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What Are You Doing to Monitor Your Claims?

Posted on June 18, 2015 I Written By

The following is an interview with Vishal Gandhi, CEO of ClinicSpectrum as part of the Cost Effective Healthcare Workflow Series of blog posts. Follow and engage with him on Twitter @ClinicSpectrum and @csvishal2222.
Vishal Gandhi
As practices prepare for the rollout of ICD-10, we’re seeing practices and hospitals make investments in upgrades to their technology to be able to support ICD-10. They’re investing in ICD-10 training in order to be ready for ICD-10. Some are even spending time and resources dual coding to make sure they’re ready for the change. While each of these are important, it’s surprising to me that we don’t see more healthcare organizations budgeting for additional help in following up with insurance companies to make sure that claims are being processed.

From my experience across hundreds of healthcare organizations, I’ve found that 20-25% claims are stuck in cyberspace at any one time. I’m talking about claims that practices assume have been delivered to the insurance company and are being processed, but instead the insurance company never received them or the claim was missing something and has gotten stuck in the insurance company’s claim process.

How many practices have a process for ensuring that their claims are being processed efficiently and effectively? Not many. That means they aren’t getting paid in a timely manner and in some cases aren’t getting paid at all.

When we send off an email or SMS, we don’t really think about whether those things are delivered to the recipient or not. We trust that they’re going to get there without issue because they usually do. It seems we’ve applied that same confidence to claims and that’s a problem. We can’t trust that claims have actually been delivered appropriately and are being processed since there are so many ways that they can fall through the cracks.

On October 1, 2015 (assuming no delays), ICD-10 is going to make this problem even bigger. ICD-10 presents a tremendous opportunity for insurance companies to lose more of the claims you’ve submitted. If you’re not checking with the insurance company regularly, you’ll have no way of knowing if an insurance company’s switch to ICD-10 has caused a glitch in their claims processing or not. The insurance company won’t care because the practice or hospital will be the ones left holding the bag.

This problem can be solved pretty easily. Your practice just needs to randomly select 100 or so claims and call (or hire an outside company to call) each insurance company to get an update on the status of those claims and verify that the claim is being adjudicated. We suggest you do this about 10-20 days after the claim is filed.

By checking on these claims, you’ll pretty quickly see which insurance companies are processing claims effectively and which ones are having issues so you can address the problem(s). Plus, you can evaluate if there are any workflow issues on your end with the claims your submitting.

Especially as we start implementing ICD-10, but also today it’s extremely important to verify how well your claims are being processed. If you’re not doing so, you’re probably not getting all your claims paid in a timely manner and could be missing out on additional revenue for your practice.

The Cost Effective Healthcare Workflow Series of blog posts is sponsored by ClinicSpectrum, a leading provider of workflow automation solutions for healthcare. ClinicSpectrum offers a Claims Watchdog service which monitors your claims for you to ensure you’re getting paid in a timely manner. Connect with Clinic Spectrum at HFMA ANI 2015 in Orlando, Booth #1256 or by tweeting @ClinicSpectrum.

No Complaint vs Normal in EHR Documentation

Posted on June 4, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I was recently talking to someone about why EHR documentation is so awful to read. It’s because billing requires that the doctor spew out all this useless documentation in order to justify billing at a higher level (Side Note: Be sure to check out my previous post about Documentation by Exception Being the Dredge of EHR Documentation).

As I discussed this challenge with clinical documentation, this person told me that their doctors don’t mark everything as normal. Instead, they marked all of these systems as “No Complaint” (or something along those lines). Basically, the patient didn’t complain about that system. I didn’t really check it to know that it’s normal, but I didn’t notice anything abnormal and they didn’t tell me something was wrong.

Hopefully some of my readers that are billing experts can let me know if this type of documentation would fly in the US as far as getting reimbursed. Everyone I’ve seen has always marked it as normal. My guess is that for billing in the US just saying that the patient didn’t complain about a system wouldn’t get you reimbursed for evaluating that system.

However, the person I was talking with was not in the US and so he didn’t have to worry about the billing requirements that we have to worry about. My question to him was, “Then, why in the world are you documenting that the patient didn’t complain?” It seriously made no sense to me. You can basically assume that if you haven’t documented a system, then the patient didn’t complain about any system that’s not documented. Why would you clutter the medical documentation with all of these “Patient Did Not Complain.” That feels even worse than saying that everything was “normal” (unless we’re talking from a liability standpoint).

Maybe my trusty readers can give me some idea of why it would be worthwhile to document all of the “No Complaints.” Am I missing something? Is there some clinical value to it? Seems like a negative to me. Let me know in the comments if you know something I don’t know or if you agree with me that documenting “No Complaints” is a waste of clinician time and actually is worse than not doing it. I look forward to hearing your thoughts.

Solving the Non-EHR Challenges Healthcare Faces

Posted on March 31, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is an interview with Vishal Gandhi, CEO of ClinicSpectrum as part of the Cost Effective Healthcare Workflow Series of blog posts. Follow and engage with him on Twitter @ClinicSpectrum and @csvishal2222.

As we head into the massive HIMSS healthcare IT conference in Chicago, I’ve been thinking a lot about the shift in healthcare technology that’s occurred over the past 5-10 years. When I first started attending HIMSS, I was all about the EHR company and what they had to offer. That trend continued on the back of $36 billion in government EHR incentive money. Now that EHR adoption is more mature, practices are becoming more and more interested in non-EHR technologies that can improve the way they work.

With that in mind, I took some time to sit down and talk with Vishal Gandhi, CEO of ClinicSpectrum to talk about their non-EHR solutions. Vishal and his team have been thinking about non-EHR technologies and pairing those with low cost human touch for a long time. For example, here’s a look at some of the challenges they’ve tackled:

  • Patient Collections
  • Physician Credentialing
  • IT Support
  • Medical Billing
  • Meaningful Patient Engagement
  • Staff Productivity

If your practice or company is facing any of these challenges, take a minute to watch my interview with Vishal to learn more about their unique approach to solving these challenges:

Also, if you don’t have time to watch the whole video interview, they’ve created this great graphic which illustrates the suite of challenges practices face today and solutions (click to see larger version of graphic):
ClinicSpectrum Healthcare IT Ecosystem

The Cost Effective Healthcare Workflow Series of blog posts is sponsored by ClinicSpectrum, a leading provider of workflow automation solutions for healthcare. Check out their suite of hybrid workflow solutions on ClinicSpectrum.com or schedule a meeting with them at HIMSS Booth: 5427 by tweeting @ClinicSpectrum.

3 Macro Health Payment Trends to Watch

Posted on June 5, 2014 I Written By

The following is a guest post by Barry Haitoff, CEO of Medical Management Corporation of America.
Barry Haitoff
It’s not a stretch to say that the healthcare payment system has hit some tumultuous waters. Medical billing hasn’t been easy for a long time, but with things like the Affordable Care Act, Value Based Reimbursement, and the shifting world of data driven healthcare there is a lot you need to watch out for when it comes to getting paid. What does seem clear is that medical billing is not going to get any easier.

Let’s take a look at three broad health payment trends worth keeping your eye on:

Increased Patient Pay
One of the major trends in the health insurance industry is the move towards high deductible plans. Some of this change is coming from employers changing their plans and the ACA insurance exchanges are driving this trend as well. I see this shift continuing as healthcare and employers work to make the patient more accountable for their healthcare.

There are two main things you need to do to prepare for these high deductible plans. First, make sure you have a solid method in place to know how much the patient owes before or immediately after the visit. There is no better way to reduce patient collections than to collect the payment while the patient is in the office. Many are ready and willing to pay, but some practices don’t have the systems that allow them to know how much to charge the patient before they leave. Second, look at your processes for collecting patient payments once they’ve left the building. Do you have a good strategy in place to make sure the patient knows how much they owe? Do you have a variety of simple ways for the patient to make the payment? The use of an online payment portal for patients is the most obvious way to make submitting payment to physicians simple for patients. If you solve these two problems you’ll go a long way to improving your patient collections.

Higher deductible plans are here to stay and so an investment in systems that address the patient responsibility portion of the visit are incredibly important.

Data Driven Reimbursement
With the increased adoption of EHR software, you can be sure that insurance plans are going to want more and more data to justify your reimbursement. This is not a new trend for insurance companies. They’ve been requiring more and more documentation to justify payments forever. However, we’re at the point where what they’ll require will be so complex that you better have your documentation ducks in a row.

Certainly this means that if you don’t have an EHR or other technology infrastructure you will likely have issues. This will become particularly poignant as payers start to pay based on population health and value as opposed to the current fee for service model. I literally can’t see how insurance companies could switch to value based payments in a non healthcare IT world. The data in these systems is going to drive future reimbursement.

Newly Insured
Offices around the country are starting to see a set of newly insured patients thanks to the Affordable Care Act (ACA or Obamacare if you prefer). Are your office staff prepared for these new patients? While millions of uninsured patients are getting insurance and visiting your clinic, offices are also seeing many of their existing patients switching from a previous insurance to an ACA plan. Does your staff have the time required to update records? Not to mention, are you accounting for the extra time spent doing eligibility checks for these new insurance plans?

A MGMA survey of mostly independent physician practices recently found that 62 percent of practices are struggling to identify patients whose insurance came from the ACA exchange and to verify their eligibility or obtain plan details. Most practices also say that patients who got their insurance via an ACA exchange are more likely to have high deductibles and don’t understand that fact. Half of the practices say they can’t provide services to ACA exchange patients because their practice is out of network.

Can you see the potential problems to your practice? What will this new patient population act like when it comes to paying you for your services? Certainly a shift by existing patients to new high deductible plans will cause issues like increased patient responsibility that we talked about above. However, the newly insured population is being shifted from the ER to your offices. If you consider the history of ER payments by patients, there’s reason to be concerned about how well this new patient population will do at paying their portion of the bill.

Plus, we’ve seen many practices that are finding it really difficult to determine their participation status with the payer. It seems that payers have cherry picked providers for their new narrow exchange networks and haven’t informed providers of whether they’re in or out. Once you finally do determine you par status, be sure your staff can recognize the new insurance cards so they can flag them or potentially turn them away if the provider isn’t par.

These are just a few of the major healthcare payment trends I see happening in the industry. I’d love to hear in the comments what trends you see happening in your offices. What other things should we be aware of in this constantly shifting healthcare payment world?

Medical Management Corporation of America, a leading provider of medical billing services, is a proud sponsor of EMR and HIPAA.

EMR’s Affect on Medical Billing Costs

Posted on September 29, 2008 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I received an email not too long ago from a medical billing company who talks about the crazy costs associated with medical billing. In their email they offered the following statistics on the costs of medical billing.

The statistics below represent industry averages taken from the MGMA.

Claims Rejected on 1st Submission – 30 %
Underpayed Claims – 20%
Gross Collection Rate – < 60% Preventable Denials - 90% Denials that are Recoverable - 67% Average days in A/R - 52.32 Cost per claim - $5-$7 Cost per FTE physician - $30,000-$60,000 Cost of billing operations - 18-22% Cost of Billing Personnel - 58-62% Cost of Technology/ Practice Management Solution - 18-22%

Source: Avisena whitepaper

I must admit that billing is far from my expertise, but it’s a well described necessary evil for almost any practice. Plus, the better you do it, the more money your clinical practice can make.

Of course, my question is how did implementing an EMR in your clinic either help or hurt these various costs? Were you better able to process claims, because the charting was done electronically and the coding done at the time of visit? Were you able to process claims at a higher rate because your documentation was more complete using an EMR? Could you more quickly process denied claims because it was electronic? Did you need more or less employees to do your billing after implementing an EMR?

I guess it would also be important to know if you decided to go with an integrated Electronic Medical Record and Practice Management System or if you tried an interface between your legacy system and a new EMR system.