CEDI: Hosted Claims Manager and Denials IQ 1

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1 CEDI: Hosted Claims Manager and Denials IQ 1

2 Centricty EDI Services

customers and was a key point of contact for EDI product demonstrations.

4 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.

6 Product Overview: Hosted Claim Manager

7 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.

8 Centricity EDI Services Hosted Claims Manager and DenialsIQ Imagination at work.

9 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.

10 Agenda Hosted Claims Manager Benefits Workflow- where does it fit in Demo Reports Case Study DenialsIQ Intro to DenialsIQ Dashboards Pattern Strengths Pattern Details

11 Hosted Claims Manager Benefits

12 PREVENT The best way to REDUCE clinical rejections and denials is to PREVENT them before they occur! Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series (2009) 12

13 Hosted Claims Manager Overview Proven 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 Correct Scrub Submit

14 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

15 Demo

16 Hosted Claims Manager: Demo 16

17 Hosted Claims Manager: Demo 17

18 Hosted Claims Manager: Demo 18

19 Hosted Claims Manager: Demo 19

20 Hosted Claims Manager: Demo 20

21 Hosted Claims Manager: Demo 21

22 Hosted Claims Manager: Demo 22

23 Hosted Claims Manager: Demo 23

24 Hosted Claims Manager: Demo 24

25 Hosted Claims Manager: Demo 25

26 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 NPD LBI MOD MFD INJ 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 Identifies a line item that contains a diagnosis code that is not appropriate for use as a primary diagnosis code Identifies that no diagnosis on the claim line supports medical necessity for the procedure billed (as specified by Local Medicare Guidelines) Identifies a line item that contains a modifier that is not permitted for use with a particular procedure code Identifies situations where you have exceeded the maximum allowed frequency for a given procedure within a given date range Prompts you to add additional procedure code for if appropriate

27 Hosted Claims Manager Dashboard Reports

28 Flag Summary for Last Calendar Month

29 Flag Summary for Last Calendar Month

30 Case Study

31 Located in Tampa Bay Florida Orthopaedic division at All Children's Hospital John Hopkins Medicine

Results with Hosted Claims Manager A customizable pre-claim clinical editing and proactive claim analysis solution: Helps increase revenue cycle efficiencies Help improve claims accuracy Assists with

32 Results with Hosted Claims Manager A customizable pre-claim clinical editing and proactive claim analysis solution: Helps increase revenue cycle efficiencies Help improve claims accuracy Assists with regulatory compliance Reduce rejections before they occur Outcomes 1 : Decreased claims rework by over 50% Reduced or eliminated clinical denials Helped speed payments by up to 22% 1. Representative results realized by Children s Orthopaedic and Scoliosis Surgery Associates, St. Petersburg, FL.

33 DenialsIQ Overview Title or Job Number XX Month 201X See tutorial regarding confidentiality disclosures. 33

34 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 % of hospitals, (in the report) denials write-offs to bad debt, equaled 2% of net patient revenue.

35 How are denials impacting your performance? A 2,000 denied claims = $50,000 34,000 denied claims = $850,000 $4m NPR = $80k $45m NPR = $900k NPR = Net Patient Revenue Re-work cost = $25 per claim

DenialsIQ surfaces unseen patterns to help capture missed opportunities 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.

36 DenialsIQ surfaces unseen patterns to help capture missed opportunities 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 Improve Revenue Reduce Cost 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 Cost of rework MGMA. Denials - The Advisory Board Driving the Denials Management Initiative A Renewed Focus GE s revenue cycle experience Serving customer for over 40 years, to help improve financial performance 36

37 Denied Charges DenialsIQ identifies denials patterns through root cause factors and prioritizes based on value, providing powerful insights that drive action, without research Traditional denial resolution approach The stuff we don t know about. With Insights DenialsIQ < Denial Factors Algorithm Dynamic Visualization Invoice Count Level of unexpectedness < A pile of denials, each with a reason 300 denials x 1 Trends queried based on experience, intuition Patterns are identified automatically, can be resolved as a unit and common themes provide context without research Where are my most costly and unexpected denials patterns? How do I fix them more effectively? 37

38 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

39 DenialsIQ specifications and FAQ s 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 39

40 Dynamic visualizations display patterns Color 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

Pattern #7 17 denials within pattern $167k in denied

41 Dynamic visualizations display patterns Algorithm results indicate level of pattern unexpectedness Pattern #7 17 denials within pattern $167k in denied charges #7 17/$167k # of factors contributing to a pattern

42 DenialsIQ Demo

43 Summary

44 Think about it $2 Average cost per claim for rework 5 44 Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series (2009)

DenialsIQ and Hosted Claims Manager Hosted Claims Manager is an ideal complementary solution to DenialsIQ, our advanced analytics solution that uncovers unseen trends based on your claim

45 DenialsIQ and Hosted Claims Manager 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. 45

46 Pricing Overview: Bundle #1: Bundle #2: Hosted Claims Manager and Denials IQ 43 % Savings CEDI Claims, Remit, Eligibility 13 % Savings Bundle #3: Full CEDI Program 26 % Savings

47 Resources GE CEDI Information including case studies and brochures For product questions and information: > For pricing details and questions about your current EDI tools:

Centricity Healthcare User Group CHUG

GE Healthcare Centricity Healthcare User Group CHUG Jason Whiteaker, Director Sales Engineering RemitDATA Terri Cipriano, HCM Analyst GE Healthcare Joe Heald, EDI Services Manager, GE Healthcare Imagination