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Improve claims turnaround and business processes – a case study

By Proclaim Partners on Wed, Aug 13, 2014 @ 09:00 AM

istock_000017882928smallCMS Says Skilled Nursing Will Face Negative Margins By 2040,” so read the headline in last Wednesday’s AHCA/NCAL Gazette. In fact, it was the top story. Yep. It grabbed my attention really quick. Now granted, I may likely not be around by 2040, but judging by my parent’s longevity, I could. I’ve been affiliated with LTC since 1978 and it’s in my blood. I care. And, yes, to be frank, the article somewhat spooked me when I read the following, “By 2040, two-thirds of skilled nursing facilities will be operating in the red, signaling more consolidations, partnerships and accountable care organizations (ACOs) on the horizon, according to a recent memo issued by the Centers for Medicare & Medicaid Services’ (CMS) Office of the Actuary.”

Here are a couple of reasons why I am spooked. First of all, I have seen projections of the future, especially those going further out than 10 years, either flat out ignored or at least not effectively addressed. Perhaps, we hope the projections are wrong or that someone someday may do something about the issue at hand. It never ceases to amaze me that the future eventually becomes the present. Have you noticed that too? Rephrased, have you acknowledged that truism as well?

Secondly, I am spooked because I’ve noticed that when it comes to health care policy, government at the federal and state levels feels that it will have the answers. Their track record has not convinced me that government is or should be the problem solver. So what can LTC providers do today to meet the challenges the years leading up to 2040 will pose? Well, they can start today to embrace and implement available practices and technologies to build a solid financial footing by quickly collecting claims processed.

Ensign Services did just that. A recently-published ProClaim Partners case study revealed that Ensign Services faced several challenges:

  • Ensign Services needed to replace a legacy clinical and financial software application which included a basic claims submission automation feature.
  • The new software Ensign Services implemented met its EMR requirements, but lacked automated claims submission to Medicare. This also became the catalyst for consideration and conversation about clearinghouse services to all payers.
  • To compensate, Ensign Services selected a widely-used clearinghouse. The new clearinghouse was unwilling and unable to support Long Term Care-specific claims submission and management requirements.

To overcome these challenges, company executives arrived at the following conclusions:

  • Ensign Services needed a responsive and easy-to-use enterprise-class claims clearinghouse designed specifically for Long Term Care to help its clients meet their respective cash flow objectives, save money, reduce unnecessary claims processing and collections tasks, increase user satisfaction, and streamline business workflows.
  • Because of its relationship with Prime Care Technologies, Inc. for IT hosting services, Ensign Services investigated PCT’s affiliate, ProClaim Partners, LLC, and discovered that it could assist them in managing client claims.

The results? Since fully implementing the ProClaim Partners solution, Ensign Services has been able to:

  • Decrease claims turn-around time
  • Significantly improve claims management-related business processes
  • Reduce frustrations related to new client on-boarding
  • Experience quicker special requests and support issues response times

Is this THE answer to the spooky negative margins providers may experience by 2040? Not entirely. But as margins get tighter, a quicker turnaround of claims processed will be critical. The fact is it is critical today. Those providers who take steps today to improve cash flow through claims automation will not only have the advantage in the future, but also right now. At least with a better cash flow position, providers can focus on the factors influencing the bottom line.

At least those are my “thunks”.

Have you fully automated the claims management process? If so, what advantages are you seeing today?

Topics: Improved Business Processes claims management clearinghouse IT hosting services claims turnaround claims turn-around clinical and financial software claims processing EMR claims management process


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