Ignorance is no excuse. Over the last few months, like me, I’m sure you’ve seen headlines and read articles about the federal crackdown on Medicare and Medicaid fraud. Millions of dollars have been identified as fraudulently paid for services either not rendered or with limited justification. I acknowledge that there are unscrupulous practitioners and providers out there who should be identified, indicted, convicted, and sentenced to the fullest extent the law allows. However, while I don’t have the numbers, I wonder to what extend “fraud” was committed by those who unwittingly engage in poor billing practices, such as miscoding and/or absence of support documentation for procedures provided. The old adage, that if you didn’t document it, it didn’t happen, may put providers and practitioners at risk of investigation and indictment with all the attendant negative results, such as loss of reputation, decline in confidence, and possibly business failure.

If this falls within the reasonable realm of plausible possibility, I have to scratch my head and wonder why. Why place your business and your future at risk, when you don’t have to? Once again, and you have to admit that this blog is consistent when it comes to waving the IT banner, IT can come to the rescue. Imagine the peace of mind you could have while reducing your DSO, assuming you are at risk not for lack of integrity, but credibility, if your organization had a billing and claims management system that would file clean claims each and every time.

Such an automated revenue cycle management system exists, specifically designed for long term care providers. Imagine a system comprised of a comprehensive and configurable user-friendly web portal to manage claims throughout the submission process, with functions for loading, reviewing, editing, and tracking claims online. With this portal, providers can fully leverage enterprise-level security and permissions with user-definable roles to satisfy their specific claims processing practices. As part of a complete health care transaction solution, providers can submit, monitor, edit claims, and review their claims on-line.

Key benefits of the ProClaim Partner’s application:

• Increased revenue stream and reduced DSO through quick claims turn-around and real-time claims management reporting viewable through a user-defined digital dashboard
• Smoother claims flow through direct connections with providers, trading partners, and value-added networks
• Eliminating avoidable payment delays by increasing successful first-pass rates, tracking claims, and automatically checking claim status
• Reduced transaction fees and paper handling costs by enabling direct connection with providers and payers
• Decreased operations costs through automated handling of routine questions and documentation requests associated with eligibility, claims status, and referrals
• Preserving investments in existing systems by offering an off-the-shelf claims management application that easily interfaces with existing adjudication, financial, and membership systems
• Reduced risk through its robust user audit functionality

Providers would be well rewarded for looking into it. At times like these and under this “gotcha” environment of fraud crackdown, doing billing right certainly has its virtues. But a system is only as good as the workflow that leads to the filing of claims – preadmissions screening and documentation; admissions documentation; clinical documentation; therapy services documentation; proper coding; charges compiled; and claims created, scrubbed, triple checked, filed, and monitored. All are critical components of the workflow and are at risk of vital data and information leakage.

In the next blog, we’ll discuss some of these workflow components which are considered industry best practices.

Question: What solid claims management practices have you observed or implemented?

A Major Health Care IT Paradigm Shift

“Best Practices” in the old days – paper pushing.
Historically, health care in general and long term care specifically, has been intensively paper based - forms, spindles, chart tables, racks, and binders. Documentation was (and still is) the name of the game and pushing paper was the only way. Even regulatory enforcement surveys were based on paper compliance with bedside visits to verify the documentation. Paper-based documentation consumed a lot of trees and filled a lot of storage files and storage units.

“Best Practices” today – Getting past the paper paradigm

• How has IT helped your operation?
• If you have embraced IT, how has it benefitted your operation and the services you deliver?

Prime Care Technologies wishes you a Happy New Year. I once had a boss whose mantra was, “All problems can be viewed as opportunities.” That being the case, then 2012 should be an amazing year of opportunities for business in general and long term care specifically. I encourage you to look at all of your “opportunities” and to explore how IT can help you convert those opportunities into gains.

To long term care and other health care providers we say, “Thank you for your selfless service to our nation’s frail and elderly in 2011.” To our Fortune 1000 clients as well as state and local government clients, “Thank you for the services and products that make our lives that much better, our country an example to the world of what freedom and liberty can mean.”  

Question: What "opportunities" would you like IT to help your company, agency, or facility tackle?