Category: Industry News

Stay current on the latest industry news, best practices, and regulatory changes in revenue cycle management. Gain the knowledge you need to make informed decisions and drive successful outcomes for your healthcare organization.

Achieve Up to 23% Cleaner Claims With Your Epic Integration

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The selection of an Electronic Health Record (EHR) solution for your practice, clinic, hospital, or health system is one of the most important decisions a healthcare provider can make. The impact on how you provide clinical care is paramount; equally important is how an EHR enables the financial health of your organization. While EHR vendors assert their abilities to help you submit clean claims directly to payers, providers remain responsible to understand, maintain, and apply the necessary payer information to process claims correctly. Recognizing the complexities of healthcare payer billing, EHR vendors such as Epic have taken steps to allow direct integration with only select healthcare claims clearinghouses such as Xpeditor™ by Quadax. If you are an Epic Resolute customer, you have options.

Most Epic customers make a significant investment in developing workflows within Resolute to handle claim processing, claim follow-up, and denial management functions—Resolute’s Accelerated Claim Reconciliation (ACRD) module enables this functionality by providing third party systems the ability to influence the workflow’s running in Epic. To fully maximize this benefit, Resolute customers will want to consider engaging the expert, Epic selected clearinghouse Xpeditor™ for the creation and maintenance of payer rules—from Medical Necessity (LCD/NCD), Medically Unlikely Edits (MUE), Correct Coding Initiative (CCI), and Outpatient Code Editor (OCE) to the thousands upon thousands of government and commercial payer-specific rules. Attempting to manage this task in-house can be difficult and the risks are high should there be issues.

Maximizing your Epic investment without compromising your claim efficiency is the reason Epic customers choose Quadax and our Xpeditor™ Host Interface Module (HIM). Xpeditor HIM provides seamless, real-time integration with Epic Resolute’s Accelerated Claim Reconciliation (ACRD) and Claim Reconciliation (CRD) modules. Claims that require intervention are processed with immediate feedback to Resolute to expedite correction efforts using Xpeditor’s industry leading claim editing rules. Clean claims are processed by the Quadax clearinghouse for payer submission with all communications fed into Resolute for a complete audit trail that includes payer acknowledgments, acceptance, or rejections through final adjudication.

When taking the “pulse” of your Epic integration, be aware of the following vitals and make the choice that best enables the financial health of your organization.

  • The average Epic facility using HIM by Quadax improved their Clean Claim Rate by 23%.*
  • Xpeditor’s claim editing rules result in an industry-leading first pass rate of 99.6% through millions of claim edits covering LCD/NCD policies, MUE, CCI, OCE, RAC audit guidelines, and thousands of individual payer rules.
  • HIM clients achieve an average Clean Claim Rate of 95%.*
  • HIM clients enjoy superior control with XpressBiller, which allows for automated error correction, custom error repair, error suppression, and other powerful claim automation features.
  • Having difficulty resolving an error in Epic Resolute? HIM clients gain the Xpeditor advantage for the ultimate fallback in claim editing capabilities to ensure claims go out clean on the first pass.

Learn more about how Quadax can help you make the most of your Epic investment, download Xpeditor’s HIM information sheet. Creating connections, providing intelligence, and equipping providers, revenue cycle optimization solutions by Quadax.

(*) Source: A recent Quadax study, Decision Support: Errors and Analysis, performed 1Q 2016 sampling 180+ facilities.

Epic and Epic Resolute are trademarks or registered trademarks of Epic Systems Corporation in the United States and/or in other countries.

Implications of Narrow Healthcare Networks on Laboratory Providers

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In less than three short years (2014-2017), narrow and ultra-narrow networks have increased from 48% to 53% of all networks. With their majority influence, these networks are reshaping the healthcare industry. To survive, labs of all kinds will need to understand the implications of narrow healthcare networks on their ability to access patients and collect reimbursement.

To begin, it is important for laboratory managers and pathologists to understand the reasons behind insurers’ creation of narrow networks and their perceived value by consumers and employers.

How do plans with limited networks provide cost savings for health insurers and health consumers?

The goal is to deliver increased patient volume (and revenue) to the provider in return for lower costs to the insurer (and ultimately the patient) achieved through reduced rates. Insurers limit the number of doctors, hospitals, and other providers a patient can visit in order to negotiate a lower cost for services with networked providers in return for a higher volume of patients. Insurers also promote to consumers that narrow networks allow insurers to influence the delivery of coordinated healthcare by offering targeted in-network solutions to help physicians and providers give patients more personalized care.

Looking for value, consumers prefer health plans with lower premiums over higher-priced health plans that offer access to more providers—22% and 19% respectively. Similarly, employers prefer the benefit of lower health plan premiums with 56% of employers considering narrow networks as a way to reduce medical costs. The level of savings could be a very good deal for consumers and employers, but whether these health plans can deliver value depends on whether or not the insurer’s selected network can provide adequate care.

With limited accessibility and availability, can narrow networks provide adequate care?

While narrow network plans might save money for insurers, consumers, and employers, they could make it harder for patients to get the care they need, where and when they need it. The plans may not include enough nearby providers and the providers they do include may be too busy to take new patients in a timely fashion. This could be problematic if a patient is unable to obtain the timely healthcare they need within their network. It can be further compounded if the plan provides limited or no out-of-network benefits.

Network Adequacy Standards

Federal and state regulations qualitatively state that networks should provide for reasonable access, without unreasonable travel or delay. Regulation of health plan provider networks often includes quantitative standards that may review the number of providers, provider-to-enrollee ratios, the mix of provider types, and the distribution/location of providers from whom enrollees may reasonably be expected to obtain services. Encouraging network transparency, regulation may also require that provider directories are updated at least once each month. The key to any successful regulation is compliance and enforcement. Without means to measure and enforce Network Adequacy Standards proactively, federal and state regulators are limited to respond after-the-fact to patient complaints regarding network compliance.

Implications laboratory providers may want to consider

Whether your laboratory pursues an in-network or out-of-network strategy, it is important to consider the effect narrow provider networks will have on your lab’s ability to access patients and collect reimbursement.

  • If your lab is seeking to be an in-network provider in a limited network plan, it may be helpful to learn about the network’s size, mix, and distribution/location as well as any governing Network Adequacy Standards that may be in effect. This information can help you communicate how your lab will fit within and add value to the network’s model. Also, be prepared to discuss price. It may be helpful to approach the topic of price from a value-based perspective. Payers will be interested to learn how your lab testing services can contribute to improve patient outcomes and reduce the cost per episode of care. You may want to demonstrate your lab’s value by sharing relevant statistics. For additional network negotiation strategies, reference Developing Clinical Laboratory Strategies to Gain Network Access.
  • If your lab remains an out-of-network provider, your lab will need to balance offering a low price through the narrow health network with preparing for patients to be responsible for paying the entire cost of the test. Be aware that out-of-network providers face new constraints on their ability to balance bill members of government-funded and commercial plans, while commercial payers are continuing to sue out-of-network providers to stop improper referrals and cost-sharing waivers.

Regardless of your network strategy, it is important to know the implications of narrow healthcare networks on your lab’s business model and to have available your lab’s performance statistics so you can negotiate value and drive efficiency and cost containment measures. Learn how Quadax can help; visit Reveal Opportunities. Analyze Impact. Deliver Results.