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.

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.