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.

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

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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 Manager Benefits

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

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

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

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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 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

Hosted Claims Manager Dashboard Reports

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

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.

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

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? 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. 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

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

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

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

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

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

DenialsIQ Demo

Summary

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 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

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

Resources GE CEDI Information including case studies and brochures For product questions and information: jasonp@healthcosystems.com > For pricing details and questions about your current EDI tools: lindah@healthcosystems.com