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Imagination at work.
Centricity Healthcare User Group CHUG
Jason Whiteaker, Director Sales Engineering RemitDATA Terri Cipriano, HCM Analyst GE Healthcare Joe Heald, EDI Services Manager, GE Healthcare
GE Healthcare
Reimbursement Analytics and Hosted Claims Manager
GE Healthcare
Key Challenges Facing Practices
There is no shortage of challenges in today’s
healthcare landscape. • Healthcare reform, new mandates • Reduced reimbursement, increase in self
pay • Lack of transparency • Making decisions on insufficient data
How can GE Help?
Centricity EDI Reimbursement Analytics and
Hosted Claims Manager provide a near real-time, closed-loop business analysis and
process improvement solution • Comparative healthcare analytics on
reimbursement, utilization and productivity • Combined with the ability to affect change
on the front end to prevent billing mistakes , denials and rework from recurring
Patient Call/Apt.
Notification
Eligibility Verification
Healthcare Service
Provided and Documented
Coding, Claim
Creation and
Submission
Payer Processing
and Adjudication
Appeal Process
Final Reconciling
Closed loop solution
Post Adjudication Analytics and
Trending
The Value of Information
Reimbursement
How are payers treating us? How do we compare to our peers?
Utilization
Are we an outlier on a code that is an “audit-trigger”? Are we under-coding and missing potential revenue opportunity?
Productivity
How is our staff performing versus our peers?
Revenue cycle efficiencies
Correct incomplete or incorrect
prior to submission. Reduce claim denials, underpayments and re-work.
Claims accuracy
Relational editing for ICD and CPT. Payer-specific claims checking before submission.
Regulatory compliance
Evaluates claims against rules and
initiatives
Get answers to resolve key challenges…
... And help improve the outcomes
Reimbursement Analytics
Hosted Claims Manager
Reimbursement Analytics
Reimbursement Analytics provides a detailed assessment of a practice’s financial well being. Using a near real-time, web-based application, the Reimbursement Analytics service provides comparative healthcare data on reimbursement, utilization and productivity.
Solution Highlights
Insight Board
“Did You Know?” module
E&M Code utilization
Denial Management Payer Performance
Interactive
Create different views and filters
Dashboard
will display
data based on
new
selection(s)
Click & drag to drill-down on your top 2
denied procedures
Create different views and filters
Create different views and filters
Create different views and filters
Comparative
Unexpected denials How do I compare?
Additional peer comparisons
Additional peer comparisons
Proactive
Monitor metrics that matter to you
Hosted Claims Manager
Hosted Claims Manager is a pre-claim, clinical editing solution and proactive claim analysis service that identifies and resolves posting errors that would later result in a rejection or a denial. The best way to prevent rejections and denials is to stop them before they occur.
Solution Highlights
Hosted Claims Manager helps to
Identify charge entry errors, allowing the
ability to resolve potential rejections or
denials
Complete pre-claim edits prior to
submission
Helps you reduce your clinical coding errors prior to your charge entry process
Provide greater confidence that claims will
get paid without disruption
Hosted Claims Manager
Offers the ability to build comprehensive invoice
history of the patient into the editing process
Can trend the effectiveness of the edits and
identify areas for continued process
improvement – payment analysis
Integrates clinical edits with TES and Enterprise
Task Manager which provides a streamlined
workflow
Prevent
Clinical edits...what are they?
DLP Identifies items entered on one or more claims that have identical Dates of Services,
Procedures , Modifiers, Departments, and Providers (including previous claim history)
EST Identifies where an established patient E&M was billed but no service has been billed within
3 years for the patient by the same organization and specialty
GFP Identifies an E&M that was billed during the global follow up period of an earlier procedure,
has the same primary Dx as on Dx for the earlier procedure and was performed by the
same provider
LBI Identifies that no diagnosis on the claim line supports medical necessity for the procedure
billed (as specified by Local Medicare Guidelines)
MOD Identifies a line item that contains a modifier that is not permitted for use with a particular
procedure code
MFD Identifies situations where you have exceeded the maximum allowed frequency for a given
procedure within a given date range
INJ Prompts you to add additional procedure code for if appropriate
Centricity Practice Solution revenue cycle Current process
Gateway Edits
Payer Edits
Rejection
Denial Payer
Adjudication
Schedule Visit
Ticket Posted
Pass
Approval Process
Edit Ticket
Fail
Fail
Fail
Pass Pass
Fail 6%
16%
Median rejection rate: 6%
Median denial rate: 16%
• Rejections and denials hinder the revenue cycle
• Rework is expensive • Some claims are written off
*Based on claims data submitted to the GE Healthcare Centricity EDI Clearinghouse
The problem*
The results
31 Centricity ED Services
3/13/2014
With Hosted Claims Manager
TES Edits
EDI Edits Ready For
Claim
Rejection
Analysis
Payer Edits
Task Manager
Denial Analysis
Payer Adjudic.
FAIL PASS PASS PASS
FAIL
FAIL
FAIL
Hosted Claims Mgr
The Benefits:
Reduce claims denials by pre-screening for billing and coding errors Realize additional ROI using
sophisticated rules and automation Closed-loop rejection and denial analyses create a process to drive continuous improvement
Charge Entry
Schedule Visit
Eligibility Verification
Reduce CO97Denials for Medicare (Global/Bundling)
Improve
Reduce CO50 Denials for Medicare /Blues (Medical Necessity)
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
Mar-0
9
Jun-09
Sep-09
Dec-09
Mar-1
0
Jun-10
Sep-10
Dec-10
Mar-1
1
Jun-11
Sep-11
Dec-11
$ Not Paid
Reducing duplicate denials
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
9-Apr
9-May
9-Jun
9-Jul
9-Aug
9-Sep
9-Oct
9-Nov
9-Dec
10-Jun
10-Dec
11-Jun
Dec'11
$Not Paid
Reduced COB15 Denials for Medicare (Payment adjusted because this procedure/service is not paid separately)
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
Feb-09
Jan-10Apr-1
0Jul-1
0Oct-1
0Jan-11
Apr-11
Jul-11
Oct-11
Jan-12
$ Not Paid
Return on your Investment (ROI)
Potential benefits of HCM
Helps support improved revenue cycle efficiencies
Enables you to correct incomplete or incorrect prior to submission, helping to reduce your claim denials, potential underpayments and costly re-work
Assists in prompt reimbursement and helps reduce days in A/R
Helps you improve claims accuracy
Sophisticated relational editing that helps optimize your accuracy and efficiency for ICD-9 and CPT-4 coding
Checks claims against payer-specific contracts before submission assisting to reduce denials & rejections
Captures claims data for analysis and releases complete claims for submission while delays claims needing review
ICD-10 ready
Supports regulatory compliance
Evaluates claims against numerous coding rules and detects Medicare Correct Coding Initiative edits
Includes the most current Medicare Local Coverage Determination (LCD) edit
“We really feel we get our
money’s worth with catching
coding/clinical errors up front
reducing re-work on the back
end. We also like the “rescrub”
functionality for those services
that need to be viewed as “a
whole package”.”
Kim Frieben , Conemaugh
Physician Group
Want to learn more? or Sign up for a Personal Demo!
• Sign up sheet in room • Email [email protected]
• Talk to your Account Manager
Appendix
You need to know...
Reimbursement Utilization Productivity
...In order to improve
Revenue cycle efficiencies
Claims
accuracy
Regulatory
compliance
Patient Call/Apt.
Notification
Eligibility Verification
Healthcare Service
Provided and Documented
Coding, Claim
Creation and
Submission
Payer Processing
and Adjudication
Appeal Process
Final Reconciling
Closed loop
Post Adjudication Analytics and
Trending
Hosted ClaimsManager: Features
Optum Insight (formerly Ingenix® ClaimsManager™) Proven, industry-leading clinical editing engine (now with LMRP/LCD) Includes over 4,000,000 pre-built rule combinations
Continuous improvement support model
Regularly scheduled rejection and denial reviews are a key part of service
Rapid install
No server, no 3rd party licensing, reduced training requirements Payer edits
Edits can be created specific to your local payers guidelines Edits can be turned off if not needed
Medical Necessity Reduction
Little Rock Oncology Hematology went live on the Hosted ClaimsManager product in November 2008. As part of the product offering, the Hosted ClaimsManager team meets with the
customer monthly to focus on their top denials and how to further reduce the denials by tweaking the edits in Hosted ClaimsManager. During the first meeting in February 2009, this organization chose Medical Necessity denial as an area where they’d like to drive improvement. By reviewing the charges before they’re submitted to the payer,
they were able to reduce their Medical Necessity denials.
SARA Clinical Denial Trend
Customer is a practice with 11 physicians who went live with Hosted Claims Manager in September 9th 2011.
Customer Comments
“We love it , love it , love it , love it . It saves time not having to build edits ourselves.”
-Linda Tuten, Gessler Clinic
“We really feel we get our money’s worth with catching coding/clinical errors up front reducing re-work on the back end. We also like the “rescrub” functionality for those services that need to be viewed as “a whole package”.”
-Kim Frieben , Conemaugh Physician Group
“It’s very helpful in advising the provider of any incorrect information prior to claim submission which allows for timely payment of claims. Also very thorough with any updates/alerts we need to know about. No areas for improvement.”
- Patti Nachmann, South Florida Associates P.A.
Hosted Claims Manager
Hosted Claims Manager:
Hosted Claims Manager:
Rejection Reporting (Payer Front-End Edits)
Rejection Reporting (Payer Front-End Edits)
Reduce CO4 Denials (procedure inconsistent with modifier or modifier missing)
Reduce CO58 (payment adjustment due to inappropriate or invalid place of service)
Reduce CO97M144 Denial (Global period – Pre/Post op care payment is included in the allowance for surgery/procedure)