Category: For Hospitals & Physician Groups

In Patient Financial Services (PFS) offices across the country, words like swamped, frustrated, and stressed can be heard as frequently as patient, billing, and coffee. The work is never-ending, with the rules ever-changing. In this world of chaos, when so many of your daily challenges are outside of your control, a claims management solution can help you avoid roadblocks, bringing order and peace of mind. How does a good claims management system deliver the control you seek?

Organize the work.

Your first line of defense against the chaos: organization. The principles of masterful organization are identify, classify, categorize, prioritize, and mobilize. To effectively deploy these strategies in your claims management system, start with workflow rules, statuses, queues, and views.

• Workflow rules
  Workflow rules put work where it needs to be, not where it doesn’t. Organized workflow rules identify and classify, routing the right work to the right people so those responsible can complete it. Only the persons responsible for completing it see it; others are not distracted by it, and the work is done once. Multiple touches impede efficiency, increase cost, and can cause confusion.

• Workflow statuses
  Workflow rules also drive the status of claims, labeling them appropriately according to the intervention required so that work is grouped efficiently and will not fall through the cracks. Review the statuses in your claims management system periodically, as well as the conventions for their assignment, to ensure that the statuses correspond to logical classification – enough to provide clarity and direction, not so many that they are perplexing.

• Work queues or views
  When the queues or views within your claims management system are organized, not only will the right work get to the right people, but it will be prioritized according to best practice for your organization. The easier it is to see what needs to be done, the easier it is to get it done.

Automate, automate, automate!

Automation is one of the best ways to ensure the cash flow is steady and dollars are not diverted from your mission. According to the 2016 CAQH Index, manual claims management processes cost providers $4 more than electronic transactions. So not only is manual work more costly, but these tedious and time-consuming tasks take your staff away from other work.

Examine the manual interventions currently required of your staff, particularly those that are highly repetitive. Configure rules within your claims management system to automatically process these tasks. Using automation you can optimize workflows and increase staff productivity.

Share knowledge and best practices.

Share knowledge and best practices with your staff. Provide an easily accessible resource that contains error details and other EDI-related information, explains payer requirements, and identifies best practices. If the answers to most questions and concerns can be found at your employees’ fingertips, costly mistakes can be avoided. Not only will your staff be more knowledgeable, but you and your team will gain control over your claim processing protocols.

Avoid claim processing roadblocks.

Are your claims traveling the best path for payment? Review your claims processing roadmap. Where in your claims’ journey is your staff experiencing roadblocks, pile ups, and bottlenecks? To help in your review, download Quadax’s claim processing infographic. A good claims management system can deliver the control you seek.

July was National Picnic Month; did you celebrate? If you did, perhaps it occurred to you, as it has to us, that there are a number of ways running a Patient Financial Services (PFS) office parallels great picnic planning. The picnic best practices listed below clearly translate into revenue cycle success, as well!

Plan Well

Planning carefully for your picnic by thinking through each facet of the event helps to avoid mishaps, making the event more pleasant for you and for your guests. Then, turning one-time planning into a reusable picnic checklist will mean even easier preparation for your next al fresco adventure!

Thorough planning is critical, too, for operational efficiency in your business office. Documenting your plans and applying continuous improvement to them over time ensures ongoing success in areas like:

• The efficient division of labor by balancing workload appropriately
• A file transfer schedule based on clearinghouse and payer acceptance cutoffs
• Programmatic automation for routine tasks

Prep Ahead of Time

Great picnicking depends on doing as much advance preparation as possible. Food prep is a given, but also napkins rolled up individually with cutlery for easy distribution, and having insect repellent, sunscreen, wet wipes and adhesive bandages on hand.

In the PFS office, the work you do up front, before your claims drop, makes a huge difference in your ability to move claims to adjudication in the most cost-effective way possible. Don’t miss these critical advance prep steps:

• Make sure that eligibility verification and medical necessity checks are being performed pre-service to avoid issues downstream
• Keep your payer table up to date in your EHR and in your clearinghouse software
• Configure auto-correct rules in your clearinghouse software to overcome known shortcomings in claim preparation by your EHR

Keep it Easy to Eat

Balancing a plate of messy food (or failing to balance it!) can really distract from the pleasant picnic atmosphere. Serving food that’s contained – hand-held, even – is a great alternative. Calzones and empanadas are easy to transport and eat, and completely prepared in advance.

Establishing containment in your business office is a good way to stay organized and prevent the distraction—and wasted resource—of work duplication or inefficient procedures. Keep your processes in hand by taking advantage of:

• Logical workflow, with well-defined work queues to keep specialists working their specialties with nothing falling through the cracks
• Electronic routing of worklists, with system notes added to facilitate collaboration when claims must be routed back to Medical Records or Utilization Review, for example
• Prioritized intervention based on expected reimbursement

Prevent Spoilage

Avoiding problematic salads with mayo-based dressings is a great preventative measure; so is making use of sturdy sliced vegetables rather than tender butter or leaf lettuces that will fade in the heat. Grain-based dishes dressed with vinaigrette like this couscous salador this gluten-free quinoa salad are tasty options less prone to spoilage.

The “spoilage” date for claims—per timely filing standards—varies by payer, so be sure that you and your staff know what the rules are, and where your claims are in each timeline. Helpful ways to keep track:

• Configure your at-a-glance dashboard to include a snapshot of the age of your claims in active inventory
• Employ aging as a factor in your claim intervention prioritization by sorting workflow queues on the pertinent date (e.g. date of service)

Avoid Throwaways

Relying on disposable goods like paper plates for outdoor eating means unnecessarily disposing of cash as well as having more trash to deal with. Keeping a set of break-resistant plates, cutlery, and glasses in your picnic stash so they’re always ready when you are eliminates both problems.

Paper means extra expense in PFS, as well. Reduce your reliance on paper and realize time and cost savings with these tips:

• Confirm that every payer able to receive claims electronically is configured as an electronic payer in your clearinghouse software payer table to avoid unnecessary paper submissions
• Make use of electronic claim attachments to cut down further on hardcopy claims
• Capitalize on your clearinghouse software’s ability to bring payer-rejected and denied claims back into your workflow electronically to eliminate working from paper reports or worklists
• Employ a system for converting paper remittances to electronic 835s

Think “Double-duty”

Planning for double-duty service from the items you take cuts down on the load you need to haul. Cloth napkins and tea towels (for place mats) make for a festive picnic and are useful for padding while packing. A resealable bag filled with ice cubes serves as a cold pack as you travel with food, then the cubes may be used in the beverages you serve.

Thinking double-duty in your business office is a necessity to reduce your cost to collect. Make the most of your investment by taking advantage of everything your systems have to offer, for example:

• Have comment records generated from your clearinghouse software to post claim modification tracking and status tracking back to your host system
• Configure a remits-for-posting folder with scripting to take ERA from your clearinghouse system for automated posting to your host system
• Allow your clearinghouse software to generate secondary and tertiary claims while processing remittance files, in order to automatically apply all primary payer remittance data required for coordination of benefits (COB)

Regardless of the similarities, of course, it probably seems a stretch to consider PFS a picnic. The challenges are real. Fortunately, so are the improvements that can be realized with these and other best practices for operational efficiency. Find out how Quadax can help—contact us today to request a consultation!

Are you frustrated with billing bottlenecks, your current vendor’s lack of flexibility and limited understanding of your needs? Tired of waiting in a queue? Dreaming about what it would be like to experience personalized client service? It might be time for a change.

Does that realization take you from frustration to fear? It’s true: the thought of implementing a new claims clearinghouse can be overwhelming. How could a new vendor understand our billing cycle’s unique complexities? How could we manage to upload all of our claim files to a new system without slowing down our billing cycle? Even if they manage to set it up, how could a new vendor maintain a high level of on-going personal service? These are just a few of the anxieties that often arise before healthcare providers successfully transition to a new vendor.

Whether you are a new provider deciding on a vendor for the first time, or switching vendors after years of service, implementing a new claims clearinghouse is a significant undertaking that requires an investment of time, money and resources, not to mention a tremendous amount of internal and external collaboration. The best way to conquer your claims clearinghouse change anxiety is to control your implementation and make your expectations known upfront.

When considering a vendor’s implementation strategy, make sure it includes these three vital steps: facilitate, automate, and educate.

• FACILITATE the transition with parallel testing.
  Parallel testing allows your organization to transition to a new vendor system seamlessly without disrupting your billing cycle. Loading duplicates of your outgoing claims into a parallel testing environment, your new vendor can ensure the proper data is present and in the correct format/location. It will also verify that the necessary payer edits are in place and identify any discrepancies between your previous system’s process and the new one. Furthermore, a good vendor maintains a robust network of payer connections to preserve your current streams of revenue and allow for development of new ones.
• AUTOMATE the electronic submission of COB claims.
  One of the most complicated processes in claims management is the COB (secondary/tertiary) claims process. It is not surprising that COB can be difficult to implement. To fully maximize your organization’s efficiency, your new claims clearinghouse needs to minimize the amount of time your staff spends dealing with COB claims. To do that, you need a vendor that can implement three critical facets of COB claim management: 1) automatic or manual creation of electronic COB claims, 2) training for your personnel on management of those claims, and 3) submission of automated electronic COB claims immediately after going live.
• EDUCATE personnel to understand and create custom edit logic.
  Given the complexity of the medical billing cycle, it’s expected that a vendor will create, track, and manage customized edits for the unique needs of your practice or facility. However, the reality is that most practices require more than just what is deemed standard. You should expect a vendor to not only provide you with tools that allow you to write your own customized logic, but also train your personnel to do so.

A claim clearinghouse that offers all five of these benefits will deliver the ultimate benefit you need: increased cash flow with decreased expense. Learn more about our Claims Management Solutions.

Ideally, claim follow-up should only be performed by your staff when taking action defends the reimbursement you deserve. Any action taken that does not directly improve your reimbursement or cash flow, erodes your profit margin by increasing costs without increasing revenue. One way to control follow-up costs is to use advance claim status to identify when claim follow-up makes “cents.”

The key is to know which claims would best benefit from follow-up.
It all begins with knowing where your claims are in your payers’ review process – assuming your claims made it to the payers’ review process.

Looking at the key stages of the payer’s review process, let’s identify when follow-up makes “cents” and when it doesn’t.

• When the claim status is in-process, no follow-up action is recommended. The payer has not yet made a decision on the claim. At this time, it may be more cost-effective to wait. After a certain amount of time has elapsed, a second claim status inquiry can be made.
• When the claim status is to-be-paid, no follow-up action is required. The payer has made a decision to pay the claim and a payment will be received. Any action taken by staff adds cost to confirmed reimbursement. Gaining insight that a claim is to-be-paid at the time of the payer’s internal decision (which may be much sooner than upon receipt of remittance advice), can help your staff avoid unnecessary follow-up.
• When the claim (or line item) is denied, rejected, or pending, it is important the right follow-up action be performed in a timely, efficient manner. To identify the best course of action, it is critical to fully understand why the claim (or line item) has not been paid. Follow-up staff can target next steps and avoid the cost of trial-and-error issue management.

So how do you obtain claim status information? Labor intensive options include calling the payer or accessing the payer portal. Both options are high-cost, low-volume solutions that require manual processing. It is more cost effective to obtain your claim status responses electronically. According to a 2016 study by the CAQH Index,® switching to an electronic process for claim status inquiry can save up to $7.94 on the cost per transaction over manual processing representing an 81% savings. Though automated ANSI 276/277 claim status inquiries and responses provide some benefit, the problem is that payer ANSI responses tend to lack the more actionable data found in payer portals. It is generally the detailed proprietary payer codes and comments found in payer portals that offer the best source of information.

Here’s where Advanced Claim Status (ACS) by Quadax can help. Electronically scraping status information directly from payer portals using web-bot technology, ACS replaces or supplements standard ANSI 276/277 transactions to provide richer, more actionable information. Reporting claim status and denials as soon as one-day post billing, ACS provides electronic access to payer proprietary remark codes and descriptions allowing you to understand why a claim is pending or rejected and to know it sooner. Using more comprehensive information to enable “workflow by exception” processes, ACS avoids the cost of unnecessary follow-up and frees your staff to pursue follow-up on the claims that would best benefit from further intervention.

When managed cost-effectively, and fueled with the right information, your claims follow-up strategy can help maximize your reimbursement and improve your revenue results. For follow-up made easy, learn more about our Advanced Claim Status (ACS) solution.