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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.

ER intends to serve older patients

A Maryland emergency department is one of the country’s first designed to serve the population of those age 65 and older, The Washington Post reports.

Holy Cross Hospital in Silver Spring uses technology in lighting and sound to make the experience in the ED as pleasant as possible for seniors.

Read the full story in The Washington Post.

Medicaid battle brews in Minnesota

The governor of Minnesota faces a dilemma because of the growing number of Medicaid-eligible patients in his state, the Minneapolis Star Tribune reports.

Governor Tim Pawlenty’s budget includes a $3 billion share for Medicaid, which is one-fifth of his budget. But cutting isn’t easy. He has a Legislature that wants to expand access to healthcare for the poor.

Read the full story in the Tribune.

Front end meets back end

If you want to get on the same page with your patient financial services team, there is a noteworthy article in the October, 2008 edition of the newsletter, Patient Access Advisor.
The article will help you:

• Understand why all the information on both ends is important
• Understand why it is not always possible to get the information
• Work together for solutions so that by the time a claim reaches patient financial services, it is ready to bill
• Understand what each denial is, why it is happening, and have a stake in cleaning up processes so that denials are reduced and, as possible, eliminated

Editor's note: The preceding tips were provided by Sandra J. Wolfskill, FHFMA, president of Wolfskill & Associates, Inc., in Chardon, OH.

Your revenue cycle in four years — better or worse?

President Barack Obama got a do-over at this week’s inauguration. Obama took the oath of office a second time on Wednesday because Chief Justice John Roberts deviated from the language in the Constitution the first time. Obama repeated the mistake, forcing a redo.

It got me thinking – why won’t CMS let revenue cycle managers do a “redo” on a bad claim and end it there? Wouldn’t it be nice if your Recovery Audit Contractor simply said, “This was wrong. Do it over. No monetary penalties.”

That won’t happen anytime soon – especially with Medicare’s Trust Fund predicted to go bankrupt by 2016. Just how will this new administration affect healthcare providers and their bottom line? I don’t have the answer.

Maybe you do. At the end of Obama’s term, where do you think your facility will be? Better off or not?

Report: CEO confidence at all-time low

CEO confidence in the U.S. economy is at an all-time low, according to The Conference Board's latest quarterly report. The survey of about 100 business leaders in a wide range of industries declined to its lowest level since The Conference Board began the survey in the second quarter of 1976. Twenty-four of the 100 executives surveyed said they felt confident about the current economic situation in the fourth quarter of 2008, down from 40 in the third quarter.

Read the full report in the Houston Business Journal.

ED bedside registration: when it does not work

Editor’s note: Last week, we talked to a patient access manager who said her facility succeeds using bedside registration in the Emergency Department. This manager says it only causes problems:

Lee Memorial Health System in Fort Myers, FL, has a bedside registration protocol that is simply “not efficient,” according to Colleen Edwards, system director of Registration and Patient Business Services at the five-hospital, 1,500-bed system.

For her facilities, bedside registration causes:

• Frustration among clinical staff who view registrars as interrupting the care process
• Discomfort for registrars trying to conduct business in a traumatic environment.
• Addition of staff members to cover overflow units in the ER.

“In general what I’ve learned since we’ve done this – and we’ve been doing it for a good five-plus years – is that patients here are to be treated as expeditiously as possible, but our function gets in the way,” Edwards says. “We become extremely inefficient. A nurse comes in, we step back out. A doctor comes in, we step back out. It is the least efficient system we have.”

You as the patient access manager must fully gauge whether or not bedside registration will work for your facility before diving in. And you must have a solid communication plan in place with the clinical team long before the initiative is rolled out.

Obama promises quality; Dunn Memorial already delivers

Barack Obama today in his inaugural speech talked about the need for better healthcare quality and lower costs. Dunn Memorial Hospital’s patient access team certainly delivers quality with its Medicare Secondary Payer (MSP) form policies.

The Bedford, IN, facility last year scored a 100% compliance when auditors visited the facility.

To see how, read the story in our Patient Access Advisor newsletter.

WellPoint barred from enrolling new patients in Medicare

Health insurer WellPoint Inc. has been barred from adding customers to Medicare plans after it denied prescription drugs to the elderly, endangering their lives, the government announced. The sanctions, outlined in a letter to WellPoint from the Centers for Medicare and Medicaid Services, followed a "sharp" increase in consumer complaints.

Elderly customers were stopped from receiving essential prescription drugs, and some were overcharged because of computer mistakes, the government said.

Read the full story in the Los Angeles Times.

Massachusetts governor weighs insurance hearing

Massachusetts Gov. Deval Patrick has asked the state's most prominent hospital and health insurance leaders to take quick action to hold down rapidly rising healthcare costs, suggesting that if they did not take steps on their own, they might face new government regulation.

Patrick said he is considering holding hearings on health insurance premiums and the primary driver of premium increases—the rates hospitals charge insurers for members' medical care. He has also said the state Division of Insurance has the power to reject rates it deems excessive.

Read the full story in the Boston Globe.