Hosted Claims Manager: Your Cure to Rejections, Denials & ICD-10Teri Cipriano, CPC, Hosted Claims Manager Support and Implementation Analyst

Debra Mitchell, RN, BSN, MBA, Children’s Orthopaedic and Scoliosis Surgery Associates. LLP

April, 2015

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AGENDA

• What is Hosted Claims Manager?

• Review features of Hosted Claims Manager

• Demo

• Examples of how Hosted Claims Manager can help

• Debi Mitchell – Children’s Orthopaedic and Scoliosis Surgery Associates, LLP

• Reports

• Summary

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PREVENT

Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series (2009)

The best way to REDUCE clinical rejections and denials is to PREVENTthem before they occur!

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Hosted Claims Manager

One of the best ways to reduce rejections & denials is to prevent them before they occur!

Hosted Claims Manager is a pre-claim, clinical editing solution and proactive claim analysis service that identifies and resolves posting errors that would later result in a rejection or a denial.

• Reduce clinical rejections and denials before they negatively impact financial performance

• Reduce costs associated with addressing rejected or denial claims

• Support regulatory compliance by evaluating claims against specified coding rules while detecting Medicare Correct Coding Initiative edits

• Support regulatory compliance by comparing claims to local payer coding regulations and guidelines

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Hosted Claims Manager

Features

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Optum™ Proven, industry-leading clinical editing engine (with state specific LMRP/LCD/NCD)

Includes between 60-90 system edits

Near Real time response: Centricity™ Practice Solution & Centricity BusinessClinical edits are integrated into the approval process

Advanced EDI Management: Centricity Group ManagementQueues and workflow designed for ClaimsManager edits

Payer editsEdits can be created specific to your local payers guidelinesEdits can be turned off/tweaked if not needed

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ICD-10 compatible

• Scrubbing will take place on ICD-9 and ICD-10 dx codes

• For instance the DCM edit will compare ICD-10 to ICD-9 diagnosis codes for historical editing. This edit is issued whenever the current line is an ICD-10 and in the history is an ICD-9 and when the current line is an ICD-9 and in the history is an ICD-10.

• Another is IMD edit is used to identify diagnosis code and modifier combinations that are not appropriate. Laterality is part of specific ICD-10 diagnosis codes and because of this conflicting laterality modifiers should not be submitted on the same line.

PQRS

• Scrubbing will take place on measures YOU bill for

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Why you need Hosted Claims Manager

Reduce Clinical Rejections and DenialsWith the Hosted Claims Manager edits occurring prior to claim submission,

allows for clean claims

Decrease AR daysHelp make efficient and optimize revenue cycle

Arm yourself with tools to code correctlyPayers have specific coding expectations Hosted Claims Manager can help ensure

those arebilled correctly

Aid in coding changesNew codes, deleted codes, required new modifiers, etc.

ICD-10!

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Clinical edits...What are they?

DLPIdentifies items entered on one or more claims that have identical Dates of Services, Procedures , Modifiers, Departments, and Providers (including previous claim history)

NPT Identifies where a new patient E&M was billed and the patient has been seen within 3 years by the same organization and specialty

GFPIdentifies an E&M that was billed during the global follow up period of an earlier procedure, has the same primary dx and was performed by the same provider

IDX Identifies claim lines that contain a diagnosis code missing required digits for appropriate specificity

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Clinical edits...What are they?

LBI Identifies that no diagnosis on the claim line supports medical necessity for the procedure billed (as specified by Local Medicare Guidelines)

MOD Identifies a line item that contains a modifier that is not permitted for use with a particular procedure code

MFD Identifies situations where you have exceeded the maximum allowed frequency for a given procedure within a given date range

NPD Identifies a line item that contains a diagnosis code that is not appropriate for use as a primary diagnosis code

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Think about it……

Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series (2009)

$25

Average cost per

claim for rework*

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Hosted Claims Manager

Live Demo

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Hosted Claims Manager: Centricity Practice Solution

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Hosted Claims Manager: Centricity Group Management

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Hosted Claims Manager: Centricity Business

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Hosted Claims Manager

Edit Examples

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Hosted Claims Manager Edit Examples

THERAPY FUNCTIONAL DATA REPORTINGThe goal and the initial level or impairment should be noted in the patients' plan of care. A functional G code needs to be billed with the evaluative procedure.

DUPLICATES, REWORK AND UNDERPAYMENTSClient was getting a large volume of duplicate denials. After researching they found they were billing some procedures codes on two separate claim lines with 1 unit each. They should have billed with one claim line using multiple units. One line on their claim paid and one line denied as a duplicate – in essence underpaying them. The Hosted Claims Manager team built an edit to catch when this would happen and allow the client to bill appropriately.

96372 AND J CODE UNITS MUST MATCHHelping to recover over $20K dollars for a client in an 18 month period.

STOP ALL DMAP TICKETSHigh dollar tickets for client need to be stopped to ensure they are billed correctly first time. In 1 month, this hits around 150 times for them.

STOP CLIA LABS NEEDING QW MODIFIERWhen billing associated labs, need to ensure the QW modifier is billed or will deny.

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Debi Mitchell, RN, BSN, MBA

Children’s Orthopaedic and ScoliosisSurgery Associates. LLP

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The content of this presentation represents the views of the author and presenters.

GE, the GE Monogram, Centricity and Imagination at Work are trademarks of General Electric Company.

www.CHORTHO.com

Located in Tampa Bay Florida

Orthopaedic division atAll Children's Hospital John Hopkins Medicine

COSSA’s Days in Account Receivable (DAR)

• In 2002 (Before Centricity Practice Solution)

– Days in AR was 35.86

• In 2003 Installed Centricity Practice Solution

• In 2006 – sending paper claims

– Days in AR was 20.93

• In 2008 started Centricity EDI Services

• 2010 Days in AR was 18.2

• In 2011 installed Hosted Claims Manager

– Days in AR 16.2

• 2014 Days in AR was 13.85

2002 2006 2008 2012 20140

5

10

15

20

25

30

35

40 DAR

DAR

Days In Account Receivables

MGMA Method • Rolling 12 months

• Days in AR = Total AR/Average Daily Billing

• Average daily billing = Gross charges for year/365

MGMA best practice Benchmark in 2011

37.11 days

12/31/2011

Total AR $948,072.27

Gross Billings past month $21,199,575.86

  

Days in AR 16.36

How to calculate DAR?

12/31/2014

Total AR $948,072.27

Gross Billings past year $24,984,914.96

  

Days in AR 13.85

12/31/2006

Total AR $960,106.37

Gross Billings past year $8,257,105.92

   

Days in AR 20.93

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Children’s Orthopaedic and Scoliosis Surgery Associates, LLP

2011• 4 Physicians• Total Charges $20,719,654.

• Billing A/R Staff• 4

2014• 5 Physicians• Total charges $24,984,914.96

• 20.58% higher• Billing Staff

• 4

Over 4 years we have seen an increase in 20.58% more chargesA decrease of DAR by 2.51 days And doing this maintaining the same staff levels

What’s next? 2015 – 6 PhysiciansICD -10

270/271Verification & Benefits

837 Claims

Hosted Claims

835ERA (EOB)EFT (Direct Deposit)Denial Management

E-StatementsReturn Mail Manager

Electronic Revenue Cycle Management

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Revenue cycle

Visit documentation/ coding

A clean claim decreases your collection cycle

Removes the most costly parts

Payment posted

Charge entry, Claim scrubbing

Claim submission

837

Secondary Insurance billed (if

applicable)

ERA/EFT/835, Patient

payment

Registration/ insurance

verification

Payment posted

Patient statement

System is based off rules

Easy to request rules!• Requesting a New Rule or Modification to exiting Rule request sheet

Example x-ray codes – new rule all plans • 73520 is used for patients over the age of 12

• 73540 is used for 0-12

Example new rule for an insurance carrier (ID 846) • We agreed not to bill established EM codes (99211 – 99214) with code

29450 with the DX code of 754.51 for a certain insurance carrier 

• To which CPT Code(s) or range of Codes does this rule apply? 29450 and 99211-99214

Request new rule

Hosted Claims Manager makes it easy to request edits • We filled out a form and saved it on the

shared file server

• Request by carrier or group

• By CPT codes

• By Diagnosis

• Define what the flag will say

Example of a request

Is this a new rule (Set Flag)? Yes

What do you want the flag message to tell the user when this rule fires? In current global period need to attach modifier 58

What denial are you trying to prevent? Included in the global package of the initial procedure

Is this a change to an existing rule? No

Please provide a short description of the general purpose of this rule:

Procedures having a 0, 10 or 90 day global value that are performed during the postoperative period of another procedure having a 10 or 90 day global value are considered included in the global package of the initial procedure unless an appropriate modifier is appended (58).

Medicare and commercial insurance companies are following this guideline under their “reimbursement policies” a cast application falls under the “0” day global value when the patient is under a global for a code a modifier 58 need to attached to the cast application code.

CPT in Global Visit

Here is an example of a flag.

We know we can not bill a casting code without a 58 modifier when we are under a global code

In 2014 this edit was hit 338 times!

Old codes

• The system will give edits if you have made the CPT code inactive

• Hosted Claims Manager will alert you if code is inactive and you have not made the code inactive

Rule communicated on note tab inside the ticket

Missing higher charges?

• Over time you will be able to use Hosted Claims Manager to help you code new visits instead of establish visit codes!

• This edit hit 149 times in 2014!

• Hosted Claims Manager needs the history before this edit will work.

New Patient vs. Established

Primary Diagnosis matters

• Hosted Claims Manager will tell you if the Dx code is inappropriate or missing, or doesn't matc

• Hosted Claims Manager hit this edit 145 times in 2014 allowing us to correct prior to batching

Missing revenue

• Missing a supply code

• This hit 682 times in 2014!

• This means increased revenue!

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Hosted Claims Manager

• This is one of the best products GE offers (in my opinion)

• Sending in a clean claim is vital to a our success

• Having the ability to have custom edit rules will make you successful

• Allows your collection staff to work on the claims and appeals they need to do

• Not fixing coding mistakes.

• ICD-10 is the next road and we are happy that Hosted Claims Manager will be there with us

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Hosted Claims Manager

Reports

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Hosted Claims Manager Reports

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Hosted Claims Manager reports

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Success Reports

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Summary

Do you know your overall rejection and denial rate by payer?

Do you know the percentage that are “clinical”?

Do you know the magnitude of the cash-flow impact?

Do you have an improvement process in place to reduce defects?

Questions?

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