Partnering with a clearinghouse with connections to many payers makes submitting claims easier and keeps cash flowing consistently. Keeping cash flow in a steady stream means understanding how managed care works – knowing the systems, procedures, and requirements are critical. A clearinghouse, like primeCLAIMS, has connections with multiple MCOs and has built into its system the pertinent requirements, procedures, and systems no matter the size of the MCO. It’s worry-free - especially when working with a clearinghouse well established in and familiar with LTC and managed care. The clearinghouse will have the people who can effectively help you, because they have done it themselves.

Getting on board with an MCO – the application process

A real clearinghouse partner, like primeCLAIMS, will send you the correct form with instructions regarding how to fill it out. It can help you confidently connect the dots and fill in the right blanks with the right information. Before submission to the MCO, you can send a copy to the clearinghouse so that its experts can review it for completion and correctness and help with follow-up. The clearinghouse can also anticipate when you should receive the response and will be there for you until you receive the final approval. It plays an active advisory role throughout the application process and it’s that personal touch that truly identifies a clearinghouse as a real partner.

Medicaid Managed Care can be a different animal

Once you have the contract, knowing how and when to submit claims can be stressful for operators, especially since many states with Medicaid Managed Care, like Tennessee, Arizona, and California, among others, have multiple contracted Managed Care Organizations (MCOs) to run the program. It’s complicated. However, you can let the clearinghouse ease some of the pain for you. It knows what information is required, where to send the claims, and how to deal with the MCOs, even the very large ones.

Example: Some MCOs have a 90-day filing limit policy. In contrast to the traditional 12-month initial claims submissions window for fee-for-service Medicare and Medicaid models, if MCOs do not receive the claims within 90 days, they won’t pay. The clearinghouse will help you submit claims within the filing time period.

Another example: Medicaid recipients can either select an MCO or the state selects one for them. A further wrinkle in the process is when the Medicaid recipient moves from one MCO to another and you may not know about it. The result? Billers will be submitting claims to multiple MCOs in any given month. The clearinghouse will help you stay on top of these this.

Note: Creating secondary payer claims should be a primary concern

When Medicare Managed Care is the primary payer, you may still need to submit claims to another payer to pick up the co-insurance. The clearinghouse should create the secondary claims automatically.

Note: Rejecting claims, not a batch of claims

If there are errors in the claims, primeCLAIMS isolates individual claims not the entire batch. While you are fixing the rejected claims, primeCLAIMS submits the rest of the batch for payment. This avoid unnecessary payment delays.

Summary

Having the right clearinghouse partner can help your inbound cash flow freely no matter how complicated the MCO payment process can be.

It makes cents.

Fallback, Fill-in, and Backup. No, that is not the call to retreat in the face of overwhelming odds. Although at times, working in a SNF business office can feel like a wave-upon-wave series of assaults on what would otherwise be a normal, methodical day of blissful productivity. Interruptions, urgent requests from the corporate office, and unanticipated call-ins by other office staff, even scheduled absences can be disruptive. But retreat is not the answer. Substitute is the better option - making sure that others are trained to cover the important aspects of the job.

Fallback – Training back-ups is critical

In preparation for this week’s blog, I interviewed Ms. Kimberly Sturm, primeCLAIMS Senior Project Manager. We discussed what business office managers (BOMs) can and should do in anticipation of those times when a member of the office staff calls in or is on maternity leave or vacation. “Cross-train and refresh is what I have advised administrators and office managers throughout my career as a consultant and regional accounts receivable manager,” advises Kimberly. “This is a particular priority for payroll and billing followed by accounts payable, patient trust reconciliation, and other office functions. It seems that facilities don’t have the time before such an absence takes place, but when it does and deadlines have to be met, training happens and sometimes haphazardly. Unfortunately, it is usually long after uncompleted critical tasks have stacked up.” When Kimberly was a regional A/R manager for a large multi-facility SNF operator, one of her office managers, a 26 year old, had a heart attack and was out for 10 weeks. “I had to do the payroll, because the facility did not have a backup,” she explains.

Fill-in – Identify and prioritize

What are the absolute essential office functions that must be performed every day without exception and who do you train? At a minimum, stay on top of the tasks needed to process claims and payroll. Each facility is different with staff members often wearing more than one hat. Unless specifically dictated by corporate policy, the facility administrator or executive director identifies those who should be cross trained.

Fortunately, with back office automation, such as payroll, billing, and accounts payable, training is much simpler with fewer opportunities for errors. Since automation simplifies many office functions, office managers can train with confidence. For example, with a clearinghouse to process claims automatically, converting revenues to cash is easy to learn and manage every day. How does a clearinghouse help? A clearinghouse can furnish all the tools needed to manage claims, DDE, track ADR status, managed eligibility, automate claims submission, plus manage denials-in one system with one log-in. Even though there is still the need for hands-on entries which requires training, it is much easier with claims automation. (Caution: This brings up an important point: with automation comes security. A key part of security is individual log-in credentials. A word from Kimberly, do NOT share log-in credentials.)

Backup – refreshers

“I recommend that even after you’ve trained your office substitutes, that you regularly conduct refresher sessions,” recommends Kimberly. “They don’t have to be long sessions and BOMs can also relate any system changes. Also, have easy-to-understand instructions with screen shots and brief ‘how-to’s’ handy, especially how to access critical files.”

Valuable highlights from 2015 blogs to prepare for 2016

Hard to believe that 2015 is rapidly passing into history. Another year, but what a year it has been for Long Term Post-Acute Providers (LTPAC) providers especially considering the incredible number of claims billers have had to prepare, submit, monitor, and manage. We congratulate billers across the country for what they have been able to accomplish in converting claims to cash in the bank.

The primeCLAIMS team works just as hard to provide an excellent clearinghouse service and also to communicate worthwhile tips and advice to help make billing tasks easier to complete. Looking back on our blogs in 2015, we have covered such topics as ICD-10, processing secondary claims, dealing with claims rejections, principles of successfully Revenue Cycle Management, tips for submitting clean claims, and what to look for in a LTPAC clearinghouse.

Regarding secondary claims, one of our recent blogs, entitled, “What you’re wasting by processing secondary claims manually,” discusses the why’s of automation. The days of manually identifying, preparing, processing, and tracking secondary payer claims is long past. If they haven’t already, we suggest billers retire such costly practices forever and start the new year right.

Managing claims does not have to be complicated we argued in the blog, “Do yourself a favor - Simplify the reimbursement process,” if billers automate the process.

Not all clearinghouses are created equal. In “How well is your claims management solution moving cash flow,” we share some insight into what a clearinghouse, processing LTPAC claims, should offer. Further, because no matter how automated the process may be, claims is still about people. And people and machines need support. In another blog, we ask the question, “Clearinghouse support – is it there when you need it?”

These blogs represent the kind of information billers and their managers should know to be successful not only in 2015, but also in 2016. We look forward to continuing to share our insights and the experiences of your peers in future blogs. After all, it just makes cents.

For your convenience, we’ve grouped the recent blogs by category:

Happy Holidays! May this season bring you and yours joy.

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

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.