Category: For Hospitals & Physician Groups

Stay informed on the latest industry news, best practices, and trends in revenue cycle management for hospitals and physician groups.

Steering Primary Care with Value-Based Reimbursement

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Primary Care Physicians often feel they’re running out of gas.  The value they provide is real: research shows significantly better healthcare access and experience for patients receiving primary care.  However, office visits to primary care physicians (PCPs) declined 18% from 2012 to 2016[i], suggesting that the value of PCP care is not widely acknowledged.  Meanwhile, physicians experience frustrations with administrative demands that encumber their ability to deliver needed care.

A JAMA Internal Medicine article reinforced the importance of primary care following a study of many thousands of US adults with and without primary care, concluding “policymakers and health system leaders seeking to improve value should consider increasing investment in primary care.”

Will the newly announced Primary Cares Initiative be the investment that makes a difference?

The American Academy of Family Physicians (AAFP) and America’s Physician Groups were among those applauding the CMS Primary Cares Initiative when it was announced on Monday, April 22.

AAFP Vice Speaker Russell Kohl, MD said, “To truly unleash the power of primary care, we must do two things: Unhinge it from the episodic-based incentives of fee-for-service, and eliminate the administrative complexity of practice that distracts family physicians from patient care. In short, it has become clear that we must create payment models that support our desired delivery models.”

Those distracting complexities cited by physicians in discussions of today’s greatest challenges include increased third-party administrative requirements, a rapidly changing reimbursement environment, and even measuring quality measure incentives and disincentives.

Time spent with EHR data entry is a significant frustration, as well.  “EHRs were supposed to make patient records easily shareable among physicians. In theory, that would lead to more coordinated care and fewer medical errors,” says Sally Pipes, president, CEO, and Thomas W. Smith Fellow in Health Care Policy at the Pacific Research Institute in Forbes.

“Instead, the mandate has been a bureaucratic nightmare. Doctors now spend half their time on EHRs and desk work — and barely a quarter of their time with patients. In 2000, doctors spent more than 60% of their day providing medical care. The increasing bureaucratization of health care has left two in three doctors feeling burned out, depressed, or both.”

Enter the CMS Innovation Center and the Primary Cares Initiative, called “a major commitment advancing primary care in this country.”  Health and Human Services Secretary Alex Azar introduced the new value-based care initiative in a speech at the Washington office of the American Medical Association.

The initiative comprises a set of five voluntary program models grouped into two paths: Primary Care First (PCF) and Direct Contracting (DC). PCF targets smaller practices, offering a general payment model and a second payment model for high-need populations. The three models in the DC path are Global, Professional, and Geographic; these target larger practices and are more ambitious.

The payment models incentivize participating providers to deliver advanced, patient-centered primary care services while keeping those patients healthy and out of the hospital.  They focus on value-driven, population-based metrics.

In the PCF general model, population-based payments and flat primary care visit fees are meant to assist in the transition from fee-for-service to a value-based model.  Performance-based adjustments can reward providers up to 50% of revenue, or risk a 10% downside adjustment. Quality measures include acute hospital utilization in all 5 years of the program; starting in year 2, quality measures will include Patient Experience of Care Survey, control of hemoglobin A1c and hypertension, care plan, and colorectal screening. The Quality Gateway for practices serving high-risk and seriously ill populations will be developed during the model.

Data sharing is a key component of the program.  The plan for PCF data sharing is for participants to submit claims (with reduced documentation requirements) to CMS, and for CMS to return performance data to providers, to be used in their own analytic tools, so that providers may assess their own and their peers’ performance in the program to encourage continuous improvement.

Administrator Verma, in remarks to the National Association of Accountable Care Organizations, said, “Technology, and the sharing of data, underpin the entire move to innovative payment mechanisms.  Without effective, open data sharing, providers cannot keep patients healthy.  Without data to track patient progress or understand quality, payers cannot tie payment to outcomes.”  To this end, CMS is moving to modernize their processes for data sharing, encouraging APIs wherever possible.  The intent is for providers to “track their beneficiaries’ healthcare utilization and spending at a granular level, and then modify a patient’s care plan in response.”

The vision for value-based care is to both hold clinicians accountable for cost and quality while also giving them the flexibility to innovate—to provide quality, coordinated, appropriate care free from the dictates of bureaucracy and regulation.  Azar referenced the 4 Ps that are the goals of value-based care according to CMS:

  • Patients in control as consumers
  • Providers acting as accountable guides through the healthcare system
  • Payments based on outcomes
  • Preventing disease before it occurs or progresses

It’s not clear whether value-based payment models will automatically result in a complete system of value-based care delivery, though such an outcome would be good for both patients and physicians.  Reimbursement has been recognized as an effective steering wheel for the vehicle of healthcare delivery, however, so there is optimism for the results of this and subsequent initiatives.  Further, by encouraging multi-payer alignment, CMS hopes to retain firm control of the steering wheel.

Administrator Verma has indicated additional value-based payment models will be forthcoming, including programs for rural care, oncology, and other specialty physicians and surgeons.  She has also said future models are likely to be mandatory rather than voluntary.

For the Primary Cares Initiative, participation is voluntary, and several conditions must be met in order to apply for the program.  The application process is expected to begin soon—“Spring 2019” according to the CMS timeline.  Qualifications for participation in PCF include geographic and demographic aspects, having experience with other value-based payment arrangements, using 2015 Edition Certified Electronic Health Record Technology (CEHRT), supporting data exchange with other providers and health systems via Application Programming Interface (API), and connecting to their regional health information exchange (HIE).  Practices must also comply with a set of “advanced primary care delivery capabilities,” such as providing 24/7 access for patients to practitioners.

What does this mean for the business office?

Under a payment model such as PCF, claim processing will be different, but still vital. Hopefully, rejections and denials will be minimal, but it is unlikely payment discrepancies will disappear. Nor will the revenue cycle functions of patient access management, coding, cash application, etc. be rendered either inconsequential or obsolete.

Data tracking and analysis will become more important than ever to practices as they evaluate performance, innovate based on outcomes, and predict and confirm performance-based adjustments.

Data preparedness is associated with disaster readiness and response; it’s the “ability of organizations to…effectively deploy and manage data collection and analysis tools, techniques, and strategies in a specific operational context.”[ii]  In the context of value-based payment, data preparedness and ease with analytics capabilities is important for providers prior to joining a model, in order to confidently assume risk.  Understand your patient population, have a clear picture of costs and budgeting, and be ready to work with payment and performance data following model implementation.

Many unknowns remain as we look to the future of healthcare reimbursement—of course, that’s nothing new.  What is known: the best way to succeed regardless of payment model (or variety of them) is to ensure all the parts of your revenue cycle are operating at peak efficiency.  When your staff enjoys greater productivity with cost-effective, connected tools for patient access, claims management, reimbursement management, and data analytics, you’ll be ready to hit the value-based road with confidence.

Quadax can help.  Contact us to hear how we’ve helped both primary and specialty physician groups optimize their workflow and their cash flow.

To learn more about each path under the Primary Cares Initiative, tune in to an upcoming CMS webinar: for Primary Care First or for Direct Contracting.

[i] Health Care Cost Institute, HCCI Brief: Trends in Primary Care Visits, October 2018 https://www.healthcostinstitute.org/research/publications/hcci-research/entry/trends-in-primary-care-visits

[ii] Nathaniel Raymond and Ziad Al Achkar, Data preparedness: connecting data, decision-making and humanitarian response, November 2016 https://hhi.harvard.edu/publications/data-preparedness-connecting-data-decision-making-and-humanitarian-response

How to do an Apples to Apples Vendor Comparison

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Making the decision to replace vendors functioning in any part of your revenue cycle is BIG. A lot is riding on uninterrupted operation in this area, particularly when it comes to the operations performed by your EDI clearinghouse vendor – the company responsible for facilitating claim submission and therefore reimbursement.

In light of recent reports suggesting that administrative costs in healthcare today are “astonishingly high,” the pressure is on to reduce spending while increasing value.  The top two business spend issues causing leaders to be concerned or very concerned, according to a HealthLeaders Media Buzz Survey, were process inefficiencies and thinning margins.  Working with a premier EDI clearinghouse can help you improve in both of those areas—so a switch can certainly be worthwhile.

But once you’ve made the decision to make a move, perhaps breaking free from clearinghouse constraints that may have held you back, how do you make an equitable, apples-to-apples comparison to determine which vendor will be the best fit as partner for your organization?

Some organizations employ an RFP (Request for Proposal) process in their attempt to fairly compare different vendors on a defined set of criteria to create a short list for deeper evaluation.  This process is mandated by law for some, due to the financing model of the entity; e.g. for government-owned facilities who must prove on a regular basis that they have selected the most cost-effective solutions.  However, an RFP process is a costly one in terms of resource required to write the RFP, manage the receipt of responses, read all the responses, and fairly judge each against one another.

Other entities will very effectively rely on the judgments of industry analysts to identify the top performers for your short list.  These analysts, using standard criteria and methodology, have accomplished a significant amount of work for you, allowing you to hone in more quickly on the particulars related to your organization’s needs.

KLAS Research has earned its spot at the top of any list of industry analysts, “providing accurate, honest, and impartial insights for the healthcare IT (HIT) industry since 1996.”  Their mission is “to improve the world’s healthcare by amplifying the voice of providers and payers.”  Each year, KLAS publishes easily-consumable reports, such as the annual Best in KLAS: Software & Services issue that names the top performers across numerous market segments.

Quadax has been named #1 for Claims Management in the Best in KLAS: Software & Services report two years running—2018 and 2019. But apart from a number-one rating and a raw numeric score, what can this rating tell you about how well Quadax, or any company, would perform as your organization’s partner for revenue cycle optimization?

You may find new letter grades helpful: beginning this year, KLAS features letter grades as performance indicators to help provide better context and transparency for vendors evaluated in the Best in KLAS report. These scores are meaningful, since KLAS scores are based on the reports of real-world experience with each vendor by their customers.

Six key categories are graded:  Culture, Operations, Product, Relationship, Value, and Loyalty.  Each category reflects a number of key questions in the standard KLAS interview.  For example, one measurement of Culture is the range of responses to queries about proactive services. Another is whether the vendor keeps their promises.  One example measuring Loyalty: would the provider choose that vendor again?  For Value: does the product drive tangible outcomes?

In the 2019 KLAS letter grades, Quadax earned As across the board: A for Culture, Operations, and Value, A- for Product and Relationship, and A+ for Loyalty.

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An overall KLAS ranking supplemented by these letter grades will give you a good start in your vendor assessment, but they can’t answer every question for you. When you’ve established your short list, build a scorecard based on the factors most important for meeting your organizational goals, and take time to talk with vendors and their clients to consider those factors.  Some you may include:

    • Do they conform to the highest standards of compliance and security?
    • Is their approach generally to fit a provider to a solution, or to fit a solution to a provider?
    • Are they able to come through in a crunch, when unexpected factors change a timeline or a deliverable expectation?
    • Do they readily and transparently communicate with clients both good news and bad news?
    • Has the firm demonstrated longevity and stability – can you count on continuing, year to year, with the same company you initially engage with?
    • Do they remain engaged long after implementation to ensure continual process improvement?
    • Do they have a well-structured organization for service delivery and issue resolution?

In the end, the vendor that’s right for you will be a good fit in areas of technology, expertise, and culture, with a track record of meeting the specific needs of healthcare providers like you. When these characteristics have been part of your equitable, apples-to-apples vendor assessment, you can be confident that you are entering a mutually-beneficial partnership with staying-power.

Quadax has a proven track record of implementing customized solutions and helping providers exceed their revenue cycle goals.  Let us help you in your assessment – contact us today!

 

[Medical] Necessity — the Mother of Insolvency??

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Medical necessity rules are a growing concern for healthcare providers. The policies are not a new phenomenon, but their impact on cash flow is increasingly sharp.

Medical necessity denials (initial) increased from 12% in 2015 to 20% in 2017 according to The Advisory Board 2015-2017 Hospital Revenue Cycle Benchmarking Surveys. The same report indicates that 27% of denial write-offs result from medical necessity denials.

The kicker is—most medical necessity denials are preventable.

It’s easy to play the blame game when it comes to medical necessity denials, since a breakdown can happen at any of several points:

  • Is the ordering physician’s documentation complete and effective?
  • Has the correct diagnosis code been selected?
  • Has the registration or intake department checked medical necessity policy and obtained a signed Advance Beneficiary Notice (ABN) from the patient when needed?
  • Has the encounter been coded appropriately?
  • Has the claim been billed properly?

Medicare publishes thousands of rules, between National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), plus Articles that in some cases define billing and coding guidelines for LCDs and in other cases stand alone. Commercial payers also use medical necessity policies, whether they have developed their own library or are relying on some set or subset of Medicare policy. Medicare policies change frequently and can sometimes be applied retroactively, but they are published in an organized manner, affording providers the opportunity to become familiar with those policies pertinent to their specialty. Commercial policies are sometimes harder to access in full, yet compliance is no less important.

Checking the applicable body of published policy before providing services is the first critical step to preventing medical necessity from becoming the mother of insolvency. Your patient access suite should be able to check Medicare medical necessity policy in real time. Registration representatives should routinely validate each patient’s procedure and diagnosis and be prepared to discuss an ABN with the patient when needed. Coaching or training of the registration staff, supplemented by talk tracks to keep on-hand, will help make this conversation beneficial to the patient and comfortable for the representative.

Using a billing system that checks medical necessity on the back end, during claim editing, is also valuable. Claims failing validation against published policy should be flagged for investigation. Is there a signed ABN on file? Are the codes appearing on the claim accurate according to the physician’s documentation? A claims processing system that facilitates electronic workflow between the billing office, patient access, and coding will make quick work of the collaboration required to ensure that claims submitted are correct and complete with accurate codes and modifiers as needed.

Be prepared to appeal when you’ve received a denial even after ensuring that medical necessity standards have been met.  A September 2018 Office of Inspector General (OIG) reportfound “When beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage Organizations (MAOs) overturned 75 percent of their own denials during 2014–16, overturning approximately 216,000 denials each year. During the same period, independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers.” Unfortunately, the same report found that during 2014-2016, only 1.1% of Medicare Advantage denials were appealed.  Identify denials and take action.

Quadax can help. Our Denials, Appeals, and Audit Management solution recognizes full and line-item denials and presents them in an intuitive interface with easy access to source documents (the original claim, 835, and EOB), and appeal letter templates making it easy for your staff to classify and work denials.  With our new Patient Access Management system, however, you will encounter fewer denials to manage because of its Medical Necessity module to identify coverage issues and generate ABNs when needed.  Our top-rated Claims Management solution, Xpeditor™, boasts an extensive claim edits library including full Medicare medical necessity checking, plus validation per some commercial payers’ policy, as well.  Best of all, our system modules talk to each other and to your EHR for complete, accurate workflow – and results.

Xpeditor checks all the boxes on the Five Must-Haves for your Claim Edits Library—does your system? Read our free e-Book to find out. And, if medical necessity, or any other group of denials, is a growing concern for your business office, let’s talk.

How Your Payer Dictionary Can Impact Your Clean Claim Rate

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Many business offices, working toward an optimally efficient, cost-effective claims process, set a Clean Claim Rate (CCR) goal of at least 95%. A high CCR means less time and expense associated with getting accurate charges billed as soon as possible following the discharge of services.

Clean Claim Rate (CCR), the ratio of claims that pass edits cleanly—not requiring any correction or manual work prior to transmitting to payers—is an important indicator of your revenue cycle performance.  A high CCR generally demonstrates that at each point through the revenue cycle to the point of claim creation, data collection has been accurate and efficient.

Procedure and diagnosis coding, modifier use, and compliance with medical necessity rules are a few of the common trouble spots that can negatively impact CCR. One that often goes unnoticed is the state of your payer dictionary.

Insurance information entered during patient intake may or may not match an appropriate entry in your system’s payer dictionary. Claims entering your system with an unmatched payer name will cause a drop in your CCR and payment delays.  Worse, claims that have been tagged with the wrong payer identifier can result in rejections, denials, incorrect reimbursement, or even unauthorized PHI disclosures.

Is potential revenue leaking from the holes in your payer dictionary?

Plug the holes by keeping your payer dictionary up to date and your claims matched accordingly with regular weekly maintenance.  When matching or confirming insurance payer entries to each appropriate payer dictionary entry:

  • Be certain to match, in every instance possible, to a payer ID set up for electronic claim submission. Sending claims on paper unnecessarily is too often the result sloppy payer matching.  One consequence will be delayed payment; a lack of tracking on either the claim or payment may also result.
  • Confirm that the payer ID is a perfect match, so that the right claim edits are applied and the claim will be submitted to the correct insurance payer.
  • Choose to apply Medicare edits for a commercial payer’s Medicare product, or Medicaid edits in the instance of a commercial payer’s Medicaid product. If the only edits applied are those that would be appropriate for the payer’s commercial plans, important rules could be missed that could result in rejections, denials, or incorrect reimbursement.
  • Don’t forget to select whether or not “shadow” or information-only claims should be generated to the MAC when a Medicare Advantage plan is being billed for inpatient services.
  • Link your payer entry to the appropriate Line of Business so that the ANSI 837 Filing Indicator will be correctly completed in the claim that goes to the payer.

Having the correct payer designated by your system when a claim is generated is critical to making the most of the claim edits library in your claims management system.  Payer specificity is key to 2 of the 5 “Must Haves” for a high-quality claim edits library.  When that library includes all of the Five Must Haves—the success of your high CCR will be amplified with a high First Pass Rate (FPR) for the fastest, most reliable cash flow possible.

5-Must-Haves-Claims-Edits-e-book-coverRead about all 5 of the Must Haves for Your Claim Edits Library in our latest e-book.  Or, to hear more about how the Quadax FPR of 99.6% can improve your cash flow, get in touch—we’d love to talk.

Changing the Course of Revenue Cycle Management in 2019

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We’ve come to the end of another calendar—each year the ride seems to go faster!  With the holidays upon us, we can count on portrayals of the Ghosts of Christmas Past, Present, and Future.  It’s inevitable, too, at this time of year that the voices of our industry look to where we’ve been, where we are, and where we’re going in healthcare.

The challenges of revenue cycle past continue to haunt us, and are certain to only become more urgent in the near future. The long list includes:

  • Financial pressures due to shrinking margins
  • Revenue leakage through denials, underpayments, and uncompensated care
  • Poor patient engagement, particularly in this era of patient-as-payer

 

Moody’s forecast for the nonprofit healthcare sector is gloomy; “its 2019 outlook will remain negative for the next 12-18 months.”  Flat or declining operating cash flows and a rise in bad debt are cited as two of the issues contributing to the projection.

Enrollment in high deductible health plans continues to grow, causing patient responsibility to often exceed the patient’s ability to pay.

While the costs of uncompensated care did decline between 2013 and 2015, the trend since then has been upward.  “According to Definitive Healthcare data, hospital bad debt totaled nearly $80 billion in 2017, with an average bad debt to net patient revenue of just over 25%.”

A list of the negative prognoses could go on and on, and like Scrooge, we want to shout, “Haunt me no longer!”

The challenges are all too familiar, but as they grow in magnitude it becomes clearer that they cannot be solved by relying on the same old strategies and tactics.

With that in mind, Quadax has been working diligently this year on new real-world solutions to some of our clients’ biggest revenue cycle obstacles, and we’re excited to bring those forward in 2019.  The first of these, Decision Intelligence, will launch early in the year.  Data abounds in the provider business environment—but how do you use it effectively to alter the course of projected doom?  Decision Intelligence by Quadax is the tool you need to leverage actionable data—to gain insight, to achieve efficiency gains, and to improve financial performance.

A highlight for January will be the Quadax webinar, “Denial Management was last year. 2019 is about Denial Disruption Solutions.”  Our presenter is Lyman Sornberger, CEO and President of Lyman Healthcare Solutions, LLC.  Mr. Sornberger has thirty years’ distinguished executive experience, and he will share the future of healthcare denial management—the new world of denial disruption.

Ebenezer Scrooge observed to the Ghost of Christmas Future that while a course may foreshadow certain ends, if the course is changed, the ends will change, as well.  In keeping with our mission, Quadax is determined to change the course of revenue cycle management to help providers gain control and improve outcomes with new approaches to tackling the issues of the past, present, and future.

As we enter the holiday season and prepare for new things to come, all of us at Quadax are thankful for another year of working with our clients and partners and working alongside our colleagues and friends. We wish you and your families great joy and peace in all your celebrations.

Cheers!

Is Your Cash Flow Engine Running at Peak Efficiency for Reimbursement?

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Claim processing rules are the power behind your cash flow.  The tool you use for scrubbing and submitting your claims is only as good as the library of claim edits under the hood that will identify errors before you submit – giving you the opportunity to send clean, error-free claims.

Five essential attributes for the claim edits library that will improve your cash performance are identified in the new e-book by Quadax, Five Must-Haves for Your Claim Edits Library.

The first Must-Have is a comprehensive set of payer-specific billing policy edits, validating claim data for all your claims: Medicare, Medicaid, and commercial. Claims for Medicare or Medicaid managed care products administered by commercial payers may require the application of standard government policies with a twist — the payer’s own unique additions or restrictions. Make sure that each of these rule sets are included in your claim edits library:

For Medicare claims:

Medical necessity policies, local and national.  Local Coverage Determinations (LCD) are published by your Medicare Administrative Contractor (MAC), and National Coverage Determinations (NCD), are published by the Center for Medicare & Medicaid Services (CMS). These govern which services are considered medically necessary, and therefore reimbursable, for Medicare beneficiaries based on the diagnosis for which they are being treated. As you know, if a service you’ve provided does not meet Medicare’s medical necessity standards, you may have just provided that service for free (unless you have an Advanced Beneficiary Notice [ABN] signed by the patient prior to the service delivery). Medical necessity policy watchers are presently observing the impact of the 21st Century Cures Act on LCD compliance.  The Act, intending to improve transparency in the LCD process, prompted a change to the Medicare Program Integrity Manual. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedure Terminology (CPT) codes are moved out of the LCD documents and into billing and policy articles published alongside LCDs in the Medicare Coverage Database.  Your claim edits library must be up to date with every policy, every ICD-10-CM code, and every CPT code, whether published in NCDs, LCDs, or separate billing policy articles.

National Correct Coding Initiative (NCCI).  CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. Two subsets of NCCI are PTP and MUE.

NCCI Procedure-to-Procedure (PTP) code pair edits prevent improper payment when certain codes are submitted together.

NCCI Medically Unlikely Edits (MUE) indicate the maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single beneficiary.  Corresponding MUE edits are similarly implemented within the Fiscal Intermediary Shared System (FISS) for Part A claims.

Outpatient Code Editor (OCE) edits. This set of rules was developed by CMS to examine outpatient facility claims and identify incorrect and inappropriate coding.  The OCE also incorporates NCCI PTP edits. The OCE as used by Medicare contractors also assigns APCs, payment indicators, etc. By applying OCE edits and correcting where necessary prior to transmission, clean claims may be processed much faster, and reimbursed faster, by Medicare.

Coverage Validation edits. These edit routines compare Medicare beneficiary data on claims with the official Medicare data in HETS (the HIPAA Eligibility Transaction System) prior to claim submission to identify any shortcomings to the exact name match needed for claim processing, as well as eligibility, therapy thresholds, max occurrences per year for certain procedures, etc.

For Medicaid claims:

Coverage Validation edits. Similar to coverage validation edits for Medicare, these edit routines query the state Medicaid information systems in real time.  They can therefore overcome the biggest challenge when filing Medicaid claims, which is identifying eligibility: verifying coverage at any given point in time; verifying coverage by a Medicaid managed care organization rather than traditional Medicaid, or verifying an identification number.  Coverage validation edits running during claim edit routines in the claims management system prior to claim submission can head off eligibility issues that will delay, if not completely obstruct, reimbursement.

Billing policy edits. Specific billing policy rules are common for commercial Medicaid products and vary by payer. These rules are not likely to be published in neat packages, reinforcing the need for diligence and tenacity to discern and confirm the policies and keep them up to date.

Medicaid NCCI. Since 2010, state Medicaid programs have been required to incorporate elements of NCCI into their claims processing systems: PTP and MUE edits for practitioner and ambulatory surgical center (ASC) claims; PTP and MUE edits for outpatient hospital services including emergency department (ED), observation care, and outpatient hospital laboratory services; and MUE edits for durable medical equipment (DME) billed by providers. In 2012, PTP edits for DME were added to the mix.  The Medicaid NCCI is slightly different from the Medicare NCCI manual and is therefore maintained separately.

For Commercial claims, including Blues:

Reimbursement Policies.  Policies that may be considered the counterpart to Medicare’s NCD and LCD are published by commercial payers to provide guidance in interpreting the payer’s benefit plans, without addressing every aspect of a reimbursement situation. Policies may be applicable by product, by treatment setting, by state, or they may be blanket policies covering all of the payer’s products to one degree or another.

Commercial application of NCCI.  Many commercial payers take advantage of NCCI rules, or a subset of them, in their own claim processing routines.

 

Claim edits libraries are not all the same. Quadax clients have an edge when it comes to claim processing because of the Quadax EDG: the Edits & Documentation Group. The work of the EDG differentiates Quadax as the leader in claim editing because of its diligence to provide each of the five claim edits library essentials discussed in the free e-book, “Five Must-Haves for Your Claim Edits Library.”  Request a copy today to read about the other four Must-Haves and learn more about the Quadax EDG.

Keep your cash flow engine running at peak efficiency and optimal performance with the powerful claim edits library of Xpeditor, diligently maintained by the Quadax EDG!