Accurate edits return $$$

By Vince Arencibia and Julie Souder

Many companies offer various services and ideas on how to improve revenue. Most, if not all, concentrate their efforts on the front-end registration process, dealing with eligibility, making sure the patients have enough insurance coverage, collection of co-pays, etc. All these procedures are important, good practices to follow and are essential to a good revenue cycle program.

One vital step in the revenue cycle program tends to be ignored or is inadequate – proper setup and use of a scrubbing system. In order to have a clean claim, there are a few components dealing with systems and personnel that need to exist. A good, reliable scrubber system needs to be in place, the billers need to know how to use it, understand the information the scrubber provides, and, most of all, know how to resolve claims issues presented by the scrubber.

Companies spend hours on research and development concentrating on how well the electronic file is built so the insurance company will accept it. However, even though it is an important step as part of claim submission, how accurate is the information within the file? What if you do not have electronic file submission established for all the carriers, and paper claim submissions need to a review?

In addition to a good scrubbing system, there needs to be a good revenue integrity person at your facility keeping up with all the various scenarios relating to reimbursement. The revenue integrity person needs to understand the types of contracts the hospital has with a particular insurance company. 

Your facility needs to have solid background on what insurance companies look for and what the best practices are in the billing and coding arena. In our experience with many clients over the years, we have determined that in order to have a good revenue cycle program, there needs to be a synergy between revenue integrity, medical records, coding, billing, and compliance. A good “scrubber” system can help to ensure you receive the most appropriate reimbursement for the services you provide. 

Besides the front-end eligibility and compliance on file structure, what are the claims issues at a hospital? There are three components:

• Compliance
• Lost charges
• Payer-specific issues

There also needs to be a good understanding on how to build edits on your scrubber to look for certain edits dealing with areas such as:

• Outpatient Medicare
• Carve out
• Interventional radiology
• Drug administration
• User-defined

The question is – do you have a person in-house dedicated to reviewing claims before or after they are billed? Are you relying on the scrubbing system to do just that? Does your scrubber perform to your expectations?  Systems are supposed to be automatic, but we know in the healthcare environment, there are too many variations for a system to automatically pick up most coding errors.

There needs to be someone or some system in place to review particular claims either right before you bill them, and/or shortly thereafter.

Only with the synergy mentioned above, will your facility experience the expedience and accuracy of claims processing and reimbursement it deserves.

Vicente Arencibia is a chief information officer with Omega Technology Solutions. Arencibia leads a team providing all aspects of electronic technologies, including compliance, claim submission and revenue management. Arencibia is a qualified manager and holds a B.S. in management and marketing degrees from Florida Atlantic University.

Julie K. Souder, CPC, CPC-H, CPATI, is a business analyst for Omega Technology Solutions with more than 22 years in the healthcare industry. Her experiences have taken her everywhere from working on systems to collect patient information during emergency situations, to patient billing, to medical record audits. Previous positions have included the business office management of what was the largest private ambulance company in South Florida, to owning her own medical collections agency. Today, she is involved in research and development of claims edit systems that report compliance issues as well as alerts for potential lost charges/revenue. She is also involved in the charge description master products provided by OTS.