Receiving actionable information and making decisions are time neutral and may or may not make a difference. There’s something missing. Think of it this way. Information that is easy to interpret and timely gives executives the power to make correct decisions to take opportune action to generate positive results – quickly. It’s more than a matter of reports, it’s the quality and timing of the information.

Many of you can recall the days of spreadsheets, the data for which was manually gathered, input, processed, formatted into reports, converted to hopefully useful information, distributed, and then interpreted for action. Too often, it was too little, too late. In today’s world, that’s changed. Data is everywhere. The key is to harvest, process, and in real-time combine and recombine the data, converting it into information that is immediate, meaningful and compelling.

In previous blogs, we have discussed the advantages and availability of business intelligence (BI) through data warehousing and data mining. The multi-dimensionality of data-driven information, therefore data-driven decisions, is limited only by the questions asked. Our customers often ask us to generate new ways to display information or to identify new information to meet emerging challenges and opportunities. Let’s explore what our customers have been able to do with BI from real-time data.

But first, executives must identify the Key Performance Indicators (KPIs) which will stimulate correct and actionable decisions. Our primeVIEW customers have identified the following categories or information sets which executives and managers at all levels of their companies can view and act on.

• Census
• Occupancy
• Labor
• Cash/AR
• Clinical
• Rehab
• Financial
• 5 Star
• RAC Audits
• And more

Within each of these categories is information that enables executives to view current performance, performance trends, current and prior year performance comparisons, performance projections, comparisons between business units, and budgetary and regulatory compliance status. Also, the system generates benchmark-based alerts which notify appropriate decision makers and stakeholders that a threshold has been or is about to be crossed. As alerts appear on their mobile devices, executives report to us, they immediately reach out to the facilities to confirm, to coach, to correct, and to facilitate. These real-time alerts stimulate timely data-driven decisions and real-time accountability

BI has helped providers enjoy the benefits of real-time accountability through threshold alerts and dashboard-based daily, weekly, and monthly business unit performance reviews. One CEO of a multi-facility operation reports that he conducts his monthly facility financial reviews using the dashboard which is displayed on screen right in front of him. He can view a facility’s performance compared to its peers, its trends, its projections, and drill down to the employee or even resident level depending on the topic at hand, from financial to cash to labor to clinical. It’s certainly timely and it’s definitely relevant. Facilities managers know that they have to be prepared to address not only the prior month’s performance, but also current issues and opportunities as well.

In the today’s world of BI, executives and managers don’t have to wait for reports which may be too late or even prone to error. They can access accurate and timely KPIs right now. Real-time information does help providers make timely, actionable, and data-driven decisions that grow results.

What advantages have you experienced through the use of business intelligence?

What a Claims Clearinghouse should do

Before I address the topic, I think reviewing what a claims clearinghouse is and what its benefits can be to you will give context to the question of processing secondary claims. In the past, to process claims, billers completed paper forms and sent them via the Postal Service to the payer. Sounds simple, but it wasn’t and in some cases where providers are still submitting some claims in this way, it isn’t. Phone calls and error-generated resubmittals contribute to a complex, cumbersome, costly, and prolonged payment process. With electronic claims preparation and submittals, however, clearinghouses have stepped in to take over for the Postal Service with a few advantages, including claims screening and claims workflows. The software manages the flow and aggregates the claims. Clearinghouses let providers securely submit and track claims to multiple payers all in one portal. Consider it like online banking. Here are some of the advantages claims clearinghouses 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

The benefits – simplification and speed

• Fewer denied claims and significantly higher claim success - you can catch and fix claim errors in minutes rather than days or weeks
• Rapid claims processing significantly reduces reimbursement times.
• Time savings - You can batch claims instead of submitting each one at a time.
• Reduced human-caused errors and the need to repeatedly re-key transaction data into each payer’s website
• Avoid phone call frustrations to payers
• Shorter payment cycles
• Reduction of cumbersome and expensive snail mail-related processes

 How not all clearinghouses are the same

Good clearinghouses have:

• A payers list - your payers need to be on their payers lists or can get on their lists quickly
• Nationwide payer network – they must have a national reach
• Claims software exchange– clearinghouses should be able to “talk” with your billing software and have a success track record.
• A flat subscription fee instead of a module-based or a la carte menu of billable services
• Support – accessible and responsive
• Dashboard-based error reports & a control panel with an easy-to-understand and navigate interface
• Long Term Care focus - For Long Term Care providers having a clearinghouse that was built from the ground up specifically for LTC is a real advantage.

Why using a clearinghouse for secondary claims is important

For all the same advantages and benefits listed above as well as:

• Efficient secondary claims processing – a sure advantage over manual billing or going to each payer’s website to key in transaction data
• Reduction of rejected and denied claims - optical readers may not be able to correctly read the paper claim. This can be particularly stressful considering the tight timeframes in which a payer will accept claims.
• Proper processing – clearinghouses know how to process the claim
• Control – because the system simply generates the claims candidates, at the click of a button you determine which claims the clearinghouse should send. This is important, because in some cases, Medicare automatically bills the secondary payer. You don’t want to submit duplicate claims.

Conclusion

Secondary payer claims are very important to Medicare Part A providers. In some cases, a provider reported that over 80% of its Medicare Part A admissions stayed longer than the initial 20 days – a significant source of revenue and, therefore, cash. Properly processing claims through a reputable and reliable claims clearinghouse engineered for LTC providers helps to expedite that revenue-to-cash conversion.

A revisit to the world of data mining

Simply stated, to data mine is to analyze data from a variety of perspectives and to convert the findings into valuable (or actionable) information in the form of graphs, charts, and/or tables. This information identifies previously hidden or difficult to spot performance patterns to help providers improve clinical outcomes, increase revenues, convert those revenues to cash, and cut costs. But let’s pause for a brief moment and go just one step deeper

What is data and data warehousing?

We throw the term, “data”, around a lot, but what is it? Data embraces any and all facts, numbers, and texts which computers can process. If your organization uses computers, you have data – lots of it. But more than likely, your data resides in disparate data locations existing in the clinical, financial, time and attendance, procurement, etc. applications your organization uses. More than likely, these applications don’t speak to each other, impeding performance pattern discovery. Data warehousing gives data meaning.

OK. So what is a data warehouse? Data warehousing centralizes data management and retrieval of all of your organization’s data. Just as the name implies, it is a virtual (in the cloud) or physical (a data server) location where you can store and manage data in a multidimensional database system. Ideally, the warehouse can automatically extract or pump data from diverse data repositories. A physical warehouse has an inventory which is only useful if you can find and combine what you are looking for to achieve your intended ends. For data warehousing to be useful, you need software to help you effectively mine all of your data to help you achieve your organizational goals

Data mining and long term care – bringing it home

The “spectrum of care” is a term used for many years to describe various health care delivery models and their relationship one with another. Just look at Long Term and Post-Acute Care – Skilled Nursing Facilities, Home Care and Hospice, Long Term Acute Care Hospitals, Inpatient Rehabilitation Facilities, Assisted Living Facilities, PACE (Program of All-inclusive Care for the Elderly), and Independent Care. Yet, we are witnesses to possibly a major shift from provider silos to a person-centric delivery model. It embodies only one healthcare segment, the individual. For that to happen, data warehousing is a must

But for now, whether the person-centric model happens sooner or later, your organization needs to know if you are the right setting for the right services at the right time at the right acuity and at the right cost. In other words, data mining can have meaning for your organization right now. It goes both ways - what the payer wants to pay and what outcomes you can afford to deliver with that paymen

Dashboards – the one-stop shop for all data-driven decisions

There is a third term to understand – business intelligence. In short, BI delivers meaningful and actionable information for business analysis purposes. And it’s available today delivering patterns of information through Key Performance Indicators (KPIs) meaningful to your organization and viewable in a dashboard with drilldown capabilities. These KPIs include census, labor, financial, cash, clinical, among others relevant to your organization’s mission

Results-focused

Users of our primeVIEW executive management dashboard have seen real, measurable results because they have been able to view performance patterns practically in real time. For example:

• An operator of 17 SNFs was able to manage 71% of its buildings to achieve overtime goals within 3 months resulting in significant savings.

• Real-time census monitoring helped the same provider keep his team focused to realize a 7% and 9% increase in ADC in Skilled and Private Pay respectively from 2014 to 2015.

• Another similarly-sized operator of SNFs reports an 18.5% improvement in Days Sales Outstanding while achieving 100% collection efforts using the financial information screens.

• A 41-facility SNF operator was able to gain back up to three FTE’s in labor hours in targeted facilities by using the labor and overtime management features.

• The same operator reports that primeVIEW has helped them track dozens of critical measures, such as 5-Star staffing, hospital readmission, and length of stay.

• Another multi-facility operator was able to reduce nursing staff overtime by 3% with organization-wide access to overtime screens.

All of this adds up to real take-it-to-the-bank meaning regardless of what the future holds for healthcare delivery.

Shrinking margins

Over the years I have observed that LTPAC providers have faced and still run the risk of facing possible shrinking profit margins or, in the parlance of not-for-profit providers, surplus revenue. For the purposes of this blog posting, I’ll keep things simple by referring to the bottom line as “margins”

In a report issued in 2013¹, from 2010 to 2012, SNF median net income declined from 1.8 percent in 2010 to 1 percent in 2012. Not only does this impact funds needed to competitively and cost-effectively operate, but also affects access to capital. Although SNFs have access to capital, they do encounter challenges other health care providers don’t; specifically, the high cost of debt financing with dependence on high yield bonds and bank loans. In one instance, a large SNF provider with similar credit ratings to two acute care providers had bonds trading at 2.3 percent to 3.5 percent higher than its acute care counterparts. Experts tie this to sector-specific reimbursement models.

SNFs are heavily dependent on Medicare and Medicaid while hospitals have a more advantageous mix of commercial payers compared to Medicare and Medicaid. The biggest problem is the risk created by Medicare and Medicaid uncertainty. With greater risk comes the need for higher returns and investor caution. While investor confidence has somewhat improved, large and, especially, small providers still face a challenge. So what can providers do in today’s world of potentially shrinking margins to keep their doors open and to grow their business? Collect revenue owed as soon as possible

Revenue cycle management is critical

Ok, The truism, “Cash is King,” is a bit passé. But it is still true today. And the biggest challenge is converting outstanding revenue to cash quickly. Some of the essential elements to sound revenue cycle management include auditing, implementing best practices, policies, technologies, and training

Providers need to acquire the experience, expertise, and technologies either internally or by contracting with experts to focus on:

• Billing and A/R management best practices
• Systems auditing and problem solving
• Business process analysis, development, and standardization as well as policy design
• Project management
• Team building
• Getting results

For those providers who are struggling with implementing effective revenue cycle management, we recommend contracting with billing and A/R consultants who have the expertise and breadth of experience to implement practices and policies resulting in:

• Reduced A/R,
• Decreased DSO,
• Lower costs, and
• Helping the internal A/R team to institute effective and time-saving policies and procedures.

Consultants can either directly provide or assist in the development and implementation of time-proven systems audits and A/R reductions best practices. The benefits of these efforts are rewarding in terms of:

• Discerning problems and/or needs
• Identifying root causes
• Proposing end-to-end solutions, and
• Moving plans forward into action and successful completion.

In today’s cloud computing world, technology knowledge and skills improve chances for effective revenue cycle management. Experts can recommend functional system modifications and user supporting/training in sophisticated accounting, billing, and collections applications and practices.

Undertrained staff can lead to wasted hours and needless costs. Discovering a skills set baseline through an accurate assessment of billing staff is critical and can help providers fine-tune training needs. This understanding leads to compliance thorough process training in conjunction with best practice A/R policies and procedures from admissions through to month-end closing.

Providers can reduce the risks of shrinking margins by implementing solid revenue cycle management best practices. It only makes cents

We can help you

Prime Care Technologies combines the skills and knowledge of our in-house revenue cycle management experts with our LTPAC-targeted primeCLAIMS clearinghouse to help you stand on solid fiscal ground even in times of potentially shrinking margins.

¹Ref: Skilled nursing facing pinched margins http://www.healthcarefinancenews.com/news/skilled-nursing-facing-pinched-margins 

ICD-10 Implementation is a journey not necessarily a destination – at least for the foreseeable future.

Remember Y2K? The proverbial sky was predicted to fall. It didn’t. Will the long-anticipated ICD-10 implementation be similarly anticlimactic? Probably not. ICD-10 has been dubbed the “complexification of healthcare” in the Washington Post, which also predicted that “the resulting confusion and inconsistency in claims processing would create unnecessary administrative costs and take resources away from patient care.” Texas Medical Association President, Dr. Tom Garcia, has been quoted as saying, “It’s the countdown to a perfect storm.” Whether the financial firmament will come crashing down on providers’ heads due to ICD-10 will depend not only on their preparations, but what they do after implementation.

It may well prove helpful to consolidate insights, tips and best practices submitted by experts around the country.

Let’s first address the Challenges. Despite all the training and preparation, providers still may encounter the following:

1. Productivity decrease. As coders attempt to employ ICD-10, decreasing productivity and inaccuracy-induced delays will have an impact on cost and the bottom line.
2. Financial impact. Cash flow disruption from increased denials and underpayment may also occur.
3. Resources. You’ve allocated required resources to prepare for implementation. Now it’s time to determine the resources needed to keep the implementation on track.
4. Technology-related challenges. These may include data transmission issues and unscheduled vendor updates. You may need to retest critical application or system functionality.

What should you be doing?

1. Create, implement, assess, and continuously correct a post ICD-10 implementation strategy. Take into account that this has not only impacted procedures, policies, and skill sets, but also people—including employee morale. Any change is threatening until employees can acknowledge what practices they need to let go of, deal with the sense of loss of the familiar, can understand and envision what ICD-10 competency can do for the organization and for them personally, and fully embrace the new best practices and skill sets. Tip: Involve your staff in troubleshooting through problem and resolution identification.
2. Assess demands on resources. Address effective allocation of the most impacted resources.
3. Set goals from the top down and the bottom up. Setting goals goes hand-in-hand with tracking key metrics. Involving ICD-10 stakeholders at all levels within your organization is critical.
4. Monitor net revenue and cash trends. Identify, understand, and mitigate the root cause(s) of any cash flow disruptions or revenue declines.
5. Assess documentation quality. Experts emphasize the need for specificity in clinical documentation.
6. Prepare to defend code assignments. Make sure that the documentation is consistent with the ICD-10 coding demands and supports the classification information details. Notwithstanding their inherent differences, learning a coding/classification system and understanding the clinical factors of a diagnosis are related…and important. Tip: Audit coding productivity and accuracy.
7. Training, training, and more training. Training will never stop. Tip: Develop a formalized on-going training program for clinicians and coders.
8. Hire coding help in the short run. Experts can help you assess where you are by conducting audits and working closely with coders and clinicians alike.
9. Review the Q&A document before submitting claims and MDS assessments that include October 2015 dates of service (include SNF clinicians, MDS coordinators, and billers in the review process)
10. Track key preparation and processing metrics. Rome wasn’t built in a day...nor will your process be built over night. If you have not already done so, identify key preparation and processing metrics and track them. Set benchmarks for the near and long term.
11. Acknowledge that it's an on-going process and accept it.

Conclusion

Taking steps throughout the ICD-10 implementation process will prevent the cash flow and bottom line storms from raining on your financial parade. Several resources are available to help you make the transition to ICD-10 successful. For example:

• CMS offers extensive education and clarifying questions and answers
• The American Health Care Association also offers ICD-10-related information.
• Contact primeCLAIMS clearinghouse for additional support

Additional thoughts from CMS

The Centers for Medicare and Medicaid Services have recently offered the following:

• The ICD-10 Ombudsman will be available to help answer nursing facility questions and can be reached at ICD10_Ombudsman@cms.hhs.gov.
• Minimum Data Set (MDS) assessments with Assessment Reference Dates (ARDs) on or before September 30, 2015 must contain a valid ICD-9 code in Section I if a diagnosis code is necessary.  SNF MDS assessments with ARDs on or after October 1, 2015 must contain a valid ICD-10 code.  CMS will reject MDS assessments if a Section I diagnosis code version does not apply for the ARD entered.