[Webinar] Best Practices in LTPAC Revenue Cycle Management

By Prime Care Tech Marketing on Thu, May 11, 2017 @ 08:28 AM

Kimberly Sturm, primeClaims Senior Project Manager, will be sharing some of the best practices from our top clients to help you get paid faster and to streamline you revenue cycle management processes.

During the webinar, we'll:

  • Explain the most common errors resulting in rejection
  • Discuss the significance of claim filing indicators
  • Explain the difference between 22X and 23X billing codes
  • Demystify 50 Shades of Medicare Secondary Payers (MSPs)

As a 25+ year veteran of LTPAC, working in both facility-based and EHR organizations, she appreciates the importance of NOT leaving cash on the table.

Register for Claims Webinar


Topics: Medicare claims Billing Practices billing basics revenue cycle LTC Claims claims revenue
2 min read

Clearinghouse 101 – a re-introduction to automated claims processing

By Prime Care Tech Marketing on Fri, Mar 25, 2016 @ 07:00 PM

pCL-Blog-Clearinghouse-Basics.jpgNow would be a good time to get back to the basics, the essentials, of what a clearinghouse is and offers. “Clearinghouse 101” – an introduction to the some of the critical features and benefits of a claims clearinghouse. Whether you are using one today or not, take a peak. You may find some of the following tips and points useful.

One portal does it all

A clearinghouse becomes the one-stop shop, the aggregator, for all claims processing actions - all in one portal with a single sign-on to submit, respond to, monitor, and manage all claims submitted to Medicare, Medicaid, Managed Care, private insurances, and other 3rd party payers. Within the portal, billers can make changes or corrections to the claims and have access to DDE, HETS, and claims-in-process.

A claims translator

The clearinghouse takes the claims created within billing software and should run them through a scrubber to make sure that they are compliant with each payer’s requirements. If the clearinghouse find errors, it notifies the billers which claims need what information. Once the clearinghouse verifies that the claims are complete and comply with the payer billing requirements, it converts them into a format readable by the payer and forwards the claims. As a link between the provider and its payers, in essence, a clearinghouse is a claims translator.

Not a billing service

Periodically, someone will ask us if we, a clearinghouse, are a billing service. The straightforward answer is, “No.” A clearinghouse works with a provider's billing service/billers to complete the revenue cycle and to get cash back in your hand.

A convenient tool to monitor, manage, and follow-through

Submitting the claims is one thing, monitoring and follow-through are another. The clearinghouse portal enables you to see into what is happening with the claims once the payer has accepted them. Through the portal, billers can view the entire lifecycle of the claim and take action as needed to keep the claims flow steady.

Create secondary claims automatically

Please refer to this blog to learn more about how a clearinghouse should help to process secondary claims automatically and timely.

Claims data storage

Our clearinghouse, for example, securely stores the data up to 10 years, retrievable for the provider at any time.


Experience and expertise are the foundation of a responsive and reliable support system. A clearinghouse can identify what is acceptable and answer claims submissions and processing questions.


A clearinghouse should have a core set of useful reports to help billers, their managers, and the executive team to track and trend the claims cycle. The reports offerings should help providers to track their billers and claims.  

The bottom line

From a benefits point of view, what does a clearinghouse offer?

  • Simplicity - An effective clearinghouse makes the submission and management of claims simple, easy to learn, and monitor – a single location for claims management.
  • Efficiency - From clearinghouse.org, we find that “the average error rate for paper claims is 28%. But using the right clearinghouse can reduce that to 2-3%.”
  • Control – A clearinghouse delivers a provider-specific portal which serves as an all-in-one centralized location to monitor, manage, and extract necessary information.
  • Speed – A clearinghouse facilitates quicker claims turnaround with higher claims success.
  • Peace of mind – With a clearinghouse, billers have the confidence that they can track all claims easily throughout the entire claims-based revenue cycle.

It all makes cents.

Topics: clearinghouse HETS Medicare claims DDE CLIP claims clearinghouse revenue cycle paper claims Managed Medicare Medicaid claims claims scrubber software portal intermediary claims cycle
3 min read

How Well is Your Claims Management Solution Moving Cash Flow?

By Prime Care Tech Marketing on Fri, Dec 11, 2015 @ 06:58 PM

Claims Management Cash flowThat 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.


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.


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.


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 Process

Topics: automated claims management cash flow clearinghouse Medicare claims claims middleware claims submissions secondary claims reimbursement workflows application upgrades compliance security
2 min read

Accurate Medicare claims submission & eligibility determination

By Proclaim Partners on Mon, Mar 10, 2014 @ 09:00 AM

Is it HETS or miss?

Man_Woman_Desk_Laptop_Clock_trimmedIn a recent issue of CMS’s Medicare Learning Network Matters News Flash, SE 1249, CMS reaffirmed its intention to replace the Common Working File (CWF) Medicare beneficiary health insurance eligibility queries with HIPAA Eligibility Transaction System (HETS). (You can refer to last year’s blog posting for more details.) However, CMS has opted to postpone (again) the CWF access termination – this time indefinitely, but with a caveat. While this announcement will not affect the use of DDE to submit claims or to correct claims and will not impact access to beneficiary eligibility information, providers “should immediately begin transitioning to the Medicare Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS).”

Succinctly put, “While termination was originally scheduled for April 2014, CMS is delaying the date. CMS will provide at least 90 days advanced notice of the new termination date.”

So, in other words, transition to HETS sooner than later or you are at risk of missing out. Borrowing from our earlier blog, at some point in time you will no longer be able to check on a resident’s Medicare eligibility through the Common Working File (CWF).  HETS is replacing CWF inquiries. In a way, CMS has made life much easier for billers, because with HETS you can check a beneficiary’s eligibility in real time. CMS has simplified the eligibility checking process so that through HETS you can submit your inquiry with a real-time 270 request and receive your 271 response, a Functional Acknowledgement (999), an Interchange Acknowledgement (TA1), or a proprietary error response over a secure connection. According to the guide, “The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.” This change will likely require you to change your billing processes.

Some of the information HETS will reveal to you will be in a format somewhat different from what you may be used to. Also, HETS will eventually be able to send Hospice information in the same format as the CWF. The HETS 270/271 Companion Guide gives you more insight into the eligibility information you will receive in the HETS 271 response.

ProClaim Partners offers direct access to HETS through its enterprise-class automated claims clearinghouse portal. Not only can you submit, monitor, and correct claims, if necessary, you can also determine a Medicare beneficiary’s eligibility. You can select exactly what information you want to see. There is no need to bounce between applications; your information regarding all things Medicare and other insurance payers is conveniently accessible in your own branded portal.

Question: If you are using HETS, how has this changed how you check a resident’s eligibility?

Topics: 270 Request HETS Medicare claims 271 Response Medicare Eligibility
1 min read

Successful Billing - Doing What’s Right and Write What You Are Doing

By Proclaim Partners on Wed, Dec 05, 2012 @ 09:00 AM

iStock_000020717251XSmall-resized-600With 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.  

Topics: automated claims management Medicare fraud ICD-9 Medicare claims AR managers diagnostic codes


Posts by Tag

See all