Claims processing automation significantly contributes to a smoother claims flow and quicker conversion of revenue to cash. The key component to claims automation is the clearinghouse which scrubs the claims and then securely transmits the claims to the payer. That sounds simple and it is MUCH simpler than any other method of submitting claims and it’s HIPAA-compliant. However, claims are submitted electronically and that means software. Where there’s software, there are computers. And where software and computers exist, there is the chance that users may need to contact the clearinghouse for questions regarding software administration, functionality, training, and support.

Whether a provider is considering clearinghouse options or has already contracted with one, the following tips may help them conduct a more useful support services due diligence:

1. Response time – Time is money and especially with claims processing. Whether the call is a how-to or a break-fix question, getting answers or problems resolved in a reasonable period of time is critical. How supportive is the clearinghouse’s team? What hoops do users have to jump through in order to get answers?
2. Tip: Be specific with the types of questions. Some questions or issues, such as password resets, can be addressed in a matter of moments, while others may require more time for resolution.
3. Knowledge of the industry – LTC providers confront a daunting task when filing claims and not all clearinghouses understand the nuances inherent in LTC claims.
4. Tip: Finding a clearinghouse that understands the world of LTC claims is key to usability, satisfaction, and the results providers need.
5. Who owns the software – There is this magic component called middleware that makes an electronic claim possible. Some clearinghouses will claim to own the software (the user interface) but they do not own the programming that actually transmits the claims. Those who do are more likely to respond quickly to requests for changes and fixes to their software than those who don’t. In our experience, it can be a matter of days compared to weeks or months.
6. Tip: Find out how nimble the clearinghouse is in response to requests.
7. Rooted in the LTC community – This ties in with item #2. Clearinghouses, whose customers are primarily acute care providers or physician practices, are more inclined to accommodate customer requests from those verticals than from LTC providers who may only represent a small portion of the customer base. It’s a matter of the 600 lb. gorilla. LTC is just harder to understand and develop solutions for than acute care and physician practices.
8. Tip: Each clearinghouse has its own strengths and weaknesses. Check LTC references to confirm each clearinghouse’s claim of LTC claims expertise.
9. Technology investment – The rules of LTC claims game are constantly changing. Is the clearinghouse keeping up? Also, does the clearinghouse support efficient practices? Take for example, claims batching. Batching claims is good, but beware. Some clearinghouses will reject all claims in a batch even if only a few are truly rejections. To avoid this, billers will submit claims one at a time which is unnecessarily inefficient.
10. Tip: Make sure that the clearinghouse can isolate, exclude, and reject only the rejected claims.
11. Never mind technology; it’s still people working with people – How are callers treated when they speak to a clearinghouse representative? Ultimately, customer service is still the king of satisfaction.
12. Tip: Check the references for this important aspect of a clearinghouse’s service.

The bottom line? Scrub your clearinghouse options before you let any of them scrub your claims. And when it comes right down to it, what really differentiates one from another is the level of support offered. Happy billers and productive billers. And getting the support they need, makes billers happy.

It just makes cents.

Yesterday’s tactics will not work in today’s LTPAC marketing game

When I was operating SNFs in the late 70’s through the early 90’s, the traditional way to forge and foster a solid referral pipeline was to schmooze the hospital discharge planners by visiting them, occasionally taking them to lunch, sending periodic greeting cards, and doing a good job. That “good job” meant that the discharge planners didn’t receive any complaints about the care given to those they referred to us. That was about the extent of it. Like most sales, it was all about personal relationships supported by the absence of complaints. But times have changed.

Today, we’d lose with just schmooze. In this data-driven world of ours and closer scrutiny of functioning relationships between acute care and post-acute care providers (read, hospital readmission rates, for example), we have to demonstrate that our goals and performance align with each hospital’s expectations. Those providers which are able to share statistics vital to acute care providers have a significant advantage over those who can’t. But to be able to do that can be a daunting task, but it doesn’t have to be.

Data – the LTPAC marketer’s (not-so) secret weapon

Data mining and business intelligence technologies simplify the collection, storage, retrieval, and conversion of data into readily retrievable and actionable information practically in real time. The information BI offers comes in the form of Key Performance Indicators (KPIs) which can include census, labor, wages, admissions/discharges/readmissions, cash and collections, clinical, 5 Star, and RAC audits, customer satisfaction, QAPI, actual-to-budget spend, job postings, and more. You get the idea. If the data exists, it can be mined and reported. As you read through this list, you can also see that a tremendous opportunity exists for providers not only to establish a substantial and mutually-beneficial relationship, but one that is easy to maintain. The key here is transparency. It’s no longer, “Just take my word for it.”

But where do you start? First and foremost, find out what matters most to the hospitals in your area. What services do they need post-acute care providers to offer? Do your services offerings align with what they need? Assuming they do, what data points/KPIs would indicate that you are in alignment with their goals? Readmission information? Customer satisfaction survey results? Staffing levels? Lengths of stay? Discharges destination? Clinical trending? Quality measures specific to the services important to the hospital? BI becomes your scorecard in the game of 21^st century census building.

Visualize your marketing team walking into the hospital’s conference room where you are introduced to its team of discharge planning stakeholders. Following introductions and the usual “getting-to-know-you” banter, you start your presentation. Now, here’s the fun part. At the right moment in your presentation, you pull out a report generated by your BI tool and distribute a copy to each person. You discern some “Aha!” facial expressions as they easily interpret the charts, graphs, and tables illustrating the KPIs germane to their specific needs. Further, you sense the building excitement as you report that you can provide updates as frequently as they require. You’ve added credibility to your claims that your facility can be the go-to facility for their post-acute discharges. This is the stuff of solid partnerships.

Let’s take rehospitalization KPIs, for example. With hospitals and SNFs under close scrutiny regarding rehospitalization rates, being able to quickly report up-to-the-moment current and trending readmissions-related KPIs by payer, by diagnosis, and by risk levels can be a positive game changer for you.

Bottom line

Using BI can help providers confidently say to their acute care referral sources, “We’re in this together.”

What a wonderful time of year this is! We have so much to be grateful for and to turn our heads and hearts to. However, while it may be the holiday season, it certainly is not the time to take a holiday from monitoring certain critical aspects of cash flow. One of those financial aspects we’d like to address here is cash collected and, specifically, year-end billing deadlines. Please be aware that each payer has windows of opportunity for submitting claims - that is, in which your organization can submit claims to payers and hope to get paid. Unfortunately, many providers find themselves in the position of not submitting claims or responding to rejections on time.

The result? No payment. Your challenge is to make sure the right people are in the right place to employ the right systems to process the claims and get paid. And it all boils down to some simple, but critical routine tasks that you don’t have to do, but your team does. You should, however, follow-up to make sure they happen.

Timely claim filing

Backstory - Medicare (the big one)

Medicare may allow 12 months[1] to file a claim. For example, for services rendered in October, November, or December of last year, you may have until December 31^st of this year to file the claim. However, no one wants to wait a year to bill a payer, but it happens. Now you may be asking yourself, why would ANYONE wait 12 months to file a claim? Answer – not on purpose. When that takes place, our team has discovered that it is often due to a rejection and subsequent request for additional information[2]. In this case, under the pressure to meet current demands, the biller may forget about the claim and/or the claim is misplaced and is not updated and resubmitted.

Here is another possible reason the payer has no record of the claim. It WASN’T submitted. How’s that? Likely scenario – The admission takes place near the end of the month. The MDS is not ready when it comes to billing at the first of the month. Because the MDS is not ready, the biller will place the claim on hold. However, when the MDS is completed, billers sometimes forget to process the initial claim or the biller is no longer working for you. Because the initial claim was never submitted, Medicare rejects next month’s claim and you receive an out-of-sequence error message. When something like the above takes place, and it happens more often than providers like to admit, there may exist a gap of days, weeks, or months before the original claim is filed. You then run the risk of encountering a timely filing issue. For multi-facility operators, this can result in millions of dollars of uncollectible claims.

The same concept can apply to Medicaid. Further complicating the matter is that the claims filing window can differ from state to state. Private insurances also have their own windows for filing claims – in some cases only 90 days.

A simple two-step process to a happier holiday, a happier year

Step #1 – Have each facility’s office manager, the regional director of finance, and the corporate director of AR or corporate controller review the aging at least quarterly for uncollected 3^rd party payer amounts that are 180 days or older. In this way, they can identify at-risk cases and act on them immediately.

Step #2 – Make sure this review takes place and request a summary report after the meeting. The report can include information about what is not collectible, what can be written off to Medicare bad debt, what can be collected.

The results? Our team has observed that providers who engage in this quarterly, or more frequent, aging review have experienced:

• Improved cash flow and
• A responsibly cleaned-up aging reflecting what is truly collectible.

We wish you a happier holiday season, because we know that by following this process you avoid the risk of leaving more than leftover turkey on the table.

It only makes cents.

[1] Here is a good rule of thumb - if the claim is over 12 months old you may have a hard time submitting the claim.

[2] Please be aware that when a claim is rejected by the payer, the payer may not have entered it into its system and therefore it will not have a record of the original submission, In effect, as far as the payer is concerned, you never really filed the original claim. The clock starts ticking.

Steer wrestling and data chasing (Yes, there is a point to this.)

I admit it. I am a born city slicker who likes to wear jeans, cowboy-style shirts from CAL Ranch, a cowboy hat (although it’s been a while since I donned one of them), and a good comfortable pair of cowboy boots. I’ve ridden a horse a handful of times, almost got thrown once, and chased more cows on foot than I care to count when I worked on a farm one summer when I was 17. Now if that don’t qualify me as a rootin’, tootin’, shootin’ wrangler, well…it just doesn’t. But I do like a good rodeo once in a while. And the event that gets my attention happens to be steer wrestling. (Probably because it’s

the quickest event and I have a short attention span – where was I?) I mean, think about it. The steer and the cowboy are rocketing along side-by-side at about 30 miles per hour. The cowboy then slides off his horse on to a 600 lb. steer, catches it behind the horns, stops its forward momentum, and then has to wrestle it to the ground. The world record currently sits at 2.4 seconds. (It took me longer that 2.4 seconds to write that last sentence.)

So, what in the pea-pickin’ world does data chasin’ have to with steer wrestlin’ or bull doggin’, as it is otherwise called?

Actually a lot. I mean think about it. It’s the end of the week, the month, the quarter, the year, you name it. Whether you’re a corporate or regional VP of Operations, a facility administrator or executive director, or a department head, you have to file reports and be accountable for the stories they tell. I recall years ago, when operating a 120-bed SNF that I had to meet with the RVP each month and, at times, the divisional VP of Operations as well, to review my facility’s performance. I had a rack on wheels on which I kept all the A/R, A/P, payroll, and P&L printouts and my own manually-generated reports.  I would roll that sucker into the facility conference room ready to present and defend my case. In retrospect it is quite comical to think about. The best way to hide a so-so performance was to bury the RVP and AVP in well-organized outdated and irrelevant summaries based on arcane and rearview-focused information. Yee-haw! It weren’t quick, Ma’am, but it sure got the job done. Sadly, it was also meaningless and unnecessarily time consuming.

Succeedin’ in data wrestlin’

What is the secret to successful steer wrestling? Speed, leverage, and strength. In previously posted blogs, we have repeatedly beat the drum of data mining and business intelligence (BI). Succinctly stated, data mining is “technology-driven processes and practices used to convert raw and sometimes disparate data into easy-to-interpret and actionable information.” Business intelligence gives you the speed and leverage to retrieve the data needed to make sound decisions quickly. And like a good “hazer” (the cowboy riding on the right side of the steer to keep it running straight), BI helps decision-makers focus on what really matters without distractions. Here’s how:

• Speed – business intelligence can retrieve data in real time or at least process the data into useful information in real time as soon as the data is available. (Most of our customers want their data retrieved several times a day.) The BI dashboard displays the data in useful graphs, charts, and tables which are readily accessible and easy to interpret and act on.
• Leverage – Such timely and actionable information gives decision-makers the leverage to make the right decisions to seize opportunities and problems and wrestle them to the ground in record time.
• Strength – Because the dashboard is viewable at multiple levels in the organization with roll-up and drill-down capabilities, organizations can concentrate their leaders at multiple levels to make things happen quickly and powerfully.

Providers today have so many issues, challenges, and opportunities before them and so many regulatory, investment, and regional and corporate stakeholders to answer to. It’s insane to try to wrestle that 600 lb. steer of data to retrieve, compile, make sense of, and report without BI. If you have BI, good job. If you don’t or are not fully taking advantage of it, you don’t need a “steer”-ing committee to create one. There are BI tools available right out of the chute, like PCT’s primeVIEW, designed for the LTPAC steer wrestlers, like you, cowboy.

Now, git off’n your high horse and take a gander.

An associate of mine at primeCLAIMS, recently related a turn of phrase that I agree can apply to working with managed care organizations (MCOs), “If you’ve seen one contract, you’ve seen one contract.”  Depending on the number of managed care organizations your company or facility works with, billing the right payer and submitting the correct claim with the correct information can be quite complicated. MCOs have parallel as well as divergent policies for correct claims submission. Knowing what those contractual requirements are and fulfilling those requirements is the key. So, how does a biller keep this as simple as possible?

What’s in each contract – knowing what is covered, not covered

The devil is in the details. And since each MCO contract may be different from the others, billers should understand what’s in each. The contracts may specify:

• Levels of care by RUG scores or service levels, which specific diagnosis codes are allowed, how many days are considered co-pay days, which ancillaries are covered in the base rate and which may be billed separately or not at all, if a pre-authorization[1] and re-authorizations for a stay is needed, and so forth. Most will agree that no two MCOs are alike. Knowing what services and procedures are covered is essential to and getting paid at the proper pay rates without unnecessary delays.

Caution: Billers need to be mindful that facilities may admit a resident/patient who is to be covered by managed care, but with whom the provider does not yet have a contract. In that event, the provider may not receive full pay for services rendered since the MCO in question may consider the claim out-of-network.

What’s in each contract – knowing how to complete the claim form

Billers need to have a working knowledge of what each MCO expects to have included in the claim form as stipulated in each contract. We recommend that billers have access to the contracts and to know what each requires. Our Managed Care Master App can help. 

Keeping it all in one place – a ready reference

We advise all providers to compile all of their managed care contracts into one location, perhaps a tickler file, a file drawer with a folder for each contract, or a binder. In front of each contract, providers should place a completed summary form highlighting what each payer will pay for under what circumstances using which codes, paying how often. Each summary sheet highlights the essentials that must be included in each claim and should serve as a reference tool during the triple-check meeting. Or better, if you don't want to physically maintain contracts, check out our Managed Care MASTER app for housing your contracts online with easy-to-reference contract summaries.

Set up the system correctly the first time

Another best practice to help simplify the process is to set up each contract’s claims requirements within the billing software, such as rates, included and excluded diagnosis codes, etc. Word to the wise - Take the time now to set it up properly or deal with possible problems later[2].

Last Word

The managed care billing process can be easier to manage if providers will:

• Use available technology, like Managed Care MASTER, or set up a reference binder for each contract and its summary. All billers need to become familiar with each contract.
• Correctly set up the contract provisions within the billing software.
• Refer to the contract summary sheets during the triple-check process.

One More Last Word

My primeCLAIMS colleague, Mike Giel, suggested we mention that in the contract negotiation period, providers need to discuss what provider enrollment procedures the MCO requires before claims can be submitted electronically. Think of it this way. The contract is the key to opening the claims flow door. The enrollment form opens the door. Completing, submitting, and receiving approval prior to submitting the first claim will ensure that the door is open and remains open so that claims can go and payments come in unhindered.  

It just makes good cents.

[1] Example: Pre-authorizations are usually required to pre-approve a specific length of stay. Providers may need to get authorization to extend the stays beyond the initial authorized period. If providers don’t secure a reauthorization, they will have to worry about who will pay for the rest of the stay. Knowing that in advance can eliminate frustrations for all involved: the resident, the resident family, and the provider.

[2] Note: Contracts have a life of their own and can change over time. When those changes occur, record them in the contact binder and billing software set up.