today’s revenue cycle process: helping you sleep better at night

Today’s Revenue Cycle Process:

Helping You Sleep Better at Night

Presentation to

N.W. Ohio HFMAAugust 29, 2012

Jim McCauley, Vice President, EDI Services

Increase Cash Flow….Drive Revenue Cycle Efficiencies….Reduce Bad Debt ….

Xpeditor Xtensions

Do More!

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Xpeditor Xtensions

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Claims ManagementX

Claims ManagementX

• Powerful edit engine– Standard: LCD, NCD, CCI, OCE,

MUE, RAC edits– Custom (client defined): written

by Quadax developers, usually 48-hour turnaround (testing may require additional time)

– Client-written: developed through the XpressBiller utility, an easy-to-use wizard

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Better cash flow!

Faster reimburse-ment

Cleaner

claims

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Claims ManagementX

Comprehensive reporting enables you to manage your claims, not just transmit them

• Every edit available for analysis

Eliminate manual intervention & compilation of data . . . .

Remittance ManagementX

Remittance ManagementX

Remittance Management

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• Full Integration• Full Support• Management Tools• Better Data

(including posting files & comment records)

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Denial ManagementX

Denial ManagementX

Denial ManagementX

• Effective denial management strategy– Identify, Classify, Quantify– Manage Denial Follow-Up– Prevent Denials Through

Process Improvement– Develop Effective

Reporting

Scheduling Service

Providing Service

Coding Service

Billing Service

Collecting Payment

Where do denials come from?

Any and all points in the revenue cycle . . . . . .

DMXBR : Basic Reporting

. . . .

Anything that is delaying payment to your

organization is ripe with data for process

improvement.

Payer Remits

835 Files

Hard Copy Remits

Denial Correspondence

Payer Rejections

277 Files

864 Files

Payer Reject Reports

Pre-Bill Errors

Quadax Batch Errors

Customer-defined Errors

XpressBiller Errors

Approximately 2,100 codes

Approximately 13,000 codes

Approximately 250 ANSI codes

Pre-mapped to standard error/denial categories

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DMXWF: Workflow• Decrease Overall A/R

– Quickly identify both full and partial denials and route them to users with best skill sets to work them

– Provide easy access to key denial source documents for follow-up users

• Decrease Costs to Work Denials– Improve staff efficiency in working denials by setting up default

orders within worklists to group similar types denials

• Increase Visibility of Denial Aging Inventory– Utilize management dashboard reporting to target key denial

inventory issues

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DMX: A Case Study

Note: Payments reflect Charges associated with Paid Claims (not actual payments); Denials Reflect Charges associated with Denied Claims/Lines. Claim Status 22 has been excluded and denials with prior payment have been excluded. Duplicate Example (18/B13/97). FYI – 96 has been included under non-covered service.

8%

29%

18%6%

5%

35%

Denial % By Count

Timely FilingEligibilityMissing Info/DocumentationMultipleBilling ErrorOthers

26%

21%14%

13%

12% 14%

Denial % By Revenue

Timely FilingEligibilityMissing Info/DocumentationMultipleBilling ErrorOthers

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EligibilityX

EligibilityX

EligibilityX

• Verify that an individual has valid Insurance coverage

• Validate demographic information to match spelling, etc. on file with payer

• Determine the level of coverage for service type

• Determine Co-Pay, Deductible, other Insurance, etc.

Tip: Do a batch eligibility check on self-pay to ensure patient was not eligible for Medicaid on date of service

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EligibilityX

– Real Time (any point of entrance)– Automated (specified claims, self-pay,

Medicaid)– Batch (pre-registration, self-pay, collection

accounts)– Back End (rejected, denied)

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EligibilityX

HIS Interface Eligibility

Individual or “Batch” (multiple transactions), in real time

270 from HIS 271 returned to HIS

Outside Xpeditor We have developed the interface for Epic, Meditech, and SMS Allegra (TCP/IP). Development of additional HIS interfaces is expected.

Batch File Eligibility

Batch File Delimited file according to agreed-upon specs

Delimited file according to agreed-upon specs

Outside Xpeditor

Standalone Eligibility – Hosted, for those offices not on the hospital network

Individual, in real time

Manual entry using form on Portal

Xpeditor-style response form

Outside Xpeditor(Separate hosted install accessing only Real-Time screens)

Transactions stored in Real-Time transaction History Database

Real-Time Eligibility

Individual, in real time

Scrape from claim or manual entry using form in Xpeditor

Xpeditor-style response form

History stored in Xpeditor; linked to claim if inquiry scraped from a claim

Rule-Based Eligibility

Automated Generated from Xpeditor; Rule-Based (custom convert required)

Xpeditor-style response form

History stored in Xpeditor; linked to related claims

For example, a rule might dictate that all self-pay claims automatically generate an eligibility inquiry to Medicaid.

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Claim StatusX

Claim StatusX

• There are always exceptions– Do you know what

they are?– Do you know why they

are?

Claim StatusX

Is there a need for an automated solution to help manage and report on these claim delays?

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Claim StatusX

• HIPAA-mandated 276/277 still coming into its own• Perform transactions manually, as needed• Automated Claim Status responses can be exported

to the host system. Either source 277 can be provided or a customized comment file.

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Automated Claim Status Transactions

• Eliminate the need for sifting through reports • Eliminate wasted time on the phone with payers • Eliminate keying into payer web sites • Rely on automated processes to catch every

outstanding (unpaid) claim • Be assured that no claims have fallen through the

cracks • Improve efficiency & Days in A/R with faster

intervention

. . . . . .

Audit ControlX

Audit ControlX

• Full suite of products to manage every kind of audit: RAC, MIC, etc.

• Preventive Edits• Audit ControlX Axis• DataXtract• Data Mining• Also available from our partners, Human

Arc and EHR: hands-on appeals management

Audit ControlX

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Audit ControlX Axis• A Secure, web-based, hosted application

– Gives everyone on your RAC team easy access • Axis™ for workflow, tracking, & reporting• Integration with

– AHA RACTrac– Human Arc– EHR

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Medicare ConnectionX

Medicare ConnectionX

• Interactivity with FISS for enhanced Medicare claims control

Faster Reimbursement

Streamlined Workflow

Better Reporting

Medicare ConnectionX

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Questions

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