With a Claims Management Solution - The gift that keeps on paying

Admittedly, the reimbursement process is complicated. Not only must billers identify who is to pay the bill, they have to know how to bill the payer and get paid as quickly as possible. This is especially the case when billing third party payers, such as Medicare, Medicaid, Managed Care, and private insurances. Each has its own requirements as far as coding, bill timing, and claims processing quirks are concerned which seem to change frequently. If billers are having to prepare, process, track, and follow up with claims manually using spreadsheets, phone calls, emails, letters, logs, and on and on, it is no wonder that billers are stressed and overwhelmed, that dollars are left on the table and claims are lost or misplaced. Reimbursement, or revenue cycle management, does not have to be complicated, however. In fact, it can be relatively simple with an automated claims management solution through a claims clearinghouse. But, buyers beware. Let’s take a closer look.

Keeping it simple – clearinghouse musts

Let’s assume that the strengths of automating claims management are a given. Specific clearinghouse features can considerably contribute to claims management simplicity. To help simplify and accelerate converting revenue to cash, a clearinghouse, like primeCLAIMS, should be able to do the following:

• In the event a claim is rejected, the clearinghouse should be able to isolate specific claims, not reject the entire batch of claims.
• The solution should give billers the ability to edit, scrub, monitor, and manage claims throughout the process.
• The clearinghouse must be able to stay on top of the almost daily changes to submission requirements, even the most obscure.

Visibility and control – an AR manager’s dream

Visibility and control with an enterprise-class claims solution also contributes to process simplification. With one log-in:

• Billers can connect directly to all Medicare payers via CMS-approved NSVs (Network Services Providers)
• Billers should have access to tools needed to manage claims, DDE, ADR status tracking, eligibility, secondary billing, and claims denied.
• AR managers can view each facility’s claims status and provide assistance where necessary.

Such simple tools to help speed cash flow with fewer rejections and cleaner claims. They also reduce costs by:

• Eliminating unnecessary paperwork
• Reducing transaction fees
• Reducing labor through elimination of such labor-intensive inefficiencies as:

• Log-ins to multiple systems to view all locations, determine eligibility, edit, and track all claims
• Manually compiling and submitting secondary payer claims

Simplicity in claims processing and managing also delivers peace of mind with:

• HIPAA checks
• Up to 10 years of data stored online

The bottom line

Using a clearinghouse to process, submit, and monitor claims yields numerous cost savings and improved cash flow. It’s much simpler and it just make cents.

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

I acknowledge that blogs are for the purpose of educating and earning your trust, but at times I think it’s alright to blow one’s own horn once in a while. After all no less a business guru than Kenneth H. Blanchard said, “If you don't blow your own horn, someone else will use it as a spittoon.” In the highly competitive world of claims clearinghouses, blowing our own horn is a must and doing it early is essential. Otherwise, the ensuing copycat cacophony will drown it out. So, here it is.

ProClaim Partners announces the release of its new integrated HETS/CLIP/DDE module as part of its automated claim processing clearinghouse software. For providers who bill Medicare this is a boon. It gives them access to Medicare eligibility and claims management tools through one portal. What is particularly noteworthy is that billers will be able to:

• Browse claims data through the ProClaim Partners proprietary web user interface
• Have a secure, high speed connection between the portal and the Centers for Medicare and Medicaid Services (CMS)
• Enjoy an integrated implementation of the new HIPAA Eligibility Transaction System (HETS) for real-time eligibility determinations
• Access Claims-in-Process (CLIP) which securely sweeps the CMS data during off hours for the latest claims activities.

The data seamlessly integrates into the ProClaim database and workflows. Together these functions will present the CMS data in a much more user-friendly, browser-based format than what billers have had through other tools. While CMS has recently delayed the sunset date for access to the older technology used for eligibility determination, the transition to HETS is still imminent. Why wait? With this new module providers don’t have to worry about a future sunset date.

Eligibility

For real-time Medicare eligibility determinations, ProClaim implements the new digital certificates (X.509), Simple Object Access Protocol (SOAP), and Multipurpose Internet Male Extension (MIME) standards within the ProClaim software service to provide web-based workflow and access to HETS. ProClaim makes instant programmatic determinations of eligibility against the CMS backend data store with minimum time and effort.

Claims in Process

The ProClaim Claims-in-Process (CLIP) function displays the current Medicare claims status, avoiding the need to navigate through the many legacy screens of the soon-to-be-phased-out eligibility inquiries into CWF using DDE for each individual claim. ProClaim’s CLIP accesses DDE during off hours to deliver programmed operator services. These services sweep the claims data off the DDE Mainframe and into the ProClaim database.

DDE Access

By design ProClaim minimizes DDE usage. However, under certain circumstances, claims administrators and billers may still need to access DDE. ProClaim provides a new and powerful DDE access solution as an integrated part of the software service. Now, providers have the choice of continuing to use 3rd party terminal emulation software for DDE access to the CMS Host or using the new ProClaim DDE access.

In summary, ProClaim Partners helps Long Term Care providers face a challenging environment converting claims to cash, especially when dealing with CMS/Medicare systems. In short, we’ve modernized and simplified the daily Medicare claims processing workload. The key benefits of using the system include:

• Real time eligibility determination
• Faster access to CWF data
• Faster access to Claims in Process
• Faster resolution of ADRs
• Reduced training time for new claims administrators
• Quicker collection of cash from claims

Tada! I have finished my horn solo. It’s nice to know that technology has caught up with the complex world of revenue cycle management.

Where are you in adopting new technologies to accelerate payments and improve cash flow?

With all that we’ve been reading about alleged LTC Medicare fraud, overbilling, claiming more services than that which were actually provided, giving incorrect treatments, or up-coding Medicare claims, it’s hard for providers not to feel like a target. Therefore, on behalf of those who are trying to do their best in a world of changing rules, retro reviews, and the dramatic expansion of diagnostic codes, we cry, “Enough already!” We want to speak out for all providers who are doing their best and are NOT trying to rip the system. We believe that the majority of providers operate with integrity and with the intent to provide service consistent with each resident’s needs. Personally, I take exception to any outcry that providers are gaming the system before all the evidence is in place – makes good headlines, but poor policymaker/provider relationships and certainly LOUSY policy.

ProClaim Partners has the opportunity to work with LTC providers managing numerous facilities across the country. Because we work directly with their billing staff and AR managers, we believe that they are doing their best to meet the real needs of their residents and are striving to make sure that the bills are clean and accurately represent the care given.

Having said that, do errors occur? Certainly. Years ago as an adult Boy Scout leader, I, along with others, maintained that scouting would be great…if it weren’t for the boys. Well, providers are in the people business employing people – fallible people. Operating a people business without the messiness of working with people would be great, but unreasonable and illogical. Despite providers’ best efforts with triple checks and even with their clinical applications screening the claims, we’ve discovered extra digits in Medicare numbers, invalid ICD-9 codes, etc.

My advice? Tell your story with claims that accurately reflect the care given and which are properly screened and scrubbed by members of your team (triple check), your clinical application, and a third-party automated claims management solution like ProClaim Partners. And tell your PR department to get off its duff and shout from the rooftops every day the wonderful things your facility and company are doing for the residents you serve, particularly if you are providing services to higher acuity residents. Tell your story. NO, tell your residents’ stories. It’s great press and a great buffer to the possible regulatory scrutiny and bad press that you could encounter in the future.