Transcription
CEDI:Hosted Claims Manager and Denials IQ1
Centricty EDI Services
Today’s PresenterClaire WrightEDI Business DevelopmentClaire Wright joined IDX/GE back in 2005 as anEDI Support Engineer. After several years, shetransitioned to a Centricity Practice SolutionEDI Migration Project Manager where sheworked very closely with new EDI customersand was a key point of contact for EDI productdemonstrations. After many years as aProject Manager, Claire joined the EDIBusiness Development team in 2014 in orderto continue her commitment to helping newcustomers grow their business. She works outof the Burlington VT office – home of the EDIData Center.
Product Overview:Hosted Claim Manager
Product Overview:Denials IQPowerful algorithm analyzes claims data weeklyto provide dashboards that reveal denial trendsby code, payor, physician, location and anumber of other categories, allowing the clinic torework denials in bulk and set rules via HCM toprevent these denials in the future.
Centricity EDI ServicesHosted Claims Manager and DenialsIQ Imagination at work.
2016 General Electric CompanyThis does not constitute a representation or warranty or documentation regarding theproduct or service featured. All illustrations are provided as fictional examples only. Yourproduct features and configuration may be different than those shown. Information containedherein is proprietary to GE. No part of this publication may be reproduced for any purposewithout written permission of GE.DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCTDIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTEA COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITYREMAIN AT GE’S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLEREGULATORY CLEARANCE.* GE, the GE Monogram, Centricity and imagination at work are trademarks of GeneralElectric Company.General Electric Company, by and through its GE Healthcare division.
Agenda Hosted Claims Manager Benefits Workflow- where does it fit in Demo Reports Case StudyDenialsIQ Intro to DenialsIQ Dashboards Pattern Strengths Pattern Details
Hosted Claims ManagerBenefits
PREVENTThe best way to REDUCE clinicalrejections and denials is toPREVENTthem before they occur!Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series (2009)12
Hosted Claims Manager OverviewProven Proven, industry-leading clinical editing engine (includingLMRP/LCD) Includes over 4,000,000 pre-built rule combinationsScrubReal time response Clinical edits are integrated into the approval processCorrectContinuous improvement support model Regularly scheduled rejection and denial reviews are a key partof servicePayer edits Edits can be created specific to your local payers guidelines Medicare LCD/NCD edits automatically updated bi-weekly for you Edits can be turned off if not neededSubmit
Hosted Claims Manager: FeaturesClaim criteriaHCFA – 1500, Primary insurance, paper & electronicClaim ScrubbingCompares lines on the claimPatient history scrubbing – current claim lines along with historyPQRSScrubbing will take place on measures you bill forICD-10 compatibleScrubbing will take place on ICD-9 and ICD-10 codes
Demo
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Clinical edits.What are they?DLPIdentifies items entered on one or more claims that have identical Dates of Services,Departments, and Providers (including previous claim history)Procedures , Modifiers,NPTIdentifies where a new patient E&M was billed and the patient has been seen within 3 years by the sameorganization and specialtyGFPIdentifies an E&M that was billed during the global follow up period of an earlier procedure, has the same primary dxand was performed by the same providerNPDIdentifies a line item that contains a diagnosis code that is not appropriate for use as a primary diagnosis codeLBIIdentifies that no diagnosis on the claim line supports medical necessity for the procedure billed (as specified byLocal Medicare Guidelines)MODIdentifies a line item that contains a modifier that is not permitted for use with a particular procedure codeMFDIdentifies situations where you have exceeded the maximum allowed frequency for a given procedure within a givendate rangeINJPrompts you to add additional procedure code for if appropriate
Hosted Claims ManagerDashboard Reports
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Case Study
www.CHORTHO.comLocated inTampa Bay FloridaOrthopaedic division atAll Children's HospitalJohn Hopkins Medicine
Results with Hosted ClaimsManagerA customizable pre-claim clinical editing and proactiveclaim analysis solution: Helps increase revenue cycle efficiencies Help improve claims accuracy Assists with regulatory complianceOutcomes1: Decreased claims rework by over 50% Reduced or eliminated clinical denials Helped speed payments by up to 22%1. Representative results realized by Children’s Orthopaedic and Scoliosis Surgery Associates, St.Petersburg, FL.Reduce rejectionsbefore they occur
DenialsIQOverviewTitle or Job Number XX Month 201XSee tutorial regardingconfidentiality disclosures.33
2%Denials write-offsequaled of net patientrevenueRe-working claimscost per claim 15-25An Advisory Board revenue cycle benchmark study reported that in 2013 76% of hospitals’, (in the report) denials write-offs to bad debt, equaled 2% of net patientrevenue.
How are denials impacting yourperformance?A2,000 denied claims 50,000 4m NPR 80kNPR Net Patient RevenueRe-work cost 25 per claim34,000 denied claims 850,000 45m NPR 900k
DenialsIQ surfaces unseen patterns to helpcapture missed opportunitiesImprove RevenueOur challenge was that the trends wewere working took too long to defineand usually didn’t pay off, even if wefixed them.Jose RiveraCorporate Director, Physician &Professional ServicesOrlando HealthReduce CostAdvanced statisticalalgorithms from GE GlobalResearch identify patterns by rootcause factorsRefined by customersUsing FastWorks methodologywith four customer partners andbuilt on Predix platformGE’s revenue cycleexperienceServing customer for over 40years, to help improve financialperformanceCost of rework – MGMA. Denials - The Advisory Board “Driving the Denials Management Initiative A Renewed Focus”36
DenialsIQ identifies denials patterns through root cause factors and prioritizesbased on value, providing powerful insights that drive action, without researchTraditional denial resolution approachWith InsightsDenialsIQ Dynamic VisualizationDenial Factors AlgorithmA “pile” of denials, each with a reason 300 denials x 1Trends queried based on experience, intuitionDenied Charges “The stuff we don’t knowabout.”Invoice CountLevel of unexpectednessPatterns are identified automatically, can be resolved as a unit andcommon themes provide context without researchWhere are my most costly and unexpected denials patterns? How do I fix them more effectively?37
Improving performance with insights thattranslates into resultsDynamic visualizationshelp prioritizeopportunities, to workdenials more quickly.Defines pattern details androot cause, to preventfuture occurrences.Advanced dashboardsfilter, monitor and reportperformance over time
DenialsIQ specifications and FAQ’sLeverages Centricity EDI dataHosted by GE HealthcareNo installation costData loads weeklyResults for last week, last month, andcurrent month to date Requires Centricity EDI clearinghouse 39
Dynamic visualizations display patternsColor indicates the rate of thedenials, i.e. red equalsdenials that are occurringmore frequently than otherdenials within the timeframePattern #717 denials within pattern 167k in denied charges# of factors contributing to apattern; the commonreasons within the denialpattern; i.e. location,insurance, reason codeTool tips display the specificcircumstances of the denialpattern; i.e. ShelburneOffice, UHC, PR 27
Dynamic visualizations display patternsAlgorithm results indicatelevel of pattern“unexpectedness”Pattern #717 denials within pattern 167k in denied charges# of factors contributing to apattern#717/ 167k
DenialsIQ Demo
Summary
Think about it 25Average cost perclaim for rework44Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series(2009)
DenialsIQ and Hosted Claims ManagerHosted Claims Manager is an ideal complementary solution to DenialsIQ, our advanced analyticssolution that uncovers unseen trends based on your claim denials.Uncover coding patterns/denials in DenialsIQ then look to what can be resolved with Hosted ClaimsManager to prevent future denials and rework; thus creating a closed loop solution.45
Pricing Overview:Bundle #2:Bundle #1:Hosted ClaimsManager andDenials IQ43 %SavingsCEDI Claims,Remit,EligibilityBundle #3:Full CEDIProgram26 %Savings13 %Savings
Resources GE CEDI Information including case studies and brochuresFor product questions andinformation:jasonp@healthcosystems.com For pricing details andquestions about yourcurrent EDI tools:lindah@healthcosystems.com
EDI Support Engineer. After several years, she transitioned to a Centricity Practice Solution EDI Migration Project Manager where she worked very closely with new EDI customers and was a key point of contact for EDI product demonstrations. After many years as a Project Manager, Claire joined the EDI Business Development team in 2014 in order
