karen cole, mba, cpc sales product consultingvividideas.com/pdf/optum-webinar3.pdf ·...

Improved Revenue Cycle ManagementKaren Cole, MBA, CPCSales Product Consulting

Proprietary and Confidential. Do not distribute.

• OptumInsight Overview • Traditional Physician Claim Workflow• A Better Way

ClaimsManager ProfessionalKnowledgebase EditsAdditional RevenueDeployment OptionsKnowledgebase Coding Relationships and Edits

• How We are Different

Agenda

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Ingenix is Now

Proprietary and Confidential. Do not distribute. 4

The leader in populationhealth management serving the physical, mental and financial needs of both individuals and organizations

Pharmacy Managementleader in service, affordability and clinical quality

(Formerly Known as Ingenix)

One of the largest health information, technology and consulting companies in the world

Market leaders within a dynamic health services market

Optum Businesses

Proprietary and Confidential. Do not distribute. 5

• An insight-driven health care solutions company since 1996• A significant footprint in health care communities

– Enable secure delivery of health claims and clinical information for more than 1 in 7 Americans

– Proprietary health care databases with 75+ million patient lives; over 15 years of longitudinal health data

– Supporting 1 in 5 Emergency Department visits– Work with 6,200 hospital facilities, 246,000 health care professionals/groups,

and 270 government entities

OptumInsight Business Profile


Key Capabilities

• Picis Workflow Solutions

• Cost Containment Consulting Services

Solution SummaryA new approach to creating sustained cost advantage.

Cost & Operational Improvement

Key Capabilities

• EHR Medical Necessity Compliance

• ICD-10 Compliance

Solution SummaryEnsure compliance and revenue integrity at the point of care for hospitals and physicians.

Compliance

Key Capabilities

• CareMedic eFR® and Revenue Cycle Management

• Actuarial consulting services

• LYNX revenue management solutions

• A-Life CAC

Solution SummaryIndustry-leading tools and operational excellence to accelerate sustainable financial results.

Financial Performance

Key Capabilities

• Picis High-Acuity Solutions

• Impact Suite to measure clinical performance

• Clinical data services

Solution SummaryDrive improved outcomes in the hospital high-acuity and ambulatory care settings.

Clinical Performance

Key Capabilities

• Claim Integrity– ClaimsManager– ContractManager

• Connectivity– Netwerkes– Validation Suite

• Axolotl HIE solutions

• CareTracker PM/EMR

Solution SummaryEmpower all Stakeholders with a Platform to Transform Claim and Clinical Information Flow

Claim Integrity& Connectivity

UsOptumInsight Provider Division “Pillars”

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Payers

• Claims management

• Care & health management

• Consumer tools

Pharma

• Clinical research• Health economics• Drug safety

Physicians

• Revenue management• Practice management• EMR• EDI• Coding & compliance• Outsourced billing• Financial & clinical

workflow consulting

Property & Casualty

• Consulting• Medical cost

containment• Work comp EDI

PublicSector

• Consulting• Medical cost

containment• Work comp EDI

Hospitals

• Coding & compliance• Medication reconciliation• MS-DRG strategies• Benchmarking & analytics• RAC support• RCM• Financial & clinical

workflow consulting

Employers

• Decision support• Provider directories• Benefits strategies• Administrative

optimization• Evidence-based health• Workforce productivity

More than 14,000 employees engage clients across the industry.

Our goal is to reduce the friction across the health care system.

The Markets We Serve

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Payers Pharma

Physicians

Property & Casualty

PublicSector

Hospitals

The Company We Keep

Employers

OptumInsight serves more than 250,000 diverse clientsNumerous federal/state agencies, 1,500 insurance companies,

Over 75 pharmaceutical and biotech firms, over 3,500 hospitals, 100-plus employers, and more than 200,000 physician practices.

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http://www.honeywell.com/

http://www.honeywell.com/

http://www2.dupont.com/DuPont_Home/en_US/

http://www2.dupont.com/DuPont_Home/en_US/

http://en.wikipedia.org/wiki/Image:BellSouthLogo.png

http://en.wikipedia.org/wiki/Image:BellSouthLogo.png

http://en.wikipedia.org/wiki/Image:IBM_logo.svg

http://en.wikipedia.org/wiki/Image:IBM_logo.svg

http://en.wikipedia.org/wiki/Image:Mayo_clinic_logo.png

http://en.wikipedia.org/wiki/Image:Mayo_clinic_logo.png

https://www.highmarkbcbs.com/indexbcbs.html

https://www.highmarkbcbs.com/indexbcbs.html

https://www.blueshieldca.com/bsc/home/home.jhtml;jsessionid=LLVOKDHRS2W3FJP3YYRCGLNF5XDCKITT

https://www.blueshieldca.com/bsc/home/home.jhtml;jsessionid=LLVOKDHRS2W3FJP3YYRCGLNF5XDCKITT

http://www.concentra.com/

http://www.concentra.com/

ClaimsManager Professional Workflow


Code, click submit, then wait for. . . • Rejections and denials

– Manually edit claims and resubmit– Then the entire process starts over

• Reimbursement

While all of this is taking place. . .• Cash flow is unpredictable• Rejections and denials increase A/R days• Productivity suffers and costs escalate• Clearinghouses provide only limited

technical edits – primary focus on connectivity

15% ► The portion of claims that are rejected or denied, necessitating rework and resubmission

$25 ► The average cost per claim for rework and resubmission

$68,000 ► The cost per physician per year in time spent interacting with payers** Medical Group Management Association study: “The Costs to Physician Practices of Interactions with Health Insurance Plans,” 2009.

Current Physician Practice Claim Workflow

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Q: What if. . .• Clinical claims editing happened prior to sending

claims Claim errors identified and edited before they are

sent to your clearinghouse• Regulatory and payer rules were automatically

updated? Medicare and Commercial updates on a

quarterly basis• Missed revenue opportunities were proactively

identified? Identify partially billed services

• The solution was affordable and within reach of even the smallest physician practice?

A: Your Practice’s. . .Denials and rejections would

decreaseA/R days would get lowerCash flow would improveProductivity would increase

and reduce costs

What if There Was a Better Way?

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ClaimsManager can help your practice:• Realize significant ROI through intelligent automation • Reduce claim denials by pre-screening for billing and coding

errors • Stay current with new and changing guidelines • Comply more easily with Medicare and commercial regulations • Develop your own edits and customize system edits to meet your

practice’s billing and reimbursement needs

St. Vincent Health reduced its AR days from 63 to 35 by using IngenixClaimsManager

*St. Vincent Health, Indiana, the nation’s largest not-for-profit and Catholic Healthcare System

Review claims before submission in order to reduce claim denial rates, shorten accounts receivable cycles, and increase the rate of collection.

ClaimsManager

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One common platform across Optum claim editing solutions for providers and payers

Medicare and commercial rule sets

Common Platform — Optum Claims Processing

Historical editing• Global periods, new vs. established

Positive editing• Identify unbilled services

Relational editing• Lines within the claim, claim to claim

Design emulates payer adjudication process• Fits with existing workflow

Fully customizable solution• Rules-creation manager

ClaimsManager is the provider market solution

• ClaimsManager Professional• ClaimsManager Facility

iCES is the payer market solution• iCES Professional• iCES Facility

Design emulates payer adjudication process• Fits with existing workflow

Fully customizable solution• Rules-creation manager

One common clinical knowledgebase

One common clinical knowledgebase

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ClaimsManager: Knowledgebase / Edits


• Contain more than 81 million government and 3rd party industry edits• Sourced at the code relationship level• Supported by disclosure statements• Updated Quarterly • Date Sensitive at the code relationship level

Comprehensive Commercial and Medicare Knowledgebase

Diverse Team of Medical and Clinical Coding Experts

Power Behind the System: ClaimsManager Knowledgebase

• Team of over 40 experts supporting content development• Team of Medical Directors, Specialty Panels, RN’s, LPN’s, RHIT’s, RHIA’s,

CPC’s, CCS-P and Legal Support• Methodology reflects clinical research, comprehensive coding expertise and

claims data analysis• Clinical, Technical and End User customer support

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Commercial Edit Sources

AMA Guidelines• AMA Consulting• CPT Assistant• CMS Program Memoranda• National Correct Coding Initiative (NCCI) – physician• Medicare Physician Fee Schedule Database (MPFSDB)• National and Local Coverage Determinations• Physician Specialty Panels

Medical Societies• American College of Radiology• American College of Surgeons• American Physical Therapy Association• American College of Cardiology• American Academy of Orthopedic Surgeons• American College of Obstetrics and Gynecology• American Society of Therapeutic Radiologic Oncologists• Society of Interventional Radiologists

ClaimsManager Knowledgebase — Edit Sources

Medicare Edit Sources

• Medicare Physician Fee Schedule Database (MPFSDB)• Federal Register• CMS Program Memoranda• National Correct Coding Initiative (NCCI) – physician• Publication #100-02 Medicare Benefit Policy Manual• Publication #100-04 Medicare Claims Processing Manual• Publication #100-03 Medicare National Coverage

Determinations Manual• Local Coverage Determinations

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ClaimsManager vs. Typical Clearinghouse Edits

Claims Form Edits (Typical Clearinghouse Edits)

• HIPAA compliance and certification (WEDI SNIP levels 1-7)

• Presence of a field (provider, provider tax ID, insurance ID)

• Payer companion guide edits (loop, segment)• Claim-level Medicare edits (CCI, MUE)• Claim-level LCD• Validation edits (CPT, HCPCS,

ICD-9)

ClaimsManager’s Clinical Edits

• CPT codes to DX to modifier relationships• Sequencing of DX codes• Appropriate use of modifiers• Age, gender, frequency relationships• Medicare unbundle (CCI)• Medicare edits (MUE, globals, reductions)• Non-covered services• Commercial unbundle edits• NCD/LCD• Missing charges• Duplicate charges• Validation edits (CPT, HCPCS,

ICD-9)

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Increase Payments for Medicare Services

Medicare Venipuncture(mVP)

Definition Validates that both the venipuncture and lab code was billed

Edit Type Positive edit

Example

It is important to take a Hemoglobin A1C test annually to detect diabetes before symptoms start to manifest. When the lab test is performed, the physician should bill for both the drawing of the blood as well as the hemoglobin test. If only the hemoglobin test is billed, ClaimsManager will flag the missed venipuncture code. The addition of the code will result in increased revenue.

Billing Established Codes for New Patients

Definition Validate that the patient is an established patient and not new to specialty

Edit Type Positive edit

Example

Patient comes into orthopedics office and saw Dr. Anderson 4 years ago when he blew his knee. Now, he is presenting with a shoulder issue. Dr. Anderson remembers this patient and bills him as an Established patient instead of a New Patient. The change between the Established Patient code and New code will increase reimbursement.

Medicare Positive Editing Examples

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Decrease Rejections and Increase Payments for Commercial Payers

Pre-Op Procedure One Day Before Surgery (PRE, PRH_

Definition Validate the surgical provider isn’t billing for E/M service one day prior to surgery (if being seen for items related to the surgery)

Edit Type Historical edit

Example

Patient comes in for an office visit, one day prior to meniscus surgical repair, for service related to surgery

• If E/M service was billed on a different claim, then the surgery PRH would trigger

• If E/M service is on same bill as the surgical procedure PRE is triggered

Commercial Editing Examples

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Decrease Rejections and Stay in Compliance with Medicare Part B

Missing or Invalid LMRP Diagnosis (LBI)

Definition Validate that diagnosis represents the need for nail trimming

Edit Type ABN, compliance edit

Example

The patient presents with an ingrown toenail with an infection. The physician performs a nail trimming to treat the nailed. The patient is also diabetic but when the physician bills the patient, he/she only includes the diagnosis code for the toenail infection 703.0. ClaimsManager does the analysis of the diagnosis code 703.0 and determines that the diagnosis doesn’t support medical necessity guidelines to support the payment for the patients foot care.

LCD Part B Typical Frequency Exceeded (BFR)

Definition Validate that the patient hasn’t been seen for nail trimming within the last 60 days

Edit Type Historical edit

Example

Diabetes patients struggle with neuropathy and poor circulation, therefore routine foot care is necessary. Some Medicare Carriers have designated routine foot care to be one session every 60 days. If the patient comes in for additional foot care more frequently than the 60 days, ClaimsManager will flag to indicate that this has been billed outside the parameters of the policy.

Medical Necessity Editing (LCD Part B) Examples

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ClaimsManager: Additional Revenue Examples


Identifying partially billed procedures before claims submission, results in complete payment for all services delivered• Identify additional revenue sources – average group fails to

capture 0.05% of potential revenue• Automatically detect missing related procedures

– If an inject-able drug is billed, the associated procedure to administer the drug should be present

– Add on codes billed without primary procedure– Cardiac catheterizations– Interventional radiology

Optum ClaimsManager

Prevea Health has gained $2,112,859 by identifying servicedollars that were previously not billed and by making substantial use of ClaimsManager'spositive editing ability.

*Prevea Health, Wisconsin. Results based on five year study (2005-2008).

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Scenario : Patient is billed for a Prolonged Service

Code CPT Description Reimbursement

99354Prolonged physician service in office or other outpatient facility; face to face, 1st hour

$115.57

Edit

Per CPT guidelines, codes 99354-99357 are used when a physician provides prolonged services involving direct patent contact that is beyond the usual service. This services is reported including other services, including E&M services at any level.

99215

The claim is modified to include the code as noted in the edit.

High level Office Visit$143.17

By adding the additional code, the total reimbursement

increases by $143.17, for a total of $258.74.

ClaimsManager Helps Increase Revenue (Family Practice Scenario)

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ClaimsManager: Practice Management Integration


• On-off or customizable

Each ClaimsManager

Edit is Individually Controlled

• Send file to ClaimsManager via TCP/IP

Run a Batch Process within a

Practice Management

System

• Analysis performed immediately after a file is received• Reports are generated to flag claims that must be corrected before releasing to payer

ClaimsManager

• Correct claims using the ClaimsManager edit error report• Release claims to clearinghouse/payer

Release Claims via Your Practice Management

System

ClaimsManager & Your Practice Management System

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• ClaimsManager Clinical Edits

• Knowledgebase Claim History

Optum ClaimsManager

• Charge Entry• Charge Entry

Work Queue• Charge

Postings/Claims Processing

Practice Management

System

• Technical Edits

EDI Clearinghouse

• Claims Adjudication

Payer

Encounters/Charges

ClaimsManager Workflow

Remittance Information, Denials, Rejections

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ClaimsManager Deployment Options• Software as a Service• Optum Clearinghouse


ClaimsManager Deployment Through SaaS Provides:• High Availability Rate — Web-based allowing for faster deployment.• Reduced Costs — Subscription-based, no large up-front capital investment• Automatic Updates — Optum manages infrastructure, upgrades, and updates • Streamlined Implementation and Integration — Customized to meet your organizations needs• A Helpful Client Portal — A single entry point

Available as a service, no server or IT staff required

Get all the benefits of ClaimsManager with a web-based service that provides instant access to rich content and functionality without the burden of installing or maintaining software or servers.

ClaimsManager Deployment Through Software as a Service (SaaS)

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ClaimsManager Deployment Through Optum Clearinghouse Services Provides”• Easy Implementation – Be up and running in a matter of weeks with ClaimsManager’s

web-based SaaS delivery mode.• Improved Process Workflow – Directly interface with Ingenix Clearinghouse Services.• Affordability with subscription based pricing.

Superior clinical editing features, integrated into existing claims management workflow.

Access all of the features and functionality of ClaimsManager through Transaction Exchange, Optum’s convenient web-based EDI claims management solution. By decreasing rejections, reducing administrative expenses, and speeding up reimbursement, ClaimsManager and Transaction Exchange help you maximize revenue potential.

ClaimsManager Deployment Through Optum Clearinghouse Services

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Optum Clearinghouse Services make it easy for you to route health care transactions to virtually all payers using a single, central point for transactions. And, its comprehensive EDI visibility makes your electronic communications rich, rapid, and secure.

Optum Clearinghouse Service Overview

Online EligibilityAccess reliable validation of patient eligibility information that is retrieved within seconds of your query

Online Referrals and AuthorizationsConduct referrals and pre-certifications quickly and effortlessly, as well as check on the status of your queries

Real-Time Claim Status

Access instant and continuous claim status information on submitted claims directly from the payer’s adjudication system

Electronic Claim Tracking

Query or “track” each claim or group of claims submitted

Electronic Claim Processing

File primary secondary institutional and electronic claims electronically, reducing billing costs and speeding payment

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ClaimsManager Deployment Through Optum Clearinghouse Services

• Charge Entry• Charge Entry

Work Queue• Charge/

Postings/ Claims Processing

Practice Management

System

• Send Claims to ClaimsManager for Clinical Editing

Optum Clearinghouse

• ClaimsManager Clinical Edits

• Knowledgebase Claim History

Optum ClaimsManager

SaaS

• Review ClaimsManager Edits and Clearinghouse Technical Edits

• Edit Claims• Review Payer

Reports

Optum Clearinghouse

• Claims Adjudication

Payer

ClaimsClaimsManager

EditsCleanClaims

Remittance Information, Denials, Rejections

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Eligibility Verification with Care Management Workflow

EligibilityPhysician

Care

Analy

sis

Identify care opportunitiesCustomize to payer

specific requirements

Eligibility response w/ care

opportunitiesRegistration & schedulingFront office

administration

Physician Payer

Confirmation of Eligibility

EDI Clearinghouse

Identify eligibility & general benefit information e.g. deductible and co-pay prior to service

Choose either real-time or batch verifications

Transactions can be stored for one year and can be reviewed at no additional cost

Eligibility

Care ManagementClinical EditingClinical Edits

Historical Editing

271 EligibilityResponse

271 EligibilityResponse

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Error indicates if the edit is a clinical edit -“CM” for

ClaimsManager sourced edits

ClaimsManager Edits within the Optum Clearinghouse

Line 2 edited from CCI guidelines

Code 27005 has an unbundled relationship from line 1 of the claim.

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ClaimsManager:• Knowledgebase Coding• Relationships and Edits


ClaimsManager: Knowledgebase Coding Relationships

CPT codes that unbundle to 59410 and modifiers that can override the unbundle relationship

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ClaimsManager: Knowledgebase Coding Relationships

Diagnosis codes that are typically associated with vaginal delivery

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If you had a claim come through with the following items coded, what kind of editing would you expect to see?

ClaimsManager: Current Claim Editing Example

When billing an E/M visit, we must first check to see if patient is a new or established patient of specialty 11

Flag issued because patient is new to specialty within last 3 years

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E/M code was billed one day prior to the surgical procedure

Flag issued to indicate part of surgical package unless E/M was

for unrelated condition

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System evaluates Diagnosis code for the second line item


System evaluates Diagnosis code for the second line item

Inappropriate Diagnosis for CPT

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ClaimsManager: Current Claim Editing Example — Looking Across Claim Lines

Flag indicates 45303 billed within Global

period of earlier procedure

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ClaimsManager: Current Claim Editing/Example — Further Evaluation

Duplicate lines are identified

Global follow- up flag

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ClaimsManager: Current Claim Editing/Example — Further Evaluation

Revenue enhancing edit identifying missing S&I for cardiac cath and

inappropriate diagnosis

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ClaimsManager: CCI Historical Editing Example

Billing for closed FX treatment

CCI flag for a procedure that was billed on previously submitted claim

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ClaimsManager: Industry-Leading Solution


What Makes ClaimsManager Different?

• Commercial editing• Over 9 million Professional coding relationships • Over 1 million Facility coding relationships

• Medicare editing (including LCD and NCD)• Over 56 million Part B coding relationships• Over 15 million Part A coding relationships

Unparalleled Clinical Content

Continuous Investment

• Resource and financial investments are made annually to help gather and maintain the content used in our editing and billing products

• Quarterly knowledgebase update / bi-monthly NCD/ LCD updates• Yearly/ bi-yearly software new feature releases

• Medicare Physician Quality Reporting Initiative (PQRI) edits and rules• Medicaid

• Ingenix will be fully prepared for ICD-10• Significant financial investments will help guarantee ClaimsManager and its content

will be ICD-10 compliant by the Oct. 1, 2013 effective date.

Industry Leader

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ClaimsManager: Customer Testimonials


Customer Testimonial — Hattiesburg Clinic

• Hattiesburg clinic reduces denial rates by 32%, improves productivity, gains nearly $200,000 in net benefits with ClaimsManager.

Successes Achieved

• Hattiesburg Clinic has reduced claim denials by more than 32%, leading to a savings of $420,000 over five years because it does not have to rework denied claims.

• Increase productivity for Hattiesburg Clinic coders and staff, leading to a savings of more than $144,000 over five years.

• Previously, it took up to six months to have some claims paid because of denials; now almost all claims are paid within seven to 10 days.

• ClaimsManager integrates well with McKesson Horizon Practice Plus practice management system used by Hattiesburg Clinic.

Highlights

• Hattiesburg Clinic is Mississippi’s largest multi-specialty clinic. It serves more than 500,000 residents who live and work in South Mississippi every day. Results based on a 5 year period, 2004-2008.

About Hattiesburg Clinic

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Customer Testimonial — Prevea Health

• Prevea Health improves productivity, handles increased claims with reduced costs, and gains $19 million in benefits with ClaimsManager.

Successes Achieved

• ClaimsManager has improved the efficiency of Prevea Health coders, leading to a cumulative, five-year productivity benefit of $875,000.

• Prevea Health dramatically reduced claims rejections, resulting in $15,256,983 in benefits over five years.• Previously, it took up to six months to have some claims paid because of denials; now almost all claims are paid within

seven to 10 days.• By using ClaimsManager, Prevea Health has been able to reduce the cost of its coding operations while handling an

increased number of claims.

Highlights

• Prevea Health is a physician-owned, multi-specialty clinic offering primary and specialized health care to patients throughout Northeast Wisconsin. Results based on a 5 year period, 2005-2009.

About Prevea Health

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Questions and Answers

karen cole, mba, cpc sales product consultingvividideas.com/pdf/optum-webinar3.pdf ·...

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