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.

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!

Why Month-End Cash Posting is Scarier than Halloween

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For a cash posting manager, Halloween’s got nothing on the horrors of manual splitting, posting, and reconciling remittances.

Skeletons and ghouls are not nearly as frightening as an impending month-end with all your posting staff working overtime to post and reconcile receipts. Needing to resolve a patient payment issue but not having a way to efficiently look up all payments posted to the patient’s account—that’s a lot more anxiety-inducing than a haunted house.  

Before Adena Health System began using RemitMax™ by Quadax, the staff spent a lot of time printing and scanning lockbox documents, because the bank only retained three months’ worth of correspondence and paper remittance data.  Paper documents waiting to be scanned filled cabinet after cabinet, which delayed insurance follow-up work, delayed answers to customer service questions, and also delayed cash posting.  Referencing the source documents to solve any posting errors meant combing through the cabinets armed with the deposit date of the batch.  If the deposit date had been entered into the scan incorrectly, they would likely never find the document, since that was all they had to search by.

Now that’s a horror story.

Implementing RemitMax at Adena Health System brought about numerous improvements for the entire business office.  One of the early wins was the document retention, the excellent search functionality, and the elimination of the perpetual printing and scanning of paper remittances and correspondence by Adena staff.  Another was the ability to reassign staff to more valuable follow-up work because of the huge time savings that RemitMax has helped them realize with automatic splitting and electronic posting.

Angela Lowery, Cash Posting Revenue Cycle Manager at Adena Health System in Ohio, will be discussing revenue cycle life before and after RemitMax when she presents “Transforming Remittance Management into a High-Performance Operation,” a live webinar on Thursday, November 1, 2018, at 2:00 p.m. (EDT).

Register For Webinar

 

Angie is enthusiastic about the difference that RemitMax has made in the entire business office at Adena Health System—for lockbox savings, for morale, for improved customer service, and for better follow-up and the opportunity for revenue recovery.  Join us to hear more about Adena’s transformational experience with RemitMax by Quadax!

To read more about RemitMax, download the e-book, Surviving the Paper Storm. If you would like to learn how RemitMax can transform your business office, Request a Demo!

Hanging in the Balance: Addressing Surprise Billing Issues

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The topic of balance billing is in the news again, closely associated with the newer term, “surprise billing.”  Patient experiences such as those of Drew Calver, who received an unexpected $109K bill following treatment for his heart attack, have focused new attention on this long-standing issue.

Balance billing is the practice of pursuing from the patient any balance remaining on account after the insurance payer has reimbursed its portion to the provider, beyond the expected co-pay, co-insurance, and deductible.  The terms of the contract between the provider and insurance plan will generally dictate what is or is not billable to the patient – the aforementioned co-pay, co-insurance, deductibles, for example – and these contract provisions (and state law, typically) will control whether or not a patient may have further financial responsibility.

When there is no contract, of course, all bets are off, since an out-of-network provider has no negotiated payment rate.  As high-deductible health plans have become more widespread, many patients are keenly aware of the benefits of staying in-network to keep those expected costs as affordable as possible. But what about when services must be rendered by an out-of-network provider?

In a number of cases highlighted by the media recently, a patient was not aware that out-of-network providers were engaged in the treatment.  This commonly happens when an emergency department physician working through a staffing agency, or an anesthesiologist or radiologist is involved in care but is not in-network. Hence, the surprise of “surprise billing” – the receipt of an out-of-network bill when the patient thought they were at an in-network facility.

New Jersey’s Assembly Bill No. 2039 has likewise garnered quite a bit of attention since its enactment and particularly since its effective date August 30, 2018. Governor Phil Murphy, who signed the legislation earlier this year, said “We’re closing the loophole and reining in excessive out-of-network costs to prevent residents from receiving that ‘big surprise’ in their mailbox. At the same time, we’re making healthcare more affordable by ensuring these costs are not transferred to consumers through increased health premiums.”

New Jersey is among 21 states that have partial or comprehensive protections against balance billing by out-of-network providers in emergency departments or in-network hospitals. Stipulations of the protections vary by state.  Variables include applicability by setting, type of managed care plan, the type of protection, and the payment outcome, whether a payment standard or a dispute resolution process. And since ERISA currently exempts self-funded employer sponsored plans from state regulation, 61% of privately insured individuals are not covered by their state’s protections, adding to the complexity.

There is speculation that changes could be made to ERISA (the Employee Retirement Income Security Act of 1974) to overcome this loophole to state protections.  Senator Bill Cassidy, M.D. (R-LA) announced on September 17 a discussion draft of a bill that would modify ERISA to defer to state limits for patient costs for emergency care; or, in absence of state limits, define restrictions within the proposed legislation itself to cap patient responsibility.  This is one issue among several concerning healthcare price transparency that is being discussed by a working group, and not the only discussion on the topic of potential laws governing balance billing.

So what’s a healthcare provider to do?

  • Be aware of the regulations applicable in your state, and be prepared to comply. As media focus continues on this topic, more legislators are taking up the issue.  Stay tuned to your state’s law-making process to eliminate surprises for your cash flow.
  • Apply your organization’s payment policies consistently.
  • Communicate clearly with patients, whenever possible, about the charges they should expect and their options for payment. In non-emergency settings, check patient eligibility, and provide a pre-service estimate based on their health plan coverage.

Complex billing issues are par for the course in today’s healthcare business office. That’s why Quadax delivers software and solutions that solve revenue cycle complexities, streamlining accounts receivable and reimbursement operations to improve cash flow and payment results.

If you’re ready to work with a partner that believes in transparency, communication, and earning our clients’ trust every day, get in touch with Quadax!

Collect More Revenue with “Clean” Claims

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When it comes to healthcare claims, cleanliness is next to, at the very least, fiscal fitness. Producing claims that are “clean” and therefore immediately reimbursable is an important factor in reducing cost-to-collect, especially in an environment where the growth of costs (7.5%) are outpacing revenue (6.6%).[i]  While some denials are inevitable, reducing your denial exposure is all about producing claims that can be paid, and can be paid now.

Two metrics important to the discussion of creating claims most likely to be immediately reimbursable are Clean Claim Rate (CCR) and First Pass Rate (FPR).  Though sometimes confused for one another, these are separate statistics, each worthy of optimization.

HFMA identifies the value of CCR as an indicator of the quality of data collected and reported.  This measure is captured through your claims processing tool, and is calculated as the number of claims that pass edits requiring no manual intervention divided by the total number of claims accepted into the claims processing tool for billing.

A high CCR indicates that the data collected and processed by the EHR may be presumed to be high-quality. That quality may be attained in one of a few ways. Well-defined processes throughout the revenue cycle, from patient intake through coding on to accurate claim production processes in the EHR, will be reflected in a high CCR.  Another way to achieve a high CCR is by applying a meticulous routine of incoming claim data conversions within the claim processing tool to overcome EHR shortcomings and human error.  Or, a combination of both factors may be in play. In any case, the effect is faster time to payment with reduced manual labor for reduced operational expense.

Another important metric is the first-pass rate (FPR): the percentage of claims which are accepted for adjudication by payers on the first transmission. This measure indicates the reliability of your claims management system: the quality of its claim editing routines is critical; so is the accurate generation of 837s to meet each payer’s unique specifications, including the correct placement of each data element. The most common reason for claim rejections is missing/incorrect data.  By catching those errors – and even better, by facilitating automated correction of such errors – the claim processing tool with a high first-pass rate also contributes to faster time to payment, and impacts manual labor expense by reducing manual correction and resubmission. For a provider processing 100,000 claims per month, a variance as little as 1% in your first-pass rate can mean an additional 1,000 claims that must be manually reviewed.

Some organizations make the choice to abandon the pursuit of an exceptionally high CCR in favor of moving claims out the door as quickly as possible.  Follow-up staff must then be mobilized to handle the resulting rejections (bounced back to the clearinghouse with errors flagged, never having made it into the payer’s adjudication system) as well as denials.  Other organizations choose to weight the process at the billing stage, examining every claim prior to release to head off the potential for follow-up work down the road.

An imbalance favoring either manual pre-work or post-work is likely to add to the cost of claims management. Greater value can be realized by balancing quality and quantity with a holistic approach to creating cleaner claims and reducing denials that incorporates intelligent efficiency and automation.

In summary:

  1. Work toward data accuracy throughout the revenue cycle to contribute toward a higher CCR.
  2. Make use of automation in your claims management tool to apply data conversions to overcome known shortcoming in your system or process during claim intake to achieve an even higher CCR.
  3. Rely on a clearinghouse with a high FPR, like Quadax, to get your clean claims into adjudication as quickly and reliably as possible.

Learn more about streamlining your claims management process in our free infographic that cues you into Roadblocks, Pile-ups, and Bottlenecks in Claims Processing.

Would you like to learn how much improvement your business office would see with an improved CCR and an industry-leading FPR rate?  Click here to get in touch with us – we’d love to talk!

[i] “Moody’s: Preliminary FY 2016 US NFP hospital medians edge lower on revenue, expense pressure,” Moody’s Investors Service, May 16, 2017. https://m.moodys.com/research/Moodys-Preliminary-FY-2016-US-NFP-hospital-medians-edge-lower–PR_366813

Quadax Earns KLAS Top Ranking for Claims Management

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The Secret is Out! 

With the release of the 2018 Best in KLAS: Software and Services report, the healthcare industry is learning what Quadax clients have known for years: Quadax can’t be beat for exceptional service and top-performing product functionality.

Although Quadax has served hospitals, laboratories, physician groups, and many others in the healthcare industry for more than 40 years, we have done so somewhat quietly. “Quadax is the industry’s best kept secret; a small but mighty company with talent and expertise to help all types of providers,” said Terry Buterbaugh, Senior Software Engineer.

Instead of making a lot of noise, we’ve focused our attention on building partnership with our clients.  We continuously work to improve our revenue cycle products and services to meet the needs of providers looking for high-performing transaction management tools to improve operational efficiency and cash flow, cost-effectively.

Quadax Performance

You expect comprehensive standard edits for cleaner claims and faster payments, and Quadax delivers.  Thanks to the diligence of our team of claim edit researchers, 99.6% of the claims we transmit are accepted by payers on the first pass. The Quadax Claims Management system, Xpeditor, also gives you powerful tools for configuration of custom edits and claim data processing rules as well as dynamic workflow rules to fit your business office. Not the other way around.

Inseparable from our superior products are the people of Quadax EDI Services that empower providers to use the Xpeditor system to its fullest by providing person-to-person, relational customer support. Whether it’s on-site, on the phone, through virtual meetings, or otherwise—we’re here for you.

Quadax is honored to receive the distinction of Category Leader for Claims Management. However, the driving force behind all that we do is not the achievement of a trophy or seal. Rather, it’s the attainment of a relationship of trust and mutual benefit with the healthcare providers we serve. We enjoy overcoming new challenges as they arise, rolling up our sleeves, and working with client teams to help them achieve success.

If the power and flexibility of Xpeditor are news to you, we’d love to let you in on the secret. Contact us so we can give you more information and show you what makes Quadax Claims Management #1!

KLAS Research

KLAS is a data-driven company on a mission to improve the world’s healthcare by enabling provider and payer voices to be heard and counted. Working with thousands of healthcare professionals, KLAS collects insights on software, services and medical equipment to deliver reports, trending data and statistical overviews. KLAS data is accurate, honest and impartial. The research directly reflects the voice of healthcare professionals and acts as a catalyst for improving vendor performance.

Each year, KLAS publishes a Best in KLAS Report, identifying the top vendors in more than 80 categories.  “Category Leader is more than a ranking. It is a recognition of vendors committed to delivering superior solutions,” said Adam Gale, President of KLAS. “It gives voice to thousands of providers who are demanding better performance, usability and interoperability in healthcare technology.”

The Best in KLAS Report scores vendors on the performance categories sales and contracting, implementation and training, functionality and upgrades, service and support, and general. What they learned put Quadax at the top of the list.

KLAS data is freely available to healthcare providers on their website. You can learn more about KLAS and the insights they provide, and download the 2018 Best in KLAS: Software & Services Report when you log in or create a free account.

Quadax earns top scores by KLAS for Claims Management

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As a testament to the superior customer service and support we provide our clients, Quadax received top marks as the best overall performing claims management vendor in the 2017 Claims and Denials Management 2017 Report by KLAS Research.  Download the report.

“Some vendors do much better at providing high-quality service and support, which is almost transformative in moving the experience from a vendor/customer relationship to more of a partnership.”  –KLAS Research

“Quadax topped the chart for claims management vendors that establish partnerships with their provider organizations.”  –Jacqueline Belliveau, RevCycleIntelligence

Quadax thanks our clients for entrusting us with their business. Creating long-lasting partnerships only strengthens our commitment to providing you continued high-quality customer service and support along with the best solutions in the industry.

RevCycleIntelligence.com article: KLAS: Quadax, SSI Group Earn Top Scores for Claims Management

Confronted by a Revenue Cycle Conversion You Didn’t Want?

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In the Healthcare industry, mergers and acquisitions (M&A) are everywhere. Even among the revenue cycle vendors who serve the industry, consolidation is the new constant. But what does this mean for you and your healthcare organization?

When a merger occurs, the newly formed vendor conglomerate may choose to convert acquired clients to a single system rather than carry the cost of supporting multiple product platforms. Through no choice of your own, your organization may be faced with the cost of an unplanned RCM system conversion.

During M&A integration, customers from both companies will face changes. How these changes impact customer choices can immediately impact customer experience. When you chose your RCM vendor, you sought the software, service, and support that best met your healthcare organization’s needs. How will the changes you are being forced to make impact your revenue cycle and reimbursement needs?

If you are being forced to make a system change, do not feel trapped by your current RCM vendor. Take back control—consider all your options. Revisit your decision model. To get started, review the 8-Item Checklist for Picking the Right RCM Partner and the Top 5 Ways to Optimize RCM Management. Focus on those capabilities you need to successfully drive your organization’s mission: data analytics, operating efficiency, and technology integration.

Data Analytics – Put Your Data to Work

Look for an RCM solution that provides visibility into your revenue cycle so you can gain insight, take action, and deliver results. Select a solution where you can monitor KPIs and benchmarks to uncover actionable patterns in your billing and reimbursement data. Make sure it has an analytics front-end that presents easily-consumable dashboards and reports—visual charts and graphs—so you can quickly identify trends and quantify impact to make data-driven decisions.

Operating Efficiency – Take Control of Your Cash Flow

You need your revenue cycle to be a highly-functioning, results-oriented operation. Find an RCM solution that will automate your claims, fast-track your receivables, and coordinate your denials and appeals management efforts. All with configurable workflows that you control and customize.

Technology Integration – Connect Everything

The right RCM partner will have technology that interfaces seamlessly with your EHR. To promote seamless integration, your RCM solution should be able to support APIs, web services, and both standard and non-standard interface types—making data connections secure, controlling access with minimum necessary use while not impeding productivity. Find a vendor who combines smart technology with superior service.

Mergers and acquisitions favor the joining partners. Customers and clients can be in for a rocky transition, especially if vendors have not fully vetted their M&A integration plan. If you are facing an unplanned RCM system conversion due to vendor consolidation, why not choose the vendor that fits you best? Make the choice that serves your RCM needs today and in the future. That may, or may not be, your newly formed vendor conglomerate.

Optimize Unplanned Transitions – Choose Agile Stability

While considering your RCM options, you may want to learn more about The Quadax Advantage.Demonstrating agile stability in the midst of healthcare’s ever-changing ecosystem, Quadax delivers innovative RCM software, service, and support. An enduring industry expert, with more than 40 years of healthcare experience, we provide clients a continuity of excellence. Creating connections, providing intelligence, and equipping providers, Quadax can help optimize your revenue cycle.

Is Your Healthcare Revenue Cycle Haunted?

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Thrills and chills may be fun at Halloween, but not when staff is trying to process claims. Things that go bump in the night can be causing payment delays! Exorcise the ghosts in your revenue cycle—review these ghost busting tips and get the most from your RCM claim processing and clearinghouse solution.

Feeling Vexed by Your Automation’s Limitation?

Intelligent automation throughout your claims process can help accelerate your revenue cycle. Are you experiencing ghastly gaps in your automation?  What can you do about it?

Frequent interruptions caused by your upload routines can make staff fear the start of a new day. If daily interfaces are failing, you may want to implement custom interface logic and monitoring tools. This can improve claim data integrity while safeguarding staff productivity.

When front-end payer rejections prevent your claims from reaching payer adjudication, it may be time to consider a new clearinghouse. If your claims first pass rate is less than 99.6%, then your RCM is being impeded by an under-performing editing engine. Your claims processing engine needs access to the must current industry rules for cleaner claims and faster reimbursement.

You cannot afford to still be processing paper when electronic options are available. If you are still sending hardcopy claims, engage your clearinghouse’s electronic payer connections to send more claims electronically. Electronic processing can expedite payment by cutting claim processing lead time by more than half.

Feeling Poorly About Productivity?

With the right RCM tools and resources, staff can enhance productivity and optimize claim processing. Are frightful system inefficiencies terrorizing your staff? Identify where and when and ways to solve them.

Repetitive manual processing delays all good men and women from achieving their best. Do not allow your staff to be held hostage by the RCM vendor who only allows for custom programming. Enable your staff with high-performance tools and resources. Your RCM solution should allow your staff access to self-help options for engaging your system’s automation. We recommend easy-to-use wizards where staff operators can create auto-correct rules and custom claim edits specific to your business needs.

Paper worklists limit management’s ability to optimize your billing operation and balance workloads. Make sure priority claims are worked first. Organize your labor force using configurable electronic worklists, integrated reports and dashboards, to prioritize work for maximum effectiveness.

Clumsy communications among claim processing teams can put your organization at risk for security issues and inappropriate disclosures. Stop staff from using emails and shared spreadsheets. Expect your software to provide for cross-functional, interdepartmental workflow and communication, especially when a claim requires special handling. It should also provide for automated comment records to keep staff and systems in-step and in-sync.

Feeling Devastated Over Missed Deadlines?

One of the most deadly claim processing errors is missing a payer filing date. Is your RCM system allowing you to miss filing deadlines?

Do not let your revenue be defeated by the walking dead; make sure your claims never miss a deadline. At-a-glance dashboards and warning flags can help you monitor age of claims and days in A/R so that filing dates are managed and met.

At Quadax, we aren’t afraid of ghosts!

If there is something strange in your RCM neighborhood, something’s weird and it doesn’t look good, who can you call? Quadax Xpeditor™ can free your RCM of haunted processing.

Make sure your claims reach payer adjudication. When selecting a clearinghouse, compare first pass rate—percentage of claims accepted for adjudication on initial submission. A difference of one percent can represent thousands of claims. Learn more about Quadax’s industry-leading 99.6% first pass rate.

 

Change Management Tools for RCM Automation Control & Oversight

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Automation is a logic process existing in a living ecosystem. Smart automation, built on the knowledge and information available at the time of design, anticipates the future and accommodates the need for change. Healthcare organizations facing ever-changing industry regulation and payer requirements can benefit from revenue cycle oversight and change management control to keep RCM automation operating at peak performance.

The Value of Automation

When tasks are repetitive and outcomes are reliably reproduced, automation brings increased efficiency and accuracy.  By quickly and reliably processing large volumes of electronic transactions, automated workflows can streamline your claims management and reimbursement activities. However, within healthcare’s reimbursement ecoystem change is inevitable, and RCM automation left uncalibrated for changes in payer requirements and government regulation can result in increased manual review and rework.

 

How Does Your Automation Account for Change?

All automation will face change. What makes automation intelligent, as well as efficient and accurate, is how it recognizes and processes change. Does your revenue cycle system alert billing specialists that it has found a new data element? Does it capture the new data and metadata? Is normal claim and remittance processing able to resume? Do billing specialists have a convenient interface for either correcting the data error or adding new logic to automated transaction processing?

 

Human intervention is critical

While it may seem appealing to program humans out of the man-machine systems we automate, the human operator provides judgment, logic, and opinion. As a component in the control system, humans are variable, interactive and adaptable—able to creatively respond to changes or unforeseen conditions. A person can identify and take creative action. With integrated change management tools, people can calibrate automation for changes as they occur. Balancing efficient and accurate RCM automation with human oversight and manual intervention is key. Smart design will determine what level of integration between automation and human intervention is best for optimal revenue cycle performance.

 

The BEST solution

An optimized system will maximize performance and minimize human error, operating somewhere between full automation and complete manual control. Where on this continuum a system should operate, of course, depends on the application. User operators should have a monitoring role in the automated system with override capabilities as needed, receive adequate feedback on system status with enough time to respond, and can trust the accuracy and reliability of the system.

 

Oftentimes systems are designed with economic benefit being the driving force for determining which aspects of the system will be automated and how. Then oversight control is integrated into the system in an “after the fact” manner leaving the user operator to manage the results of the automation. User operators can find themselves held hostage by automation that has become obsolete. Automation without the support of change management tools, can have a short shelf life. Be sure you have the ways and means to keep your automation operating at peak performance.

 

Stay in Control of Your RCM

At Quadax we understand your organization is poised for growth and change and that the revenue cycle automation we help you implement today will need to solve for your future state as well. With deliberate planning, our solutions offer user-friendly options for manual intervention, allowing our automated solutions and workflows to remain flexible and configurable to meet our clients’ changing needs. With various wizards and user interfaces, we integrate your staff and system. With responsible monitoring, our systems notify staff when new data events occur and support manual intervention for exception processing and handling. At Quadax we make sure your RCM automation stays current with your changing demands, ready to solve your revenue cycle complexities today and in the future.

Automation can rev your RCM and optimize your ride. Keep your automation operating at peak performance. Quadax oversight and change management controls allow you to tune-up your RCM without having to take it into the shop.

How to Protect Your Cash Inflow with Contract Management

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Know what you are owed, collect what you are due, and negotiate what you are worth. With so much of healthcare reimbursement administered by contracts, oftentimes complex and requiring lengthy payment terms, it is not surprising that hospitals and health systems experience leakage in their revenue cycle. Revenue assurance through contract management can plug the leaks, preventing unplanned and unexpected cash outflow. Consider implementing net patient service revenue assurance measures. Integrating contract management into your revenue cycle can help you calculate your expected cash correctly and protect its inflow.

The average healthcare organization experiences a 5% loss in annual net patient service revenue due to preventable revenue leakage.* It is also estimated that 7-11% of claims are underpaid.** The American Medical Association estimated that 7.1 percent of paid claims contain an error. That means for every 100,000 claims your organization processes, 7,143 will be paid incorrectly.

 

At the heart of the issue is an organization’s ability to apply contract management control to its claims management and reimbursement cycles. Managing and maintaining dozens of payer contracts, each administrating different payment terms and conditions based on numerous factors, can make calculating expected net patient service revenue complex. But without that calculation an organization cannot identify the true worth of a claim or if the reimbursement received was in variance.

 

Imagine the power of being able to project your cash flow with confidence; to monitor and act on payment variances. What if you could recoup identified underpayments and shortfalls en masse with “one-click” ease? How would it improve your payer negotiations if you could analyze actual and expected cash flow by procedure, by payer, by contract? With the right contract management and modeling solution, you could gain the strategic control to prioritize and maximize your revenue results.

 

But what about the cost of implementation? No matter how good a contract management solution claims to be, it is only most efficient when it is seamlessly integrated with the industry’s best clearinghouse as its foundation. Learn more about the Quadax Contract Management Solution when you download the FREE e-book. Let us help you optimize your revenue cycle!

 

Download Strategic Cash Flow Control Using Contract Management for Hospitals and Health Systems.

 

 

 

(*) source: 2016 Healthcare IT Forum, Advisory Board

(**) Medical Group Management Association (MGMA) Research