10 years.

4. Avoid submitting a claim to Medicare without providing the other insurer’s information.
Medicare may erroneously pay the claim as primary if it meets all Medicare requirements, including coverage and medical necessity guidelines. However, if the beneficiary’s Medicare record in HETS indicates that another insurer should have paid primary to Medicare, Medicare will deny the claim, unless it may rightly pay conditionally.

5. Avoid the penalties to failure to filing correct and accurate claims with Medicare.
Medicare can fine providers, physicians, and other suppliers up to $2,000 for knowingly, willfully, and repeatedly providing inaccurate information related to the existence of other health insurance or coverage.

MSP is a serious matter you should carefully address BEFORE you file a claim. By following these five steps you will be in good shape to cross the collection finish line successfully and in good time.

[1] The term "Medicare Secondary Payer" is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the "gaps" in Medicare's coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program.

[2] Medicare Secondary Payer (MSP) Manual, Chapter 3 - MSP Provider, Physician, and Other, Supplier Billing Requirements, 20.2.1 - Admission Questions to Ask Medicare Beneficiaries.

Topics: MSP HETS collections Medicare Secondary Payer


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