Now would be a good time to get back to the basics, the essentials, of what a clearinghouse is and offers. “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 following tips and points useful.

One portal does it all

A clearinghouse becomes the one-stop shop, the aggregator, for all claims processing actions - all in one portal with a single sign-on to submit, respond to, monitor, and manage all claims submitted to Medicare, Medicaid, Managed Care, private insurances, and other 3^rd party payers. Within the portal, billers can make changes or corrections to the claims and have access to DDE, HETS, and claims-in-process.

A claims translator

The clearinghouse takes the claims created within billing software and should run them through a scrubber to make sure that they are compliant with each payer’s requirements. If the clearinghouse find errors, it notifies the billers which claims need what information. Once the clearinghouse verifies that the claims are complete and comply with the payer billing requirements, it converts them into a format readable by the payer and forwards the claims. As a link between the provider and its payers, in essence, a clearinghouse is a claims translator.

Not a billing service

Periodically, someone will ask us if we, a clearinghouse, are a billing service. The straightforward answer is, “No.” A clearinghouse works with a provider's billing service/billers to complete the revenue cycle and to get cash back in your hand.

A convenient tool to monitor, manage, and follow-through

Submitting the claims is one thing, monitoring and follow-through are another. The clearinghouse portal enables you to see into what is happening with the claims once the payer has accepted them. Through the portal, billers can view the entire lifecycle of the claim and take action as needed to keep the claims flow steady.

Create secondary claims automatically

Please refer to this blog to learn more about how a clearinghouse should help to process secondary claims automatically and timely.

Claims data storage

Our clearinghouse, for example, securely stores the data up to 10 years, retrievable for the provider at any time.

Support

Experience and expertise are the foundation of a responsive and reliable support system. A clearinghouse can identify what is acceptable and answer claims submissions and processing questions.

Reports

A clearinghouse should have a core set of useful reports to help billers, their managers, and the executive team to track and trend the claims cycle. The reports offerings should help providers to track their billers and claims.  

The bottom line

From a benefits point of view, what does a clearinghouse offer?

• Simplicity - An effective clearinghouse makes the submission and management of claims simple, easy to learn, and monitor – a single location for claims management.
• Efficiency - From clearinghouse.org, we find that “the average error rate for paper claims is 28%. But using the right clearinghouse can reduce that to 2-3%.”
• Control – A clearinghouse delivers a provider-specific portal which serves as an all-in-one centralized location to monitor, manage, and extract necessary information.
• Speed – A clearinghouse facilitates quicker claims turnaround with higher claims success.
• Peace of mind – With a clearinghouse, billers have the confidence that they can track all claims easily throughout the entire claims-based revenue cycle.

It all makes cents.

Our company promotes that with the right information, you, the provider, can make the right decisions, right now! But even if the information is right, timely, and relevant, rendered actionable (Gotta love that word), making “the right decision” is a skill. Is it a skill of the arts or is it a skill of science? In this blog, I would like to get to the heart of the matter (which by inference would mean that decision making is an art, but I prematurely pass judgment. J). But some who ask, “What do you think about a situation,” instead of, “How do you feel about a situation,” may justifiably consider it a science. Having served in a number of leadership and management roles, I may rationally argue with some feeling that it is possibly both. But where does business intelligence figure into this oft written about conundrum? Let’s see.

I am not a scholar by any means, but sometimes such topics as this give me pause to do a little research and I want to share with you, who are for all intents and purposes among the brightest decision makers in the business world, some insights I gleaned while searching the internet.

The science and art of decision making

From none other than a Harvard Business School blog, dated December 2, 2010, authored by Jim Heskett, entitled, “Making the Right Choices: Art or Science,” I gleaned the following nuggets of thought.

• Many concluded that (choosing/decision making) is (an art and a science), depending on such things as the level of complexity, stage of the decision-making process, the purpose of the decision, the context in which the choice is made, whether we are deciding or rationalizing the decisions we've already made, or our personal makeup.

• Creation of choices is more of an art … and evaluation (of alternatives) a science. (Italics added)

• One of my favorites - All we can do is use science to understand the uncertainty of choosing … while using art to sharpen the intuitiveness that goes into the moment of choice. (Italics added)

• The longer you take to make a decision … the further away you are from the reality that exists at this moment.

• A delayed decision, no matter the greatness of it, loses its sheen 

What these nuggets suggest about decision making

These latter two bullet points are particularly germane to our tag line of, “Right information. Right decisions. Right now.” Why? Because the fresher and more immediate the information, the more likely will be the brightness of the decision you make. (Yes, the use of “brightness” is an intended play on words.) Decision makers need current relevant information in order to deal with the realities that exist right now. With current information refreshed several times during the day, the science of evaluation more effectively stimulates the art of creating choices.

Business intelligence drives the science of decision making

In another posting, dated March 27, 2013, on the “Awesome Mind Secrets!” site, I found the blog, Decision Making: Is It An Art Or Science? In summary it states, and I quote,

The Decision Making Process

There are several scientists, psychologists and management gurus who have created outlines of decision making processes. One of the best ways to describe a decision making process was outlined by Dr. Pam Brown. According to him, decision making involves the following steps:

1. Clearly outline the goal
2. Collect information that may help in arriving at the conclusion (Italics added)
3. Use brainstorming or other techniques to find out alternatives
4. Once you have alternatives, then look for pros and cons of each option
5. Choose the best alternative
6. Implement the decision
7. Evaluate the effectiveness of the decision, and take it as learning (Italics added)

Business Intelligence tools, especially those, like PCT’s primeVIEW designed for LTC decision makers, contribute significantly to “right decisions” by enabling them to “collect information” and to “evaluate the effectiveness of the decision” with regularly refreshed actionable information.

Science supports the art of decision making

Bottom line, what matters is that you have the right information (the science) so that you can employ the skill of decision making (the art) right now to make the right decisions, decisions that can have an immediate impact on the quality of the services you and your team deliver and subsequently on the bottom line.

Partnering with a clearinghouse with connections to many payers makes submitting claims easier and keeps cash flowing consistently. 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 connections with multiple MCOs and has built into its system the pertinent requirements, procedures, and systems no matter the size of the MCO. It’s worry-free - especially when working with a clearinghouse well established in and familiar with LTC and managed care. The clearinghouse will have the people who can effectively help you, because they have done it themselves.

Getting on board with an MCO – the application process

A real clearinghouse partner, like primeCLAIMS, will send you the correct form with instructions regarding how to fill it out. It can help you confidently connect the dots and fill in the right blanks with the right information. Before submission to the MCO, you can send a copy to the clearinghouse so that its experts can review it for completion and correctness and help with follow-up. The clearinghouse can also anticipate when you should receive the response and will be there for you until you receive the final approval. It plays an active advisory role throughout the application process and it’s that personal touch that truly identifies a clearinghouse as a real partner.

Medicaid Managed Care can be a different animal

Once you have the contract, knowing how and when to submit claims can be stressful for operators, especially since many states with Medicaid Managed Care, like Tennessee, Arizona, and California, among others, have multiple contracted Managed Care Organizations (MCOs) to run the program. It’s complicated. However, you can let the clearinghouse ease some of the pain for you. It knows what information is required, where to send the claims, and how to deal with the MCOs, even the very large ones.

Example: Some MCOs have a 90-day filing limit policy. In contrast to the traditional 12-month initial claims submissions window for fee-for-service Medicare and Medicaid models, if MCOs do not receive the claims within 90 days, they won’t pay. The clearinghouse will help you submit claims within the filing time period.

Another example: Medicaid recipients can either select an MCO or the state selects one for them. A further wrinkle in the process is when the Medicaid recipient moves from one MCO to another and you may not know about it. The result? Billers will be submitting claims to multiple MCOs in any given month. The clearinghouse will help you stay on top of these this.

Note: Creating secondary payer claims should be a primary concern

When Medicare Managed Care is the primary payer, you may still need to submit claims to another payer to pick up the co-insurance. The clearinghouse should create the secondary claims automatically.

Note: Rejecting claims, not a batch of claims

If there are errors in the claims, primeCLAIMS isolates individual claims not the entire batch. While you are fixing the rejected claims, primeCLAIMS submits the rest of the batch for payment. This avoid unnecessary payment delays.

Summary

Having the right clearinghouse partner can help your inbound cash flow freely no matter how complicated the MCO payment process can be.

It makes cents.

PBJ is just around the corner. So, what is it and what does it mean for you?

PBJ, or Payroll Based Journal describes what CMS requires you to submit online, effective 3Q 2016 and due 45 days after the quarter ends – that’s November 14.  From there, it will become a routine requirement for all SNF providers. And it comes with a kick in 2017 – a Five Star Rating kick. You are probably familiar with PBJ, but let’s net out the essentials so you can understand and act with some urgency. 

Background: With the passing of “The Improving Medicare Post-Acute Care Transformation Act,” or IMPACT Act, providers must submit “payroll and other verifiable and auditable data” electronically to the Department of Health and Human Services. It’s objective? Improve transparency and reduce potentially fraudulent reporting. You can check out the tedious details on the CMS and Federal Register websites:

• FAQs: Electronic Staffing Data Submission Payroll-Based Journal System
• Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection

The Change: In short, PBJ is the CMS’s latest push to keep providers honest when reporting labor hours and census – and eventually, will critically impact your 5 Star Rating.

• Every quarter, providers must use the online PBJ system provided by CMS to report the hours staff – AND contractors – were paid to perform onsite services for facility residents, excluding paid time off (e.g., vacation, sick leave, etc.).
• The PBJ system will only allow XML file submission – one per facility – and/or manual data entry at this time.
• CMS started collecting staffing and census data through the PBJ system on a voluntary basis beginning on October 1, 2015.
• Submission will be mandatory, effective July 1, 2016. Providers will be required to file both staffing and census data no later than 45 days after the last day of each fiscal quarter (i.e. for the quarter ended September 30, 2016 electronic reporting must be completed no later than 11:59 pm EST on November 14, 2016).

Don’t be lulled by the November 14 3^rd quarter reporting deadline. Collecting this data and preparing it for submission will take time – lots of time (and money) – especially if you are trying to do this manually.

There is a way to make this PBJ requirement easier to swallow. We proactively added a PBJ tab to our primeVIEW business intelligence dashboard to help our clients. New clients can also purchase this component on a stand-alone basis to meet the CMS mandate.

Our PBJ Reporting Platform empowers providers to:

• Integrate cross-facility data from employee and census systems
• Manually enter and append contractor data to existing file
• View/monitor a summary of employee and contractor hours
• Automate mapping of labor codes to CMS codes
• Export one all-inclusive XML file per facility for quarterly upload

With staffing and census playing a key role in the CMS’s Five Star rating and compliance, providers can’t afford to waste critical time building reports and checking data. An already-built solution quite simply frees up your time, so you can focus on proactive performance management.

The first mandatory reporting period, starting July, will be here before you know it. The time to act is now. 

And, if PBJ is the first major step you’ll take to aggregate all of the performance data you need to affect your Five-Star Quality Rating, check out our business intelligence blog. 

Fallback, Fill-in, and Backup. No, that is not the call to retreat in the face of overwhelming odds. Although at times, working in a SNF business office can feel like a wave-upon-wave series of assaults on what would otherwise be a normal, methodical day of blissful productivity. Interruptions, urgent requests from the corporate office, and unanticipated call-ins by other office staff, 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 of the job.

Fallback – Training back-ups is critical

In preparation for this week’s blog, I interviewed Ms. Kimberly Sturm, primeCLAIMS Senior Project Manager. We discussed what business office managers (BOMs) can and should do in anticipation of those times when a member of the office staff calls in or is on maternity leave or vacation. “Cross-train and refresh is what I have advised administrators and office managers throughout my career as a consultant and regional accounts receivable manager,” advises Kimberly. “This is a particular priority for payroll and billing followed by accounts payable, patient trust reconciliation, and other office functions. It seems that facilities don’t have the time before such an absence takes place, but when it does and deadlines have to be met, training happens and sometimes haphazardly. Unfortunately, it is usually long after uncompleted critical tasks have stacked up.” When Kimberly was a regional A/R manager for a large multi-facility SNF operator, one of her office managers, a 26 year old, had a heart attack and was out for 10 weeks. “I had to do the payroll, because the facility did not have a backup,” she explains.

Fill-in – Identify and prioritize

What are the absolute essential office functions that must be performed every day without exception and who do you train? At a minimum, stay on top of the tasks needed to process claims and payroll. Each facility is different with staff members often wearing more than one hat. Unless specifically dictated by corporate policy, the facility administrator or executive director identifies those who should be cross trained.

Fortunately, with back office automation, such as payroll, billing, and accounts payable, training is much simpler with fewer opportunities for errors. Since automation simplifies many office functions, office managers can train with confidence. For example, with a clearinghouse to process claims automatically, converting revenues to cash is easy to learn and manage every day. How does a clearinghouse help? A clearinghouse can furnish all the tools needed to manage claims, DDE, track ADR status, managed eligibility, automate claims submission, plus manage denials-in one system with one log-in. Even though there is still the need for hands-on entries which requires training, it is much easier with claims automation. (Caution: This brings up an important point: with automation comes security. A key part of security is individual log-in credentials. A word from Kimberly, do NOT share log-in credentials.)

Backup – refreshers

“I recommend that even after you’ve trained your office substitutes, that you regularly conduct refresher sessions,” recommends Kimberly. “They don’t have to be long sessions and BOMs can also relate any system changes. Also, have easy-to-understand instructions with screen shots and brief ‘how-to’s’ handy, especially how to access critical files.”