2 min read

Claims scrutiny – getting it right the first time

By Proclaim Partners on Wed, Oct 03, 2012 @ 08:30 AM


The headlines in the long term care media continue to highlight RACs audits, claims scrutiny, and claims denial. Further, at a time when sequestration threatens to reduce Medicare reimbursement by as much as 1.8%, revenue cycle management needs to have the constant attention of all providers every day. Of course, the first thing to do is to minimize the risk of denied claims as well as rejected claims.

Even if you are able to withstand an audit, assuming the clinical documentation supports the claims submitted, you still run the risk of poor cash flow management if your claims are rejected because of inadequate or outmoded claims preparation and “scrubbing” processes. Just as it’s important to “get it right the first time” by having the documentation to support your claims, you need to get it right when preparing the claims. In our free download position paper, Five Most Common Billing Errors, we offer insights into ways to avoid billing errors, improper diagnosis codes, invalid hospital stay dates, incorrect service dates, and etc. What we’re talking about in this post is taking your claims submission process to a higher level through claims automation. Claims automation can help by consolidating the claims submission and management process through one portal. This is the premise behind the ProClaim Partners clearinghouse. It’s a one-stop-shop for scrubbing, correcting, submitting, and monitoring claims as well as receiving payment notifications all in one place. You no longer have to trouble with multiple portals or applications.

Designed for long term care providers, the ideal enterprise-class portal will enable you to centrally monitor and manage all claims before and after they are submitted. From a central home page or dashboard, depending on the permissions/security levels you configure, you can review information and take action at a corporate, regional, or facility level. You can check for errors and clean them up before submitting the claims. The system’s scrubber, which constantly updates itself through its evolving database, can search for errors and omissions according to each payer’s rules. Within the portal you have the opportunity to make corrections in a number of ways according to your preferred workflow and internal policies. You can use the Search function to research claims and where they are in the submission-payment cycle.

You even have access to DDE and multiple MACs log-ins through this portal. While you can make corrections in the DDE, our clearinghouse lets you correct errors within the portal itself.

Other features allow you to stay on top of the revenue cycle for all payers. For example, your claims can be loaded into the system conveniently either via FTP or frequent data sweeps determined by you. Once the system receives the 835 payment notices, it sends emails to those you’ve designated to receive them.

To avoid unnecessary delays in payment, getting the claims submission process right the first time is critical for long term care providers. Visit us at our booth, #1418, during the AHCA/NCAL 63rd Annual Convention and Expo or during the 2012 LeadingAge Annual Meeting and Exposition, Prime Care Technologies, booth #530, We can show how you can accelerate payments, increase collections, and reduce DSO. It’s the right thing to do.

Topics: Medicare fraud Medicaid fraud automated revenue cycle management system revenue cycle management reducing DSO
2 min read

Avoiding Unintentional Medicare and Medicaid Fraud

By Proclaim Partners on Wed, Jun 13, 2012 @ 08:00 AM

business_man_sad_face-resized-600Ignorance 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 extent “fraud” was committed by those who unwittingly engage in poor billing practices, such as miscoding and/or absence of support documentation for procedures provided. Ignoring 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, 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. In 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?

Topics: Medicare fraud Medicaid fraud automated revenue cycle management system revenue cycle management web portal to manage claims reducing DSO


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