Category: Resource Center

This guide aims to explain the ins and outs of the Medicare claims process and outlines the necessary tools to make your life easier and help maximize your reimbursement.

The foundation of the revenue cycle management process is patient access. Having a solution in place on the front-end can substantially minimize denials and rework on the back-end of the RCM process.

Patient satisfaction is an important goal for providers for reasons going way beyond a desire to be kind humans.  It’s the first part of the Institute for Healthcare Improvement Triple Aim.[i]  Better patient satisfaction has been associated with better medical outcomes and with reduced readmissions.[ii]  Patient satisfaction scores influence reimbursement, both for the Inpatient Prospective Payment System (IPPS) and value-based care. And, in an era of competition for patients from non-traditional healthcare outlets, ensuring patient satisfaction is an important way to protect patient relationships and future revenue opportunities.

Ways to achieve better patient interaction are not closely-held secrets.  Lists of helpful tips may be found in abundance in collections of 5 or 10 or even 30 top ways to improve patient satisfaction.  Boiled down to the most common theme, though, it’s all about Communication, Communication, Communication. 

The characteristics of good communication– listening patiently and respectfully, making eye contact, answering questions fully, expressing empathy –belong in both the clinical and in the financial environment.

Communicating Patient Financial Responsibility

The Healthcare Financial Management Association (HFMA) published a comprehensive guide to patient financial communications in 2016 which remains a valuable resource on the topic. The guide was developed in partnership with experts including representatives of patients, hospitals, and physicians, advised by national policymakers including Sen. Tom Daschle, Sen. Bill Frist, former Secretary of Health and Human Services Donna Shalala, and others. Its goal is to bring “consistency, clarity, and transparency” to patient financial communications with best practices for Emergency Department (ED), time of service (outside the ED), and advance of service settings.

One best practice identified for all settings is, “Providers should have technology that gives financial representatives up-to-date information about patient balances and financial obligations.”

Patients today are frequently, and understandably, anxious about the debt they may incur for diagnosis and treatment. Twenty-five percent of Americans, according to Gallup, name cost as the most urgent health problem facing the U.S.  Forty-five percent of Americans fear a major health event will leave them bankrupt.

Clear, credible, compassionate communication, then, about a patient’s financial obligation is essential to caring for patients in a way that will foster satisfaction and result in better outcomes.

Fortunately, the technology to give patient access or financial representatives up-to-date estimates of a patient’s out-of-pocket responsibility is available and easy to use.

In the Quadax Patient Access Management suite, the Out-of-Pocket Estimation tool is a contracts-based estimation engine able to produce an individual professional or technical estimate or a combined estimate. The engine analyzes the provider’s negotiated contractual stipulations, chargemaster, historical procedural information, and patient-specific, year-to-date benefit data to arrive at the best estimate of a patient’s financial responsibility possible prior to the current procedure.  Auto-add technology includes related procedure codes—additional procedures found to generally be done in conjunction with the primary procedure—for a more realistic estimate to eliminate surprises down the line.

Patient Access representatives using the Quadax Out-of-Pocket Estimation tool are guided through the process of generating the estimate and talking with the patient about the document. Through this open communication, a patient is better equipped to make care decisions and financial plans, and is more likely to express satisfaction about the financial communication experience with their healthcare provider.

Are you ready to learn more about the role an easy-to-use Out-of-Pocket Estimation tool can play in your mission to provide care to your patient population? Click here to request a no-obligation consultation.

Fostering high patient satisfaction is one way of thriving in an environment of increased competition for patient-consumers.   A recent Definitive Healthcare survey of important trends identified consumerism as the second most important topic causing apprehension for healthcare providers.  If the rise of consumerism in healthcare today has you concerned about the implications for your practice and for your patients, request our latest White Paper, Healthcare Consumerism & Your Revenue Cycle: Flip the narrative and build loyalty through patient-centric tools and processes. Request your complimentary copy here.

[i] http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx

[ii] Jacob Imber, MD, “Lower rates of patient satisfaction may predict readmission,” The Hospitalist, May 23, 2019, https://www.the-hospitalist.org/hospitalist/article/201061/mixed-topics

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The kicker is—most medical necessity denials are preventable.

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

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

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

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

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

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

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

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