today’s revenue cycle process: helping you sleep better at night presentation to n.w. ohio hfma...
TRANSCRIPT
Today’s Revenue Cycle Process:
Helping You Sleep Better at Night
Presentation to
N.W. Ohio HFMAAugust 29, 2012
Jim McCauley, Vice President, EDI Services
Increase Cash Flow….Drive Revenue Cycle Efficiencies….Reduce Bad Debt ….
Xpeditor Xtensions
Do More!
. . . .
Xpeditor Xtensions
. . . .
Claims ManagementX
Claims ManagementX
• Powerful edit engine– Standard: LCD, NCD, CCI, OCE,
MUE, RAC edits– Custom (client defined): written
by Quadax developers, usually 48-hour turnaround (testing may require additional time)
– Client-written: developed through the XpressBiller utility, an easy-to-use wizard
. .
Better cash flow!
Faster reimburse-ment
Cleaner
claims
. . . .
Claims ManagementX
Comprehensive reporting enables you to manage your claims, not just transmit them
• Every edit available for analysis
Eliminate manual intervention & compilation of data . . . .
Remittance ManagementX
Remittance ManagementX
Remittance Management
. .
• Full Integration• Full Support• Management Tools• Better Data
(including posting files & comment records)
. . . .
Denial ManagementX
Denial ManagementX
Denial ManagementX
• Effective denial management strategy– Identify, Classify, Quantify– Manage Denial Follow-Up– Prevent Denials Through
Process Improvement– Develop Effective
Reporting
Scheduling Service
Providing Service
Coding Service
Billing Service
Collecting Payment
Where do denials come from?
Any and all points in the revenue cycle
. . . . . .
DMXBR : Basic Reporting
. . . .
Anything that is delaying payment to your
organization is ripe with data for process
improvement.
Payer Remits
835 Files
Hard Copy Remits
Denial Correspondence
Payer Rejections
277 Files
864 Files
Payer Reject Reports
Pre-Bill Errors
Quadax Batch Errors
Customer-defined Errors
XpressBiller Errors
Approximately 2,100 codes
Approximately 13,000 codes
Approximately 250 ANSI codes
Pre-mapped to standard error/denial categories
. .
DMXWF: Workflow• Decrease Overall A/R
– Quickly identify both full and partial denials and route them to users with best skill sets to work them
– Provide easy access to key denial source documents for follow-up users
• Decrease Costs to Work Denials– Improve staff efficiency in working denials by setting up default
orders within worklists to group similar types denials
• Increase Visibility of Denial Aging Inventory– Utilize management dashboard reporting to target key denial
inventory issues
. . . . . .
DMX: A Case Study
Note: Payments reflect Charges associated with Paid Claims (not actual payments); Denials Reflect Charges associated with Denied Claims/Lines. Claim Status 22 has been excluded and denials with prior payment have been excluded. Duplicate Example (18/B13/97). FYI – 96 has been included under non-covered service.
8%
29%
18%6%
5%
35%
Denial % By Count
Timely Filing
Eligibility
Missing Info/Documentation
Multiple
Billing Error
Others
26%
21%14%
13%
12% 14%
Denial % By Revenue
Timely Filing
Eligibility
Missing Info/Documentation
Multiple
Billing Error
Others
. . . .
EligibilityX
EligibilityX
EligibilityX
• Verify that an individual has valid Insurance coverage
• Validate demographic information to match spelling, etc. on file with payer
• Determine the level of coverage for service type
• Determine Co-Pay, Deductible, other Insurance, etc.
Tip: Do a batch eligibility check on self-pay to ensure patient was not eligible for Medicaid on date of service
. . . . . . . .
EligibilityX
– Real Time (any point of entrance)– Automated (specified claims, self-pay,
Medicaid)– Batch (pre-registration, self-pay, collection
accounts)– Back End (rejected, denied)
. . . .
EligibilityX
HIS Interface Eligibility
Individual or “Batch” (multiple transactions), in real time
270 from HIS 271 returned to HIS
Outside Xpeditor We have developed the interface for Epic, Meditech, and SMS Allegra (TCP/IP). Development of additional HIS interfaces is expected.
Batch File Eligibility
Batch File Delimited file according to agreed-upon specs
Delimited file according to agreed-upon specs
Outside Xpeditor
Standalone Eligibility – Hosted, for those offices not on the hospital network
Individual, in real time
Manual entry using form on Portal
Xpeditor-style response form
Outside Xpeditor(Separate hosted install accessing only Real-Time screens)
Transactions stored in Real-Time transaction History Database
Real-Time Eligibility
Individual, in real time
Scrape from claim or manual entry using form in Xpeditor
Xpeditor-style response form
History stored in Xpeditor; linked to claim if inquiry scraped from a claim
Rule-Based Eligibility
Automated Generated from Xpeditor; Rule-Based (custom convert required)
Xpeditor-style response form
History stored in Xpeditor; linked to related claims
For example, a rule might dictate that all self-pay claims automatically generate an eligibility inquiry to Medicaid.
. . . .
Claim StatusX
Claim StatusX
• There are always exceptions– Do you know what
they are?– Do you know why they
are?
Claim StatusX
Is there a need for an automated solution to help manage and report on these claim delays?
. . . . . .
Claim StatusX
• HIPAA-mandated 276/277 still coming into its own• Perform transactions manually, as needed• Automated Claim Status responses can be exported
to the host system. Either source 277 can be provided or a customized comment file.
. . . . . .
Automated Claim Status Transactions
• Eliminate the need for sifting through reports • Eliminate wasted time on the phone with payers • Eliminate keying into payer web sites • Rely on automated processes to catch every
outstanding (unpaid) claim • Be assured that no claims have fallen through the
cracks • Improve efficiency & Days in A/R with faster
intervention
. . . . . .
Audit ControlX
Audit ControlX
• Full suite of products to manage every kind of audit: RAC, MIC, etc.
• Preventive Edits• Audit ControlX Axis• DataXtract• Data Mining• Also available from our partners, Human
Arc and EHR: hands-on appeals management
Audit ControlX
. . . .
Audit ControlX Axis
• A Secure, web-based, hosted application– Gives everyone on your RAC team easy access
• Axis™ for workflow, tracking, & reporting• Integration with
– AHA RACTrac– Human Arc– EHR
. . . .
Medicare ConnectionX
Medicare ConnectionX
• Interactivity with FISS for enhanced Medicare claims control
Faster Reimbursement
Streamlined Workflow
Better Reporting
Medicare ConnectionX
. . . .
Questions
. . . . . .