Industry News Archives

Changing the Course of Revenue Cycle Management in 2019

Posted on December 20, 2018June 29, 2020

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!

Quadax Industry News Bulletin

Posted on December 6, 2018June 29, 2020

Keeping you in the know on the constantly changing world of medical billing and reimbursement, Quadax compiles industry news and articles covering important billing-related topics and issues.

ASC 606: Lessons Learned and What You Need to Know

Posted on November 29, 2018July 1, 2020

This webinar reviews the principles-based guidelines of ASC 606 and highlights the potential impact within the healthcare industry.

Considerations for Private Companies Implementing ASC 606 Revenue Guidance – Part 2

Posted on November 13, 2018June 29, 2020

Part 2: Audit Requirements

To assist private companies in understanding what the auditors will request and review, we have identified some of the relevant auditing standard requirements below.

Management’s implementation plan and documentation

Management’s implementation plan encompasses many activities—scoping, accounting assessment, solutions development, and other activities. Auditors need obtain an understanding of this plan.

From a scoping perspective, management is expected to have a variety of key processes and controls implemented to identify revenue streams, relevant contract components and features and business practices to support their accounting policy conclusions. Auditors need to understand how management selected contracts to validate the contract components and features identified during the initial scoping phase. Auditors will also need to perform testing to validate management’s assessment in order to provide support to the audit opinion.

From an accounting assessment perspective, the auditing standards require the auditor to obtain an understanding of the entity’s accounting policies including the reasons for any changes in these policies. To do so, auditors will be reviewing management’s documentation to determine if the accounting policies comply with ASC 606, and validating that the company’s accounting complies with those policies.

Internal control considerations

The auditing standards require the auditor to obtain an understanding of company’s internal controls relevant to the audit. Further, the auditor must evaluate the design of the controls and determine whether they have been implemented by performing procedures in addition to inquiry of the entity’s personnel. As a result, management must evaluate how any changes due to the implementation of ASC 606 impact its control environment.

Further, the new guidance requires management to either recast prior-period financial statements presented for comparative purposes (full retrospective method) or record a transition adjustment and provide disclosures of significant changes by financial statement line item (modified retrospective method). Management must have controls and processes in place for either method chosen. Auditors must obtain an understanding of those controls and test to substantiate there is not a material misstatement.

Extensive new disclosures

The extensive new disclosures required by ASC 606 may require companies to update systems, processes, and controls used to develop disclosures. It is important to note that those companies that assert they will experience little or no impact to top line revenue due to adopting ASC 606 will likely still expend a significant amount of effort to comply with the extensive new disclosure requirements. The auditors will need to perform testing in order to substantiate the new disclosures and underlying information used to support those disclosures.

Management’s progress

It is important for companies to keep their auditors abreast of implementation issues and progress. The more communication the company and auditors have throughout the implementation process, the less likely it is that surprises will arise.

The following indicators may lead the auditor to conclude that management is behind or failing to execute their implementation plan and, therefore, may necessitate additional work:

- - Inability of management to articulate the details of their implementation plan or make progress toward implementing that plan
  - Lack of a detailed implementation plan and timeline
  - Evidence that key deadlines from the timeline have been missed and that there are neither plans to catch up nor enough time to do so
  - Poor tone at the top, including lack of involvement from those charged with governance

Where do we start?

A comprehensive implementation plan that includes the right people across the right functions is critical to a successful implementation of the new guidance. Companies should consider the following action items as they tackle ASC 606:

- - Train employees across the organization on ASC 606, and allow employees to help identify impacts to their own functional areas (forecasting, employee benefits, tax, sales teams)
  - Develop an overall implementation plan and timeline
  - Evaluate competence across the organization, and consider hiring external service providers to assist with the implementation process, as needed
  - Inventory all contracts with customers and identify key terms and conditions, as well as any deviations from those standard terms
  - For areas of change between existing GAAP and ASC 606, identify cross-functional impacts to the organization (including tax impacts)
  - Make any accounting policy elections and document new policies, as needed
  - Document and implement any internal control changes
  - Identify disclosure gaps that require system updates or changes, and initiate the process to close those gaps

“One of the biggest takeaways we hear from public companies is not to underestimate the amount of time required to complete the implementation of ASC 606. Because the new guidance touches so many areas of the business, the implementation requires extensive coordination across functional areas which, of course, takes time and effort.”

Cullen Walsh, Partner
Grant Thornton Accounting Advisory Services

Want to learn more about how ASC 606 can affect your organization? Join Cullen Walsh, Partner, Accounting Advisory Services at Grant Thornton and Walt Williams, Director of Revenue Optimization and Strategy at Quadax, as they present, “ASC 606 – Lessons Learned and What You Need to Know” on Tuesday, November 27 at 2:00 p.m. EST.

Register For Webinar

For more information on how Grant Thornton can help your company, contact your GT Audit Partner Daryl Buck, Cullen Walsh, Matthew McCleary, Chris Stephenson, or your local GT service provider.

“Grant Thornton” refers to Grant Thornton LLP, the U.S. member firm of Grant Thornton International Ltd (GTIL), and/or refers to the brand under which the GTIL member firms provide audit, tax and advisory services to their clients, as the context requires. GTIL and each of its member firms are separate legal entities and are not a worldwide partnership. GTIL does not provide services to clients. Services are delivered by the member firms in their respective countries. GTIL and its member firms are not agents of, and do not obligate, one another and are not liable for one another’s acts or omissions. In the United States, visit grantthornton.com for details.

Considerations for Private Companies Implementing ASC 606 Revenue Guidance – Part 1

Posted on October 23, 2018June 29, 2020

By: Grant Thornton LLP (Special Guest Post)

As the effective date for the new revenue guidance in ASC 606, Revenue from Contracts with Customers, quickly approaches for many private companies (January 1, 2019 for calendar-year companies), management and audit committee members are faced with many questions.

What lessons have been learned from public companies’ implementation of the new revenue standard?
What will my auditor be looking for?
Where do we start?

This blog addresses these questions and serves as a conversation prompter to help executive management engage with those parties involved in the implementation process.

Remember, implementing the new revenue guidance is not just an accounting exercise. The implementation process is a cross-functional exercise that requires coordination between tax, sales, and information technology (IT), among other functions.

“Even companies that are not expecting a material change in revenue must undergo an exercise to identify gaps between existing accounting and ASC 606, determine if any changes need to be made (including system changes), implement the changes, and document the analysis for the external auditors. This process can be time-consuming and require significant effort.”

Daryl Buck, National Managing Partner
Accounting Advisory Services

What lessons have been learned?

As public companies are in the process of finalizing their ASC606 implementations, we can share some “lessons learned” from observing the implementation process and interviewing those overseeing the implementation process.

Get the right people involved, earlier rather than later

Because of the pervasive effect of the new guidance on an organization, management must identify the right stakeholders to provide input into the implementation process. Not only does a company need to identify the right people within the organization to provide input (sales teams, IT, tax), but a company should not hesitate to engage external professionals where assistance is needed (training, technical accounting expertise, IT changes, etc.). Getting the right team in place from the start is key to a successful implementation.

Do not underestimate the effort required to inventory contracts

One of the first implementation tasks for many companies is to inventory their existing revenue contracts, identify standard terms and conditions, then determine if any contracts deviate from those standard terms. For companies that allow sales teams to deviate from standard contract wording, this process can be time consuming and require extensive communication and coordination.

Allow extra time for key contract terms

The new revenue guidance requires companies to evaluate their existing arrangements against the new five-step revenue model. This analysis may be straightforward for some contracts, but if your contracts include any of the following provisions, plan to spend extra effort and time to address these provisions and document your analysis:

1. Multiple goods or services — Performance obligations are the unit of account for applying the new revenue standard, so determining the appropriate performance obligations in a contract is critical to how a company will recognize revenue. The criteria for identifying performance obligations are new and therefore companies need to take a fresh look at their goods and services and assess them against the new criteria.

2. Variable consideration (meaning any consideration that causes the transaction price to vary) such as retrospective volume discounts, rebates, bonuses, or penalties — The new revenue standard generally requires companies to estimate these amounts for purposes of determining the transaction price and evaluate whether to constrain the amount of estimated variable consideration to ensure that revenue is recognized only to the extent it is probable that a significant reversal in cumulative revenue recognized for the contract will not occur when the uncertainty is resolved.

3. Material rights (for example, a prospective volume discount that is incremental to the range of discounts typically given to a particular class of customer in a geographical area or market) — Under the new model, a company must account for a material right as a separate performance obligation and this may require a complex accounting exercise to allocate a portion of the overall transaction price to the material right performance obligation.

4. Modifications — ASC 606 includes prescriptive new guidance for modifications and this has necessitated some companies to implement system solutions to track and account for these modifications.

5. Contract costs — The new revenue standard introduces guidance for costs incurred from a contract with a customer, which has been codified in ASC 340-40. Companies are required to capitalize certain costs under this new guidance and therefore companies that may have elected to expense certain costs in the past may experience a change under the new guidance.

6. Customized goods — Companies that produce customized goods and have an enforceable right to payment for work completed to date may experience a change in accounting as the new guidance requires the company to recognize revenue as it performs the work, that is, over time (rather than at a point in time).

Do not forget about disclosures

Private companies may be spared from some of the new, extensive disclosure requirements that public companies have to comply with, but private company disclosures will still require significant time and effort. Private companies must disclose disaggregated revenue information, information about performance obligations, and significant judgments in determining the timing of satisfying performance obligations and in estimating variable consideration.

Watch for Part 2 of this blog series addressing audit requirements and considerations on November 13.

Register For Webinar

For more information on how Grant Thornton can help your company, contact your GT Audit Partner Daryl Buck, Cullen Walsh, Matthew McCleary, Chris Stephenson, or your local GT service provider.

Hanging in the Balance: Addressing Surprise Billing Issues

Posted on September 25, 2018October 14, 2021

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!

Three Ways Providers Can Prepare for MBI Impact

Posted on March 12, 2018June 29, 2020

March 12, 2018 By: Quadax

UPDATE: Commencing January 1, 2020, Providers must submit claims to Medicare with the Medicare Beneficiary Identifier (MBI) regardless of the date of service.

Beginning January 1, 2020:

Medicare will reject claims submitted with the old Health Insurance Claim Numbers (HICNs) with several exceptions.*
Medicare will reject all eligibility transactions submitted with HICNs.
Customer service representatives on the phone will not be able to identify patients using the HICN.
Since the MBI has more alpha characters than the HICN, CGS suggests using their tool to convert the MBI into characters to use on the telephone number pad for IVR inquiries before calling. The tool can be located here. Other MACS have a conversion tool, too.
The MBI will not be on the Medicare Summary Advice or 835 if the HICN was submitted on the claim and the claim denies for submitting the claim with the HICN.

If you do not use MBIs on claims on and after January 1, 2020 you will receive:

Electronic claims reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)
Paper claim denial codes: Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”

Railroad Medicare beneficiaries will have the same format of numbers and will not be identifiable by their MBI. The patient cards will have a Railroad Retirement Board logo on them.

Medicare Advantage plans have their own subscriber identification numbers which are not MBIs.

*For more information, see the MLN Matters Article.

Original 10/7/17 post: The transition to Medicare Beneficiary Identifiers (MBIs) will universally impact the world of healthcare. Given the sheer volume—150 million MBIs assigned to 60 million active and 90 million archived beneficiaries—the magnitude and foundational nature of this change could potentially affect when and if providers’ receive payment. Being prepared for the MBI transition is a provider’s best strategy.

Starting April 2018 and running through April 2019, Centers for Medicare & Medicaid Services (CMS) will begin issuing new Medicare cards to beneficiaries. On the new Medicare cards, the current Health Insurance Claim Number (HICN) will be replaced with an MBI—a unique, randomly generated number.

When planning your MBI transition strategy, consider the impacts of rollout, data capture, and random-generation on your billing system, office procedures, and automation logic.

Lengthy MBI Rollout

This is not a flip-the-switch transition. With a year-long rollout, the affected population will present a mix of the old Medicare cards and the new. Your billing system and your patient-facing procedures will need to accommodate both. Once the rollout starts, a patient may have claims active that were submitted with an HICN and other newer claims submitted with the new MBI. Your system will need to track both, during the rollout and after, for the full length of your reimbursement cycle for each claim. When filing appeals, CMS is asking providers to use the beneficiary identifier (MBI or HICN) that was used to submit the original claim.

Capturing MBI

One of the biggest challenges for providers in making this change will be getting the new MBIs. Providers will need to get the information directly from patients. The goal is for each beneficiary to provide their new Medicare card at the first visit after the new card was issued. As a result, the best method for capturing MBI will be during your patient eligibility verification procedures. Patient communication before and during the transition is key.

Start communicating with your Medicare patients now so that they will know what to expect. Train staff so they will be prepared to answer questions about the change, the timeline, and what patients need to do. CMS Medicare Card Messaging Guidelines provide guidance on how to talk with Medicare patients about this change.

Then, beginning April 1, 2018, start reminding Medicare patients to bring their new Medicare card to their appointment. Consider adding this reminder to your appointment notice sent to Medicare patients a few days before their scheduled date of service.

If the patient has forgotten to bring their new Medicare card, CMS has just announced that starting in June 2018 providers will be able to look up a Medicare patient’s new Medicare number through their Medicare Administrative Contractor’s (MAC’s) secure web portal. If you do not have access to your MAC’s portal, CMS is recommending that you sign up now. And starting in October 2018, through the transition period, CMS will return both the HICN and the MBI on every remittance advice when providers submit a claim using a patient’s valid and active HICN.

MBI random-generation Effect on Automation

Being randomly-generated, the new MBI 11-digit character string will not be formatted with built-in intelligence. The old Medicare number (HICN) was formatted so that certain values in certain positions within the HICN character string had meaning. Any process referencing the Medicare number’s character string for values to drive automation, will need new programming logic and/or procedures. The Railroad Retirement Board (RRB) is an example of this. It will not be possible to identify from the MBI if patients are eligible for Medicare because they are railroad retirees. Only through a visual inspection of a patient’s Medicare card and seeing the RRB logo in the upper left corner, and “Railroad Retirement Board” at the bottom, will providers be able to identify and manually capture this information. Consider how this will impact your data capture strategies. If you are not already doing so, you may want to include the scanning of insurance cards to your patient eligibility verification procedures.

Be Prepared!

MBIs will begin to hit your office and systems April 2018. Make sure you and your vendors are ready by April 1st—no fooling! Visit Quadax RESOURCES to stay informed about future developments on the MBI transition.

Are You Ready for the new Medicare Beneficiary Identifier?

Posted on March 12, 2018June 15, 2020

Latest Update 12/19/19: Commencing January 1, 2020, Providers must submit claims to Medicare with the Medicare Beneficiary Identifier (MBI) regardless of the date of service.

Beginning January 1, 2020:

Medicare will reject claims submitted with the old Health Insurance Claim Numbers (HICNs) with several exceptions.*
Medicare will reject all eligibility transactions submitted with HICNs.
Customer service representatives on the phone will not be able to identify patients using the HICN.
Since the MBI has more alpha characters than the HICN, CGS suggests using their tool to convert the MBI into characters to use on the telephone number pad for IVR inquiries before calling. The tool can be located here.
- Other MACS have a conversion tool, too.
The MBI will not be on the Medicare Summary Advice or 835 if the HICN was submitted on the claim and the claim denies for submitting the claim with the HICN.

If you do not use MBIs on claims on and after January 1, 2020 you will receive:

Electronic claims reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)
Paper claim denial codes: Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”

Railroad Medicare beneficiaries will have the same format of numbers and will not be identifiable by their MBI. The patient cards will have a Railroad Retirement Board logo on them.

Medicare Advantage plans have their own subscriber identification numbers which are not MBIs.

Quadax EDI has updated several existing edits to accommodate the MBI and edit the HICN for the submission date of January 1, 2020 and after.

*For more information, see the MLN Matters Article.

Updated 6/8/2018

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 mandates that the Centers for Medicare & Medicaid Services (CMS) remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. All Medicare accounts will be updated with a new Medicare Beneficiary Identifier (MBI) beginning in April 2018, which will replace the SSN-based Health Insurance Claim Identifier (HICN). From April 1, 2018, through December 31, 2019, a transition period will be in place, during which both the MBI and HICN are accepted for Medicare transactions.

To prepare for this change, Quadax will be updating several elements of our software by April 1, 2018. These updates will ensure that Quadax’s suite of Revenue Cycle Management products can seamlessly make the switch to the new MBI.

This page will be a resource for information on Quadax’s efforts to help our clients with the shift to MBIs.

UPDATES:

The MLN Fact Sheet, “Transition to New Medicare Numbers and Cards” published by CMS October 2017 answers a number of questions about using the new identifier, and gives information about the format for the MBI, which will be 11 alpha-numeric characters.
To assist in communicating the change to patients, CMS created a one minute video to explain when and how patients will receive their new card. Consider playing the New Medicare Cards Are Coming video in your waiting room.
6/18/2018: MBI Lookup Tool Now Available through Your MAC All Medicare Beneficiary Identifier (MBI) lookup tools are ready for use on Medicare Administrative Contractor (MAC) secure portals. If you don’t already have access, sign up for your MAC’s portal to use the tool. Submit four data elements about your patient through the tool, and it will return the MBI if the new Medicare card has already been mailed.
Medicare is mailing new cards in phases by geographic location. For more information about the MBI, read the MLN Matters® Special Edition Article. Medicare is currently mailing new cards to people who:
- Live in Alaska, American Samoa, California, Delaware, District of Columbia, Guam, Hawaii, Maryland, Northern Mariana Islands, Oregon, Pennsylvania, Virginia, and West Virginia
- Get Railroad Retirement Board benefits
- Are newly entitled to Medicare

Quadax Earns KLAS Top Ranking for Claims Management

Posted on January 30, 2018June 29, 2020

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.

OPPS 2018 Revisions: Outpatient 14-Day Rule Changes to Laboratory DOS Policy

Posted on December 14, 2017June 29, 2020

Centers for Medicare and Medicaid Services (CMS) published its final rule with comment period revising the Medicare Hospital Outpatient Prospective Payment System (OPPS) for 2018. Labs that provide services to hospital outpatients may want to review the new OPPS rule changes, particularly the revisions to the laboratory date of service (DOS) policy (see CMS excerpt highlighted below).

The new carve out exceptions to the 14-day rule will allow labs to bill Medicare directly under the Clinical Laboratory Fee Schedule (CLFS) for molecular pathology tests and advanced diagnostic laboratory tests (ADLTs) that are excluded from OPPS packaging rules and ordered less than 14 days after a patient’s outpatient hospital discharge. In these instances, the DOS for the excepted tests would be the date of testing rather than the date of specimen collection. The OPPS 2018 definition of a qualifying ADLT only refers to criterion A, and does not qualify a test as an ADLT using criteria B or C. The new rule goes into effect with January 1, 2018 date of service. This new rule does not change the inpatient 14-day rule.

How the new rule will impact your revenue cycle depends on the type of testing your lab performs for Medicare hospital outpatients. The biggest change is the opportunity for labs who perform testing excluded from the OPPS packaging policy to bill Medicare directly, using the date of testing as the date of service on the claim.

How will this impact your lab’s reimbursement? Hospitals who have been administratively and financially burdened by the outpatient 14-day rule, may be incented to withdraw from institutional billing arrangements in favor of the lab billing Medicare directly. Consider the following.

If your lab test is covered by Medicare, is the allowed amount listed on the Medicare CLFS more or less than your current institutional billing fee schedule? How will your lab address and process Medicare pre-claim requirements such as medical necessity or local coverage determinations? Does your claims clearinghouse check for Medically Unlikely Edits (MUEs)? When exposed to MUEs, will your claims submission process perform the necessary edits to ensure your Medicare claims make it to adjudication?
If your test is not covered by Medicare, or Medicare’s reimbursement is not at an acceptable level, you may want to attempt to retain the current institutional billing arrangement—such an arrangement is not precluded by the new rule. Ensure your billing system can report the appropriate DOS on the institutional invoice for the ADLTs and molecular pathology tests excluded from OPPS packaging policy. As hospitals have historically absorbed the cost of these tests performed for Medicare hospital outpatients, they may be unwilling to retain institutional arrangements except for those qualifying tests that are in high-demand.

How will the outpatient 14-day rule change affect test ordering behavior? Hospitals waiting to place test orders on day fourteen, can now order tests earlier. Will earlier ordering improve test result quality and delivery? Working with viable specimens, producing better results, and providing faster turnaround times?

The OPPS 2018 laboratory DOS policy exceptions open up a whole new world of reimbursement for labs who perform testing excluded from the OPPS packaging policy. As you consider how these changes will impact your lab’s revenue cycle process and reimbursement results, learn how Quadax can help. Experienced in laboratory revenue cycle optimization, we help labs of all types maximize their revenue.

***UPDATE: Commencing January 1, 2020, Providers must submit claims to Medicare with the Medicare Beneficiary Identifier (MBI) regardless of the date of service.***

UPDATE: Commencing January 1, 2020, Providers must submit claims to Medicare with the Medicare Beneficiary Identifier (MBI) regardless of the date of service.