improved revenue cycle managementvividideas.com/pdf/optum-webinar2.pdf · physician practices and...

Improved Revenue Cycle ManagementCathrina Caldwell, CPC, CPC-HDirector, Sales Product Consulting

Proprietary and Confidential. Do not distribute. 2

The leader in populationhealth management serving

the physical, mental and financial needs of both

individuals and organizations

Pharmacy Management

leader in service, affordability and clinical quality

(Formerly Known as Ingenix)

One of the largest health information,

technology and consulting companies

in the world

Market leaders within a dynamic health services market

Optum Businesses


Breadth of Offerings


Industry-leading technologies address critical pain points across the hospital enterprise and the broader care delivery system.

Early pioneers of clinical messaging technology for health information exchange (HIE) initiatives.

Pioneers in computer-assisted coding (CAC) for billing services, physician practices and in-patient and out-patient care settings.

Pioneers in high-acuity solutions to connect hospital information systems, pharmacy, laboratory, medication dispensing systems and medical devices.

The market leader in medical necessity compliance, providing real-time medical necessity review and retrospective appeals services.

Offers next-generation revenue cycle solutions, including its patient-centric, real-time Electronic Financial Record (eFR®) information platform.

Provider Division ― Acquisitions that Have Expanded Our Capabilities


Provider Division “Pillars”

Key Capabilities• Picis Workflow

Solutions• Cost Containment

Consulting Services

Solution SummaryA new approach to creating sustained cost advantage.

Cost & Operational

Improvement

Key Capabilities• EHR Medical

Necessity Compliance

• ICD-10 Compliance

Solution SummaryEnsure compliance

and revenue integrity at the point of care for hospitals

and physicians.

Compliance

Key Capabilities• CareMedic

eFR® and Revenue Cycle Management

• Actuarial consulting services

• LYNX revenue management solutions

• A-Life CAC

Solution SummaryIndustry-leading

tools and operational

excellence to accelerate sustainable

financial results.

Financial Performance

Key Capabilities• Picis High-Acuity

Solutions• Impact Suite to

measure clinical performance

• Clinical data services

Solution SummaryDrive improved outcomes in the

hospital high-acuity and ambulatory care settings.

Clinical Performance

Key Capabilities• Claim Integrity

– ClaimsManager– ContractManager

• Conectivity– Netwerkes– Validation Suite

• Axolotl HIE solutions

• CareTracker PM/EMR

Solution SummaryEmpower all

Stakeholders with a Platform to

Transform Claim and Clinical

Information Flow

Community& Connectivity

Us

ClaimsManager Overview


15% ► The portion of claims that are rejected or denied, necessitating rework and resubmission

$25 ► The average cost per claim for rework and resubmission

The Problem

Lack of Transparency in Current Hospital Workflow

• Rejections and denials• Manually edit claims and resubmit• Then entire process starts over

• Reimbursement

Code, click submit, then wait for. . .

• Cash flow is unpredictable• Rejections and denials increase A/R days• Productivity suffers and costs escalate

While all of this is taking

place. . .


Reviews claims before submission to payers to reduce claim denial rates, shorten accounts receivable cycles, and increase the rate of collection

Helps Hospitals: • Reduce claim denials by pre-screening for

billing and coding errors • Stay current with new and changing guidelines • Comply more easily with Medicare, Medicaid

and commercial regulations • Realize significant ROI through intelligent

automation

The Solution ― ClaimsManager by Optum

• Commercial editing• Over 1 million facility coding relationships• Medicare editing (including LCD and NCD)• Over 15 million Part A coding relationships

Unparalleled Clinical Content

• Resource and financial investments are made annually to help gather and maintain the content used in our editing and billing products

• Quarterly knowledgebase update/bi-weekly NCD/LCD updates

• Yearly/bi-annual software new feature releases• Medicaid unbundling and MUE edits

Continuous Investment

• Fully prepared for 5010 and ICD-10

Industry Leader


The Power Behind ClaimsManager

• 16+ million industry sourced coding relationships Contains 1 million Facility

knowledgebase edits Contain more than 15 million Part A,

Sourced at the code relationship level• Supported by disclosure statements• Date sensitivity at the code relationship

level• Quarterly knowledgebase update / bi-

weekly NCD/ LCD updates• ICD-10 Ready

Comprehensive Commercial and Medicare Knowledgebase

• Team of over 40 experts supporting content development

• Team of Medical Directors, Specialty Panels, RN’s, LPN’s, RHIT’s, RHIA’s, CPC’s, CCS-P and Legal Support

• Methodology reflects clinical research, comprehensive coding expertise and claims data analysis

• Clinical, technical and end user customer support

Diverse Team of Medical and Clinical Coding Experts


Clinical Editing Knowledgebase ― Specific Types of Editing (not all inclusive)

Historical-Based Clinical Editing

• Invalid use of ModifiersModifier 25 may be requiredModifier 27 may be requiredModifier not appropriate with CPT code

• Unbundling across claimsMedicare Unbundle (CCI/OCE)Medicaid UnbundleWill a modifier override an unbundle?Should component codes be transferred to a

different code such as a lab panel?• FrequencyMedicaid MUEMedicare MUE

• New vs. Established patient Should an Established Patient be billed vs.

New?• Duplicate Line/Claim

Historical-Based Clinical Editing

• LCD/NCD Part A editsCPT to Diagnosis appropriatenessSequencing of Diagnosis CodesFrequency allowed for ProceduresAge/Gender RequirementsPOS or Modifier Requirements

• Condition codesAppropriate condition code billed with TOBAppropriate condition code billed with Modifiers

• Observation services allowed only on bill types 13X

• Overlapping Observation Periods• Partial Hospitalizations

Revenue Enhancing Edits• Complete services were not billed forWere both the Injection and Injectable material

billed?Device codes missingIs Patient really considered a New Patient?

Proprietary and Confidential. Do not distribute. 11© Ingenix, Inc. 11

Diagnoses Code Based on Medical Necessity

Chronic Airway Obstruction

Definition

COPD Code 496 Chronic airway obstruction not elsewhere classified is one of the few three-digit codes in the ICD-9-CM manual. The code includes a subcategory listing of “chronic obstructive pulmonary disease (COPD) NOS” and is both a not otherwise specified (NOS) and not elsewhere classified (NEC) diagnosis. Code 496 is a legitimate diagnosis but it lacks specificity.

Edit Type Diagnosis Sequencing

Example

According to ICD-9-CM instructions, Code 496 should not be reported with chronic bronchitis (491.xx), emphysema (492.x) or asthma (493.xx). Just as shortness of breath normally should be integrated in the coding for pneumonia, COPD should be incorporated into categories 491-493 for other lung diseases listed.

Appropriate Use and Sequencing of Diagnoses Codes ― Example


Analysis Results within CM FE-LCD DX Inappropriate


All data points used in analysis for Med

Necessity

Data That is Used for Analysis ― Viewable to Customers

ClaimsManager Technology and Integration


ClaimsManager Deployment Models

• Client maintains the server and manages diskspace, backup procedures

• Client maintains the softwareset-up and software dataupdates

Installed

• Connect to ClaimsManager online through a secure hosted environment for a subscription fee

• Includes standard databasemanagement, disk space monitoring, backup procedures, Oracle maintenance, security,and product upgrades performed by our IT staff

Hosted

• 24/7/365 access from anywhere in the world via the web-based platform

• The same robust content and functionality as the traditional models with no software or download to install

• Reduce costs with no large upfront capital investment by eliminating the need for hardware, software, or IT support staff ― pricing is subscription based

• Automatic updates as Optum manages the infrastructure, upgrades, updates, and availability to ensure access to the most current content

SaaS


Access all of the features and functionality of ClaimsManager Facility through Netwerkes, our web-based clearinghouse service. Superior clinical editing features, integrated into existing claims management

workflow.

ClaimsManager and Netwerkes helps you maximize revenue potential by:Reducing denialsDecreasing rejectionsAccelerating the accounts receivable cycle

ClaimsManager Facility Deployment Through Netwerkes Provides:Easy Implementation – Be up and running in a matter of weeks. Affordability with a one-time only implementation fee.Improved Process Workflow – Leverage one vendor for your clinical editing and EDI needs, eliminating the need to build an interface with your practice management system. ClaimsManager edits are integrated into the Netwerkes workflow.

ClaimsManager Facility Deployment Through Netwerkes


ClaimsManager Deployment Through Netwerkes Workflow

• Charge entry• Charge entry

work queue• Charge/

postings/claims processing

PracticeManagement

System

• Send claims to ClaimsManager for clinical editing

OptumNetwerkes

Clearinghouse

• ClaimsManager clinical edits

• Knowledgebase claim history

Optum ClaimsManager

SaaS

• Review ClaimsManager edits and clearinghouse technical edits

• Edit claims• Review payer

reports

OptumNetwerkes

Clearinghouse

• Claims adjudication

Payer

ClaimsClaimsManager

EditsCleanClaimsClaims

Remittance Information,

Denials,Rejections


ClaimsManager Facility Can Help Your Organization. . .• Identify partially billed or missed charges• Reduce administrative expenses and avoid the delays associated with incorrect codin• Comply with National Medicare, Medicaid, and commercial regulations with a consistent,

automated standard• Comply with Local Coverage Determinations (LCDs) and National Coverage Determinations

(NCDs); load and view updated LCD/NCD policy relationships as they become available to ensure that the claims are in compliance with Medicare policy

• Develop your own edits and customize system edits to meet your facility’s billing and reimbursement needs

• Review current claim or claim line history, allowing for a better view of patient history

Reduce your RAC vulnerabilities

The number of medical necessity errors a hospital triggers could point to overpayment and result in RAC audits. ClaimsManager Facility provides Part A guidelines which can help ensure claims include complete and accurate documentation, reducing the risk of an audit.

ClaimsManager Facility Recap


ClaimsManager Facility Integration with GE Healthcare’s Transaction Editing System (TES)

• Seamless integration and connectivity• Allows for customization through a bi-directional support interface

– Interface increases workflow efficiency to improve the revenue cycle

Lower denial rates. Identify unbilled items. Shorten accounts receivable cycle times.

How it Works

• ClaimsManager Facility evaluates claims by leveraging a deep clinical knowledgebase of content• Claims are filtered into TES work files for efficient editing, which allows them to be corrected and re-

evaluated before they are sent to the payer


ClaimsManager Facility with TES Integration Features

• Send and receive transactions to and from ClaimsManager Facility in real-time or batch mode• Schedule transactions to occur either at every encounter filing and/or during nightly edit evaluation

Real-Time or

Batch Mode

• View and correct ClaimsManager edits within the TES edits system• All ClaimsManager Facility edits can be easily identified• Users can be assigned to TES work files depending on the type of edits that need correction

ClaimsManagerFacility Edits

Reports in the TES system that display ClaimsManager Facility edits include:

Reports • Edit summary report• Force-extracted transactions report

• Edit condition locator report• Edit management report


ClaimsManager Deployment Through Netwerkes Workflow

• ClaimsManager Clinical Edits

• Knowledgebase Claim History

ClaimsManager Facility

• Charge Entry• Charge Entry

Work Queue• Charge

Postings/Claims Processing

TES

• Technical Edits

EDI Clearinghouse

• Claims Adjudication

PayerGEHPA

Remittance Information, Denials, Rejections

Thank You.

Contact Information:Cathrina CaldwellTelephone number: [email protected]

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