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UC Irvine and Centricity™ BusinessEligibility OptimizationGoing at risk to share in the gain!

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©2015 General Electric Company – All rights reserved.

The results expressed in this document may not be applicable to a particular site or installation and individual results may vary. This document and its contents are provided to you for informational purposes only and do not constitute a representation, warranty or performance guarantee. GE disclaims liability for any loss, which may arise from reliance on or use of information, contained in this document. All illustrations are provided as fictional examples only. Your product features and configuration may be different than those shown. Information contained herein is proprietary to GE. No part of this publication may be reproduced for any purpose without written permission of GE.

DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCT DIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE A COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITY REMAIN AT GE’S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLE REGULATORY CLEARANCE.

GE, the GE Monogram, Centricity, and imagination at work are trademarks of General Electric Company.

All other product names and logos are trademarks or registered trademarks of their respective companies.

General Electric Company, by and through its GE Healthcare division.

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Introductions

Elizabeth BurrowsIT Director, Physicians Billing Group, UC Irvine Health

Jamie StallwoodSystems Registration & Support Supervisor, UC Irvine Health

Simone ArmsOptimization Solutions Consulting Manager, Centricity Business

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What is there to Gain?

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Key Performance Indicators for Eligibility Optimization

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Opportunity

December 2013 – 3 month average

Utilization – 42% Target 85%

Verification – 62% Target 85%

Automation – 0% Target 85%Active Response

Automation – 0% Target 50%Enterprise

Denials $$ - 3% Target 1%

Denials by count – 3.5% Target 1%

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The UC Irvine Perspective

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About UC Irvine Health

UC Irvine Medical Center has ranked among the nation’s best hospitals for the past 14 years and is home to more than 800 specialty and primary care physicians. We have 1 of only 41 nationally designated comprehensive cancer centers, a level I trauma center and a level II pediatric trauma center.

We have about 45 various outpatient clinics

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Physicians Billing Group (PBG)

Bills for 90% of UCI physician services

CB v5.1, 28 active BAR groups (3 non-PBG)

AVM, TES, BAR, ETM, Reporter, Informatics

Medical Center uses Allscripts on front end

ADT interface

GE plans kept in sync with Allscripts

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Centralized Registration Unit

8 FT representatives

Hold Bills, TES edits, BAR claim edits across groups, across visits

Eligibility related hold bills

Approx 2000 open items on daily basis

Manual registration for outside facilities

Part-way thru project PBG took on 2 large departments, no increase in staff

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Key Business Drivers

GE eligibility not up to date

Desire to improve what and how we were checking eligibility

PBG taking on additional business with no increase in Reg staff

needed better workflow

needed visibility into what/how users were working

Enterprise-wide goal of reducing front end-related denials

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Project Outline

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Project Team

GE Optimization Team:

Functional Resources/Project Management - 2

Engineering Resources – 2

UC Irvine Team:

Leadership – Elizabeth and Jamie

Billing Analysts – 3 Members of the Registration team

IT Staff – 2 Analysts

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Project Plan and Timeline

May – Kick-off Call, KPI Review to set our baseline

June - On-site – Week long Overview, Design, Build

June / July – Testing

August – Phase I / Phase II – Live events

September onward – Tweaking and ongoing KPI reviews

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Technology and Workflow Changes• Increase Electronic Payer Mix

• Specific results screens by Payer

• Automation – Auto file Active results and FSC/Plan follow up

• Needs Review Logic – to support work by exception

• Hold Bills/VM Alerts – to help manage the Eligibility Work

• TES Edit Integration – Complete work before billing

• Self Pay screening – Active Medicaid?

• New ETM Workflows to manage eligibility and hold bills

• Claim logic changes and claim edits

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Increasing Electronic Utilization – Electronic Payer Mix

Utilization Rate: Measure of the % of visits could have an electronic eligibility check because an electronic connection is available.

June 2014 –

CIRV Utilization Rate 42%

50,214 visits - 21,150 had FSC’s with an electronic connection.

December 2014

CIRV Utilization Rate 85%

50,016 Visits - 42,573 had FSC’s with an electronic connection.

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Needs Review – Work by exception

Needs Review

• Evaluates result data to identify exception situations

• Notifies the user and provides specific messaging around scenario

• Payer reports other primary payer review and adjust FSC’s accordingly

• Medicare Part A only

• Medicare Part B only

• Conflict with subscriber reported – verify name, DOB, relationship with data on file

Unworked NR can trigger alert, Hold Bill, TES or claim edit

Results Screen: Medicare, Medicaid, CommercialInfo on left is from registration/IMS, right from the payer

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Automation

Automatically file variant information into Eligibility Variance FSC Follow up questions to allow for use of that information on claims:

You send “Smith, Joseph” - Payer sends “Smith, Joseph Michael”• Variant name auto files to be used on claims and future eligibility

requests, but demographic name stays as supplied by the patient.

• No human intervention required – no need to work these responses even with variance

Automatically manage Mixed Responses• Rules defined on data to look for when Mixed is received, what situations

do you want to show something Besides “Active” , otherwise seen as Active and Auto Filed.

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TES Integration

• Edits delivered to hold Charges with Eligibility Unworked, NR Unworked, Eligibility Hold Bills on the Visit, Self pay with an Active Eligibility Response

• DBMS GERD’s - Queries to scan incoming charges without an Eligibility Request and then Process the request, Self pay Scan for Active Eligibility, Charges without Visit attached

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Managing the Work - To positively affect eligibility denials• Needs Review tracks the Exceptions

• Hold Bills/Alerts – Worklists to work NR, Inactive, Rejected– Hold Bill Work-list

– Alerts Manager

– ETM Worklists

• TES Edits – stops what hasn’t been worked before charge is released

• Claim edits – last stop to capture released unworked charges before they are submitted

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Workflow and Process Improvement Gains

Actually using GE eligibility checking as opposed to website

Immediate gains in terms of what was being checked without intervention

Uniform process and instructions for users on how to work

ETM workflows provide increased visibility into what the user is doing, how much they are doing

Exception-based workflow, more specific logic

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Challenges and Lessons Learned

• Main challenge was volume – increase in FSC’s being checked resulted in huge increase in hold bills/edits• 2000 vs 20,000 (plans 1, 2 and 3)

• Business Growth – now responsible for additional departments

• Needs Review - must define what really needs to be reviewed as opposed to what would be nice to review

• TES edits based on Hold Bills – impacted charge lag days

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Challenges and Lessons Learned continued

• Working Hold Bills – started with Alerts Manager, moved to ETM

• Volume testing in test environment – visits, charges

• Change in overall approach – team struggled

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Recognizing The Gains

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Before and After

Baseline - 2013

• Utilization – 42%

• Verification – 62%

• Automation (Active) – 0%

• Automation (Enterprise) – 0%

• Denials $$ - 3%

• Denials Count – 3.5%

Current State - 2015

• Utilization – 85%

• Verification – 98%

• Automation (Active) – 71%

• Automation (Enterprise) – 63%

• Denials $$ - 2.79%

• Denials Count – 3.7%

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Time Recovery Opportunity due to Automation

June – 16,217 requestsNeeded to work them all.

December 51, 453 requests13,145 that need to work – 38,308 Active /Auto

Processing almost 3 X the volume with same FTE count – would not be possible without automation.

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Denials Analysis

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Denials Analysis

Tools to review what staff is working and how - Manage the change!

Monthly we review all KPI’s including Denials

• Scenario (denial codes), division & Billing Area, payer and scenario

• Determine where based on highest volume we want to focus

• Start looking at individual invoices that have particular scenario etc.

• Focused denial workouts get to root cause to reduce future denials

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Contact information

Optimization Solutions: Centricity.Business@ge.com

Simone Arms: simone.arms@ge.com

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