Data is everywhere; it’s pervasive. The challenge as well as the opportunity lie in retrieving the raw data and converting it into useful and actionable information. In the past, we have posted a number of blogs on a wide range of Business Intelligence (BI)/data mining-related topics - from Payroll-based Journal (PBJ) reporting to data-driven decision making, from BI’s role in helping providers stand out in the ACO crowd to how BI helps providers demonstrate value, and so on. But let’s step back and reexamine what has driven BI to become what it is today.

The challenge

Long Term Care (LTC) providers are sitting on a vast reservoir of data. However, many do not have the resources to tap into that data and to convert it into something useful to solve current problems, to seize emerging opportunities, and to plan for the future. But, where to start?

BI’s purpose

Let’s wrap our arms around what BI’s purpose would, could, and should be. Succinctly put, BI reports, provides online analytics, and delivers Key Performance Indicator (KPI) visualization and monitoring.

BI’s use

As we visit with our BI customers and industry leaders across the country, we’ve observed that decision makers use BI to measure, monitor, and act on clinical quality outcomes, financial analysis, operational performance, cost management, compliance, and market-specific information. Executives use such information to take direct action, as needed, and to work with their teams to better align performance with company and facility-specific benchmarks/goals.

BI drives development and market acceptance

The evidence is clear that no one thing has been the agitator for BI acceptance and growth. Rather, the following factors have each played a contributing role:

• Federal and state health reforms
• Availability of healthcare-related data
• The imperative to identify and control costs
• Quality Assurance and Performance Improvement (QAPI)
• The need to increase customer satisfaction
• The demanding and complex regulatory environment, such as PBJ reporting, HIPAA, etc.
• Cloud-based computing technologies
• The availability of data through IT adoption
• Health Information Exchanges (HIEs)
• New value-based payment models
• And others

BI Stakeholders

Who uses BI? Here is a “short list” of those who rely on and use BI:

• BI software and services providers
• Healthcare providers
• Healthcare payers
• Accountable Care Organizations (ACOs)
• Managed Care Organizations (MCOs)
• Health Information Exchanges (HIEs)
• Investors/lenders
• Federal and state governments
• Researchers

All of these entities and people have a stake in the BI world and they all have some influence on how providers conduct business.

What this means to you

If you haven’t yet fully caught the larger vision of what BI has become and could be, you need to do so now or you will be left behind. In today’s world, the old manual ways of gathering and processing data, responding to the information gleaned, and taking action are too slow and cumbersome. Besides, some stakeholders, such as government agencies, are not giving you a choice. I highly recommend that you conduct an assessment of your organization’s BI needs today and in the future and devise a plan to help you ramp up as quickly as possible. A sure bet, is to look at existing BI tools, like PCT’s primeVIEW, designed for LTC providers, like you.

Discover how easy it is to integrate staffing and census data with PCT's PBJ Reporting Platform

In a recent blog, we highlighted some benefits of automating secondary claims processing through a clearinghouse. The ROI is potentially huge.

Traditionally billers completed paper forms and mailed them to the payer. Sounds simple, but it wasn’t and, some providers are still submitting claims in this way. Phone calls and error-generated resubmittals contribute to a complex, cumbersome, costly, and prolonged payment process. With electronic claims preparation and submittal, providers can securely submit and track claims to multiple payers all in one portal. Here are some of the advantages a claims clearinghouse can offer:

• Single location electronic claims management with real-time electronic claims verifications
• Smooth claims flow to payers with a significantly reduced risk of rejections - since claims clearinghouses are connected to multiple payers and understand the peculiar format and workflow requirements
• Electronic Remittance Advice (ERA) –view all payments and adjustments
• Claim Status Reports
• Rejection analysis in which the system explains error codes in English
• Edit and correct claims online anytime
• Real-time support

ROI - Secondary claims process saves time

Think of time savings in two ways:

1. Billers’ time – The manual workflow of copying, mailing, and filing claims takes time. Even hand keying claims to each payer takes time. Billers have to know the specific submission requirements of each payer. In a manually-generated claims environment, such complexities can result in errors and slower claims turnaround. With a clearinghouse, such as primeCLAIMS, the system prepares the secondary claims automatically. All billers have to do is review the claims in the Secondary tab and click on the button to send them. It’s simple. And our customers love using it. The ROI? A reduction in claims processing and related costs.

2. Claims turnaround time - Office Managers can go right to the Secondary payer tab once they have downloaded the 835 ERAs (Electronic Remittance Advices). The secondary claims are there for review and submission. No delays. And the claims are accurate and prepared automatically to meet payer-specific requirements the first time. The ROI? A reduction of 4-6 weeks in claims turnaround and payment. One of our customers has stated that it has had a major impact on the reduction of Days Sales Outstanding (DSO).

To give you an idea of what’s at risk, if you are not using a clearinghouse to submit secondary payer claims, take a look at our Secondary Claims ROI calculator and see for yourself. The calculator helps you to identify what revenue may be at risk as well as the time and money it takes to manually generate the claims.

Are you collecting all your secondary claims and how much does it cost to do so?

Check it out.

90 days, give or take, may sound like a lot of time, but when tackling something like PBJ reporting, it’s actually just around the corner. This blog will help you to identify the 8 tasks providers need to complete in order to be ready.

In the recent blog, published March 15^th, we highlighted PBJ reporting requirements. We emphasized that reporting automation is vital to help providers, like you, not “waste critical time building reports and checking data.” However, automation is only as good as the data collected. So, here are 8 steps we recommend you take to fully leverage the PBJ reporting requirement:

1. Go automated. Automated reporting tools, such as primeVIEW’s PBJ reporting tool, takes the data processing and reporting preparation time down to a minimum. It’s a no-brainer. With today’s advanced data processing technology already available, why reinvent the wheel or, worse yet, do it manually? Remember – it must be auditable and mistakes can be costly.
 
2. Know the reporting requirements. Who does CMS consider to be direct care staff? The criteria involves individuals, including agency/pool/registry and contract staff who:
   • Have interpersonal contact with residents or resident care management (This includes medical directors and consultants.)
   • Provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well being
   • Note: Physical plant maintenance and upkeep staff are not considered direct care staff
 
3. The PBJ reporting system set-up requires four items
   • Unique employee ID – avoiding any personally identifiable information (no social security numbers)
   • Hire date – whether directly employed by the facility or under contract, this is the first date of employment by the facility and payment for services delivered at the facility
   • Termination date – whether directly employed by the facility or under contract, this is the last date of employment by the facility and payment for services delivered at the facility
   • Pay type code – identifies whether the staff member is an exempt or non-exempt direct facility employee or a contracted employee

Tracking this can be complicated. An employee’s job responsibilities can change throughout the day. Report hours worked based on each employee’s primary role tied to the employee’s position and shift. To make this somewhat easier, you may want to work with your staff scheduling, time and attendance, and payroll vendor(s) to see if job code assignment can be automated.

4. Know what doesn’t count. Here are some things that CMS identifies that you should not count.
   • Hours paid for any leave or work-related absence
   • Overtime for exempt staff (ex: 40 hours per week hours paid, not hours worked)
   • Hours that are billed directly to Medicare
   • Hours for services provided to residents in non-certified beds

5. Know what counts. This includes hours that your time and attendance application tracks for facility direct staff. You also need to track the following possible scenarios: 
   • Contract and agency
   • Corporate staff who may be filling in for a staff memeber whose roles meet the CMS job categories
   • Salaried staff who don't use the time clock

6. Be reasonable. Now that’s what we would like to say to CMS, but actually that is what CMS is advising how your tracking and allocation systems need to be – reasonable – in accounting for, calculating, and reporting direct care hours. Keep in mind that an audit will likely review payroll and invoices tied to contracts.

7. Plan carefully. Your team can work with the vendors mentioned above to create as audit-proof a set of procedures as possible. The plan should include objectives with a July 1^st deadline for having all components in place.

8. Staff according to needs. Flat PPD direct care budgets are great, but they are not usually responsive to aggregated resident needs. Check staffing levels every day and adjust accordingly to call-offs, time-off requests, no-shows, and the dynamics of census, activities, acuity, and workload.

Decide now on an auditable system to identify and retrieve those hours. Test. Test. Test. And learn. Then implement. This process begs another blog, but you get the idea. It will take time to prepare, but it will be well worth it.

Contact us today about PCT’s PBJ reporting solution - save time, save money, reduce stress.

This month’s revenue cycle management blogs explored a number of topics, including the basic concepts of a claims clearinghouse, how to ensure managed care claims flow smoothly, 3 ways to help your back office runs smoothly, and 8 ways to avoid False Claims Act pitfalls. Here are some highlights from each and links to access each blog in full.

Clearinghouse 101 – a re-introduction to automated claims processing

“Clearinghouse 101” – an introduction to the some of the critical features and benefits of a claims clearinghouse. Whether you are using one today or not, take a peak. You may find some of the tips useful.

Back to the basics.

Ensure Managed Care claims flow smoothly

Partnering with a clearinghouse with connections to thousands of payers makes submitting claims easier and revenue moving.  Keeping cash flow in a steady stream means understanding how managed care works – knowing the systems, procedures, and requirements are critical. A clearinghouse, like primeCLAIMS, has the ability to connect with multiple Managed Care payers, helps to ease the transition into Managed Care and your revenue cycling.

Learn how.

3 ways to make sure the back office is running smoothly during absences

Interruptions, urgent requests, and unanticipated call-ins, even scheduled absences can be disruptive. But retreat is not the answer. Substitute is the better option - making sure that others are trained to cover the important aspects when needed.

Discover how.

The False Claims Act: 8 ways providers can avoid penalties and fines

Periodically, you will see settlements or court decisions rendered for False Claims Act violations. Claims may be subject to false claims accusations for treatments or services provided that are not deemed medically necessary, do not meet coverage qualifications, or medical record indicates they were not provided as ordered.

How to avoid them.

Moving the Revenue Needle with Secondary Claims

In this month’s BI-focused blog postings, we explored the process of decision making, PBJ compliance reporting automation, using BI to help providers beneficially get the attention of ACOs, and, along that same line, establishing and strengthening relationships with key referral sources.

Data-driven decisions – an art and a science?

With the right information, you, the provider, can make the right decisions, right now! But even if the information is right, timely, relevant, and rendered actionable, making “the right decision” is a skill. But is decision making an art or a science? And what role does BI play? Read on.

It’s about time - Providers should automate PBJ reporting

Like it or not, Payroll-based Journal reporting is just around the corner and will become a routine requirement for all SNF providers. And it comes with a kick in CY 2017 – a Five Star Rating kick. How can automation expedite the monitoring and reporting process? Find out.

How Business Intelligence can help execs stand out in an ACO crowd

In our recent blogs, we’ve highlighted how Business Intelligence (BI) can help providers more effectively tell their stories to stakeholders, investors, and referral sources. However, providers have another key audience to whom they could effectively present data-driven demonstrations of value and quality – ACOs. Learn more.

Business Intelligence can help demonstrate value to referral sources

As the reimbursement world changes from fee-for-service to pay-for-performance models, demonstrating value is key. To be able to effectively demonstrate value compliant with payment model expectations, providers need to be able to know how well their facilities are performing today. The technology needed to effectively identify and communicate such value is available through BI. Discover how.

Are you able to make the right decisions with the right intel when you need it?