Imagination at work.

Centricity Healthcare User Group CHUG

Jason Whiteaker, Director Sales Engineering RemitDATA Terri Cipriano, HCM Analyst GE Healthcare Joe Heald, EDI Services Manager, GE Healthcare

GE Healthcare

Reimbursement Analytics and Hosted Claims Manager

GE Healthcare

Key Challenges Facing Practices

There is no shortage of challenges in today’s

healthcare landscape. • Healthcare reform, new mandates • Reduced reimbursement, increase in self

pay • Lack of transparency • Making decisions on insufficient data

How can GE Help?

Centricity EDI Reimbursement Analytics and

Hosted Claims Manager provide a near real-time, closed-loop business analysis and

process improvement solution • Comparative healthcare analytics on

reimbursement, utilization and productivity • Combined with the ability to affect change

on the front end to prevent billing mistakes , denials and rework from recurring

Patient Call/Apt.

Notification

Eligibility Verification

Healthcare Service

Provided and Documented

Coding, Claim

Creation and

Submission

Payer Processing

and Adjudication

Appeal Process

Final Reconciling

Closed loop solution

Post Adjudication Analytics and

Trending

The Value of Information

Reimbursement

How are payers treating us? How do we compare to our peers?

Utilization

Are we an outlier on a code that is an “audit-trigger”? Are we under-coding and missing potential revenue opportunity?

Productivity

How is our staff performing versus our peers?

Revenue cycle efficiencies

Correct incomplete or incorrect

prior to submission. Reduce claim denials, underpayments and re-work.

Claims accuracy

Relational editing for ICD and CPT. Payer-specific claims checking before submission.

Regulatory compliance

Evaluates claims against rules and

initiatives

Get answers to resolve key challenges…

... And help improve the outcomes

Reimbursement Analytics

Hosted Claims Manager

Reimbursement Analytics

Reimbursement Analytics provides a detailed assessment of a practice’s financial well being. Using a near real-time, web-based application, the Reimbursement Analytics service provides comparative healthcare data on reimbursement, utilization and productivity.

Solution Highlights

Insight Board

“Did You Know?” module

E&M Code utilization

Denial Management Payer Performance

Interactive

Create different views and filters

Dashboard

will display

data based on

new

selection(s)

Click & drag to drill-down on your top 2

denied procedures

Create different views and filters

Create different views and filters

Create different views and filters

Comparative

Unexpected denials How do I compare?

Additional peer comparisons

Additional peer comparisons

Proactive

Monitor metrics that matter to you

Hosted Claims Manager

Hosted Claims Manager is a pre-claim, clinical editing solution and proactive claim analysis service that identifies and resolves posting errors that would later result in a rejection or a denial. The best way to prevent rejections and denials is to stop them before they occur.

Solution Highlights

Hosted Claims Manager helps to

Identify charge entry errors, allowing the

ability to resolve potential rejections or

denials

Complete pre-claim edits prior to

submission

Helps you reduce your clinical coding errors prior to your charge entry process

Provide greater confidence that claims will

get paid without disruption

Hosted Claims Manager

Offers the ability to build comprehensive invoice

history of the patient into the editing process

Can trend the effectiveness of the edits and

identify areas for continued process

improvement – payment analysis

Integrates clinical edits with TES and Enterprise

Task Manager which provides a streamlined

workflow

Prevent

Clinical edits...what are they?

DLP Identifies items entered on one or more claims that have identical Dates of Services,

Procedures , Modifiers, Departments, and Providers (including previous claim history)

EST Identifies where an established patient E&M was billed but no service has been billed within

3 years for the patient by the same organization and specialty

GFP Identifies an E&M that was billed during the global follow up period of an earlier procedure,

has the same primary Dx as on Dx for the earlier procedure and was performed by the

same provider

LBI Identifies that no diagnosis on the claim line supports medical necessity for the procedure

billed (as specified by Local Medicare Guidelines)

MOD Identifies a line item that contains a modifier that is not permitted for use with a particular

procedure code

MFD Identifies situations where you have exceeded the maximum allowed frequency for a given

procedure within a given date range

INJ Prompts you to add additional procedure code for if appropriate

Centricity Practice Solution revenue cycle Current process

Gateway Edits

Payer Edits

Rejection

Denial Payer

Adjudication

Schedule Visit

Ticket Posted

Pass

Approval Process

Edit Ticket

Fail

Fail

Fail

Pass Pass

Fail 6%

16%

Median rejection rate: 6%

Median denial rate: 16%

• Rejections and denials hinder the revenue cycle

• Rework is expensive • Some claims are written off

*Based on claims data submitted to the GE Healthcare Centricity EDI Clearinghouse

The problem*

The results

31 Centricity ED Services

3/13/2014

With Hosted Claims Manager

TES Edits

EDI Edits Ready For

Claim

Rejection

Analysis

Payer Edits

Task Manager

Denial Analysis

Payer Adjudic.

FAIL PASS PASS PASS

FAIL

FAIL

FAIL

Hosted Claims Mgr

The Benefits:

Reduce claims denials by pre-screening for billing and coding errors Realize additional ROI using

sophisticated rules and automation Closed-loop rejection and denial analyses create a process to drive continuous improvement

Charge Entry

Schedule Visit

Eligibility Verification

Reduce CO97Denials for Medicare (Global/Bundling)

Improve

Reduce CO50 Denials for Medicare /Blues (Medical Necessity)

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

Mar-0

9

Jun-09

Sep-09

Dec-09

Mar-1

0

Jun-10

Sep-10

Dec-10

Mar-1

1

Jun-11

Sep-11

Dec-11

$ Not Paid

Reducing duplicate denials

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

9-Apr

9-May

9-Jun

9-Jul

9-Aug

9-Sep

9-Oct

9-Nov

9-Dec

10-Jun

10-Dec

11-Jun

Dec'11

$Not Paid

Reduced COB15 Denials for Medicare (Payment adjusted because this procedure/service is not paid separately)

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

Feb-09

Jan-10Apr-1

0Jul-1

0Oct-1

0Jan-11

Apr-11

Jul-11

Oct-11

Jan-12

$ Not Paid

Return on your Investment (ROI)

Potential benefits of HCM

Helps support improved revenue cycle efficiencies

Enables you to correct incomplete or incorrect prior to submission, helping to reduce your claim denials, potential underpayments and costly re-work

Assists in prompt reimbursement and helps reduce days in A/R

Helps you improve claims accuracy

Sophisticated relational editing that helps optimize your accuracy and efficiency for ICD-9 and CPT-4 coding

Checks claims against payer-specific contracts before submission assisting to reduce denials & rejections

Captures claims data for analysis and releases complete claims for submission while delays claims needing review

ICD-10 ready

Supports regulatory compliance

Evaluates claims against numerous coding rules and detects Medicare Correct Coding Initiative edits

Includes the most current Medicare Local Coverage Determination (LCD) edit

“We really feel we get our

money’s worth with catching

coding/clinical errors up front

reducing re-work on the back

end. We also like the “rescrub”

functionality for those services

that need to be viewed as “a

whole package”.”

Kim Frieben , Conemaugh

Physician Group

Want to learn more? or Sign up for a Personal Demo!

• Sign up sheet in room • Email inside.sales@med.ge.com

• Talk to your Account Manager

Appendix

You need to know...

Reimbursement Utilization Productivity

...In order to improve

Revenue cycle efficiencies

Claims

accuracy

Regulatory

compliance

Patient Call/Apt.

Notification

Eligibility Verification

Healthcare Service

Provided and Documented

Coding, Claim

Creation and

Submission

Payer Processing

and Adjudication

Appeal Process

Final Reconciling

Closed loop

Post Adjudication Analytics and

Trending

Hosted ClaimsManager: Features

Optum Insight (formerly Ingenix® ClaimsManager™) Proven, industry-leading clinical editing engine (now with LMRP/LCD) Includes over 4,000,000 pre-built rule combinations

Continuous improvement support model

Regularly scheduled rejection and denial reviews are a key part of service

Rapid install

No server, no 3rd party licensing, reduced training requirements Payer edits

Edits can be created specific to your local payers guidelines Edits can be turned off if not needed

Medical Necessity Reduction

Little Rock Oncology Hematology went live on the Hosted ClaimsManager product in November 2008. As part of the product offering, the Hosted ClaimsManager team meets with the

customer monthly to focus on their top denials and how to further reduce the denials by tweaking the edits in Hosted ClaimsManager. During the first meeting in February 2009, this organization chose Medical Necessity denial as an area where they’d like to drive improvement. By reviewing the charges before they’re submitted to the payer,

they were able to reduce their Medical Necessity denials.

SARA Clinical Denial Trend

Customer is a practice with 11 physicians who went live with Hosted Claims Manager in September 9th 2011.

Customer Comments

“We love it , love it , love it , love it . It saves time not having to build edits ourselves.”

-Linda Tuten, Gessler Clinic

“We really feel we get our money’s worth with catching coding/clinical errors up front reducing re-work on the back end. We also like the “rescrub” functionality for those services that need to be viewed as “a whole package”.”

-Kim Frieben , Conemaugh Physician Group

“It’s very helpful in advising the provider of any incorrect information prior to claim submission which allows for timely payment of claims. Also very thorough with any updates/alerts we need to know about. No areas for improvement.”

- Patti Nachmann, South Florida Associates P.A.

Hosted Claims Manager

Hosted Claims Manager:

Hosted Claims Manager:

Rejection Reporting (Payer Front-End Edits)

Rejection Reporting (Payer Front-End Edits)

Reduce CO4 Denials (procedure inconsistent with modifier or modifier missing)

Reduce CO58 (payment adjustment due to inappropriate or invalid place of service)

Reduce CO97M144 Denial (Global period – Pre/Post op care payment is included in the allowance for surgery/procedure)