Centricity Healthcare User Group CHUG

Transcription

1 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 at work.

2 GE Healthcare Reimbursement Analytics and Hosted Claims Manager

3 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

4 How can GE Help? Centricity EDI Reimbursement Analytics and Hosted Claims Manager provide a near realtime, 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

5 Closed loop solution Patient Call/Apt. Notification Eligibility Verification Healthcare Service Provided and Documented Coding, Claim Creation and Submission Payer Processing and Adjudication Post Adjudication Analytics and Trending Appeal Process Final Reconciling

6 The Value of Information Get answers to resolve key challenges Reimbursement How are payers treating us? How do we compare to our peers? Utilization Reimbursement Are we an outlier on a code that is an audit-trigger? Are we under-coding and missing potential revenue opportunity? Analytics Productivity How is our staff performing versus our peers?... And help improve the outcomes Revenue cycle efficiencies Correct incomplete or incorrect prior to submission. Reduce claim denials, underpayments and re-work. Hosted Claims Claims accuracy Manager Relational editing for ICD and CPT. Payer-specific claims checking before submission. Regulatory compliance Evaluates claims against rules and initiatives

7 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.

8 Solution Highlights

9 Insight Board

10 Did You Know? module

11 E&M Code utilization

12 Denial Management Payer Performance

13 Interactive

14 Create different views and filters Dashboard will display data based on new selection(s)

15 Create different views and filters Click & drag to drill-down on your top 2 denied procedures

16 Create different views and filters

17 Create different views and filters

18 Comparative

19 Unexpected denials How do I compare?

20 Additional peer comparisons

21 Additional peer comparisons

22 Proactive

23 Monitor metrics that matter to you

24 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.

25 Solution Highlights

26 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

27 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

28 Prevent

29 Clinical edits...what are they? DLP EST GFP LBI Identifies items entered on one or more claims that have identical Dates of Services, Procedures, Modifiers, Departments, and Providers (including previous claim history) 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 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 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

30 Centricity Practice Solution revenue cycle Current process Edit Ticket Fail Schedule Visit Ticket Posted Approval Process Pass Gateway Edits Pass Fail 6% The problem* Median rejection rate: 6% Median denial rate: 16% The results Rejections and denials hinder the revenue cycle Rework is expensive Some claims are written off Payer Edits Rejection Fail 16% Pass Denial Fail Payer Adjudication *Based on claims data submitted to the GE Healthcare Centricity EDI Clearinghouse

31 With Hosted Claims Manager Schedule Visit Eligibility Verification The Benefits: Task Manager Charge Entry TES Edits Hosted Claims Mgr FAIL PASS PASS Ready For Payer PASS EDI Edits Claim Edits Reduce claims denials by prescreening for billing and coding errors Realize additional ROI using sophisticated rules and automation FAIL Rejection Analysis Denial Analysis FAIL FAIL Payer Adjudic. Closed-loop rejection and denial analyses create a process to drive continuous improvement 31 Centricity ED Services 3/13/2014

32 Reduce CO97Denials for Medicare (Global/Bundling)

33 Improve

34 Reduce CO50 Denials for Medicare /Blues (Medical Necessity) $350,000 $300,000 $250,000 $200,000 $150,000 $100,000 $50,000 $0 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-11 Sep-11 Dec-11 $ Not Paid

35 Reducing duplicate denials $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 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

36 Reduced COB15 Denials for Medicare (Payment adjusted because this procedure/service is not paid separately) $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 Feb-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 $ Not Paid

37 Return on your Investment (ROI)

38 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

39 Want to learn more? or Sign up for a Personal Demo! Sign up sheet in room inside.sales@med.ge.com Talk to your Account Manager

40 Appendix

41 You need to know... Reimbursement Utilization Productivity

42 ...In order to improve Revenue cycle efficiencies Claims accuracy Regulatory compliance

43 Closed loop Patient Call/Apt. Notification Eligibility Verification Healthcare Service Provided and Documented Coding, Claim Creation and Submission Payer Processing and Adjudication Post Adjudication Analytics and Trending Appeal Process Final Reconciling

44 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 3 rd 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

45 Medical Necessity Reduction Little Rock Oncology Hematology went live on the Hosted ClaimsManager product in November 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.

46 SARA Clinical Denial Trend Customer is a practice with 11 physicians who went live with Hosted Claims Manager in September 9 th 2011.

47 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.

48 Hosted Claims Manager

49 Hosted Claims Manager:

50 Hosted Claims Manager:

51 Rejection Reporting (Payer Front-End Edits)

52 Rejection Reporting (Payer Front-End Edits)

53 Reduce CO4 Denials (procedure inconsistent with modifier or modifier missing)

54 Reduce CO58 (payment adjustment due to inappropriate or invalid place of service)

55 Reduce CO97M144 Denial (Global period Pre/Post op care payment is included in the allowance for surgery/procedure)