Category: Resource Center

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.

This e-book describes the five essential elements of a claim edits library that will positively impact your cash flow.

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 21^st 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!