Centricity EDI Product Overview

CEDI: Hosted Claims Manager and Denials IQ 1

Centricty EDI Services

Today’s Presenter

Claire Wright

EDI Business Development

Claire Wright joined IDX/GE back in 2005 as an EDI Support Engineer. After several years, she

transitioned to a Centricity Practice Solution EDI Migration Project Manager where she worked very closely with new EDI customers and was a key point of contact for EDI product demonstrations. After many years as a Project Manager, Claire joined the EDI Business Development team in 2014 in order to continue her commitment to helping new customers grow their business. She works out

of the Burlington VT office – home of the EDI Data Center.

Product Overview: Hosted Claim Manager

Product Overview: Denials IQ

Powerful algorithm analyzes claims data weekly to provide dashboards that reveal denial trends by code, payor, physician, location and a number of other categories, allowing the clinic to rework denials in bulk and set rules via HCM to prevent these denials in the future.

Imagination at work.

Centricity™ EDI ServicesHosted Claims Manager and DenialsIQ™

©2016 General Electric Company

This does not constitute a representation or warranty or documentation regarding the

product or service featured. All illustrations are provided as fictional examples only. Your

product features and configuration may be different than those shown. Information contained

herein is proprietary to GE. No part of this publication may be reproduced for any purpose

without written permission of GE.

DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCT

DIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE

A COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITY

REMAIN AT GE’S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLE

REGULATORY CLEARANCE.

* GE, the GE Monogram, Centricity and imagination at work are trademarks of General

Electric Company.

General Electric Company, by and through its GE Healthcare division.

Agenda• Hosted Claims Manager Benefits

• Workflow- where does it fit in

• Demo

• Reports

• Case Study

• DenialsIQ• Intro to DenialsIQ

• Dashboards

• Pattern Strengths

• Pattern Details

Hosted Claims ManagerBenefits

PREVENT

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Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series (2009)

The best way to REDUCE clinical rejections and denials is to PREVENTthem before they occur!

Hosted Claims Manager OverviewProven

• Proven, industry-leading clinical editing engine (including

LMRP/LCD)

• Includes over 4,000,000 pre-built rule combinations

Real time response

• Clinical edits are integrated into the approval process

Continuous improvement support model

• Regularly scheduled rejection and denial reviews are a key part

of service

Payer edits

• Edits can be created specific to your local payers guidelines

• Medicare LCD/NCD edits automatically updated bi-weekly for you

• Edits can be turned off if not needed

Submit

Correct

Scrub

Hosted Claims Manager: Features

Claim criteria

HCFA – 1500, Primary insurance, paper & electronic

Claim Scrubbing

Compares lines on the claim

Patient history scrubbing – current claim lines along with history

PQRS

Scrubbing will take place on measures you bill for

ICD-10 compatible

Scrubbing will take place on ICD-9 and ICD-10 codes

Demo

Hosted Claims Manager: Demo

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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)

NPT Identifies where a new patient E&M was billed and the patient has been seen within 3 years 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

and was performed by the same provider

NPD Identifies a line item that contains a diagnosis code that is not appropriate for use as a primary diagnosis code

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

Hosted Claims Manager Dashboard Reports

Flag Summary for Last Calendar Month

Flag Summary for Last Calendar Month

Case Study

www.CHORTHO.com

Located in

Tampa Bay Florida

Orthopaedic division at

All Children's Hospital

John Hopkins Medicine

http://www.chortho.com/

Results with Hosted Claims Manager

Decreased claims rework by over 50%

Reduced or eliminated clinical denials

Helped speed payments by up to 22%

A customizable pre-claim clinical editing and proactive

claim analysis solution:

Helps increase revenue cycle efficiencies

Help improve claims accuracy

Assists with regulatory compliance

Outcomes1:

1. Representative results realized by Children’s Orthopaedic and Scoliosis Surgery Associates, St.

Petersburg, FL.

Reduce rejections before they occur

DenialsIQOverview

Title or Job Number | XX Month 201X See tutorial regarding

confidentiality disclosures.

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2% Denials write-offs

equaled of net patient

revenue

Re-working claims

cost per claim $15-25 An Advisory Board revenue cycle benchmark study reported that in 2013 76% of hospitals’, (in the report) denials write-offs to bad debt, equaled 2% of net patient

revenue.

How are denials impacting your performance?

2,000 denied claims = $50,000 34,000 denied claims =

$850,000

$4m NPR = $80k $45m NPR = $900k

A

NPR = Net Patient Revenue

Re-work cost = $25 per claim

DenialsIQ surfaces unseen patterns to help capture missed opportunities

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Imp

rove R

eve

nu

e

Reduce Cost

Our challenge was that the trends we were working took too long to define and usually didn’t pay off, even if we fixed them.

Jose Rivera

Corporate Director, Physician &

Professional Services

Orlando Health

Advanced statistical

algorithms from GE Global

Research identify patterns by root

cause factors

Refined by customers Using FastWorks methodology

with four customer partners and

built on Predix platform

GE’s revenue cycle

experience Serving customer for over 40

years, to help improve financial

performanceCost of rework – MGMA. Denials - The Advisory Board “Driving the Denials Management Initiative A Renewed Focus”

DenialsIQ identifies denials patterns through root cause factors and prioritizes based on value, providing powerful insights that drive action, without research

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DenialsIQ

Where are my most costly and unexpected denials patterns? How do I fix them more effectively?

A “pile” of denials, each with a reason 300 denials x 1

Trends queried based on experience, intuition

With Insights

“The stuff we don’t know

about.”

Patterns are identified automatically, can be resolved as a unit and

common themes provide context without research

Denia

l Facto

rs A

lgorith

m

Dynam

ic V

isualiz

atio

n Invoice Count

Denie

d C

harg

es

Level of unexpectedness

<

<

Traditional denial resolution approach

Improving performance with insights that translates into results

Dynamic visualizations

help prioritize

opportunities, to work

denials more quickly.

Defines pattern details and

root cause, to prevent

future occurrences.

Advanced dashboards

filter, monitor and report

performance over time

Leverages Centricity™ EDI data

Hosted by GE Healthcare

No installation cost

Data loads weekly

Results for last week, last month, and

current month to date

Requires Centricity EDI clearinghouse

DenialsIQ specifications and FAQ’s

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Dynamic visualizations display patternsColor indicates the rate of the

denials, i.e. red equals

denials that are occurring

more frequently than other

denials within the timeframe

Pattern #7

17 denials within pattern

$167k in denied charges

# of factors contributing to a

pattern; the common

reasons within the denial

pattern; i.e. location,

insurance, reason code

Tool tips display the specific

circumstances of the denial

pattern; i.e. Shelburne

Office, UHC, PR 27

Dynamic visualizations display patterns

#7

17/$167k

# of factors contributing to a

pattern

Algorithm results indicate

level of pattern

“unexpectedness”

Pattern #7

17 denials within pattern

$167k in denied charges

DenialsIQ Demo

Summary

Think about it……

44Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series

(2009)

$25

Average cost per

claim for rework

DenialsIQ and Hosted Claims Manager

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Hosted Claims Manager is an ideal complementary solution to DenialsIQ, our advanced analytics

solution that uncovers unseen trends based on your claim denials.

Uncover coding patterns/denials in DenialsIQ then look to what can be resolved with Hosted Claims

Manager to prevent future denials and rework; thus creating a closed loop solution.

Pricing Overview:

Bundle #1:

Hosted Claims Manager and Denials IQ

Bundle #2:

CEDI Claims,Remit, Eligibility

43 % Savings

13 % Savings

Bundle #3:

Full CEDI Program

26 % Savings

>

Resources

• GE CEDI Information including case studies and brochures

[email protected]

[email protected]

For product questions and information:

For pricing details and questions about your current EDI tools:

http://www3.gehealthcare.com/en/products/categories/healthcare_it/revenue_cycle_management/centricity_edi_services#tabs/tabCB6A452561694D458E26E44CC1256647