Using Medicare Eligibility Verification to Protect Medicare Revenue

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1 Using Medicare Eligibility Verification to Protect Medicare Revenue 1

2 Agenda Introduction Business drivers for checking Medicare eligibility Components of real-time eligibility verification Case study Question and Answer Paul Yauger Director of Sales, Healthcare Dianne Houtz Product Manager, Healthcare If you experience any technical difficulties during the webinar, please call

Paul.Yauger@ivans.com 203-698-7205 Dianne Houtz Product Manager, Healthcare Dianne.Houtz@ivans.

3 IVANS Provides Technologies and Expertise that Facilitate One-to-Many, Many-to-Many Communications 350 property & casualty customers 30,000 independent agents 200 payers 135,000 providers 6,000 retail and other business sites 3

property & casualty customers 30,000 independent agents

4 IVANS Long Standing Relationship with Medicare Gives Us Insight Into the Latest Tools Available IVANS is authorized by Centers for Medicare & Medicaid (CMS) to provide direct connectivity to Medicare We work with all Medicare Administrative Contractors, Fiscal Intermediaries and Carriers We meet regularly with CMS and payers to update providers on changes 1983 Formed ,000 Submitters and Growing 2002 Healthcare Networking Unit Healthcare Membership 1990 Billing Program 1993 BCBS Services Health Programs 2000 Submitter Network

Intermediaries and Carriers We meet regularly with CMS and payers to update providers on changes 1983 Formed 2010 135,000 Submitters and

5 Eligibility Errors Consistently Account for Claims Issues Approximately 25% of all healthcare claims are rejected Of total Medicare claim lines rejected, 45% are due to patient eligibility related issues* 5 *American Medical Association 2009 National Health Insurer Report Card

Medicare claim lines rejected, 45% are due to patient eligibility

private medical practices, home healthcare, nursing homes and billing companies.

6 Medicare Ineligibility is a Leading Cause of Uncompensated Care for Healthcare Providers IVANS 2009 Healthcare Provider Survey: Nationwide survey of over 500 healthcare providers including: hospitals, private medical practices, home healthcare, nursing homes and billing companies. Medicare represents a major portion of revenue for these healthcare providers 59% of survey respondents lost revenue due to Medicare ineligibility 6

7 Reduce Denied Claims by Adding Eligibility Checks to Your Workflow Sample Medicare Provider Not Checking Patient Eligibility: X X X 7 4,800 claims per year 30% are Medicare Claims 7% of claims denied due to ineligibility $85 lost revenue per claim $8,585 at risk, per doctor An average healthcare provider generates 25 claims each day, per doctor, totaling 4,800 claims per year Thirty percent of this provider s claims are sent to Medicare adding up to 1,440 claims a year, per doctor This provider had 7% of their Medicare claims denied due to ineligibility resulting in a total of 101 rejected claims in a year The average Medicare claim is $85 This provider could have reduced uncompensated care by checking patient eligibility

claims per year Thirty percent of this provider s claims are sent to Medicare adding up to 1,440 claims a year, per doctor This provider had 7% of their Medicare claims denied due to

8 CMS HETS System Enables Providers to Check Patient Eligibility Electronically to Reduce Denied Claims HIPAA Eligibility Transaction System (HETS) allows healthcare providers to check patient Medicare eligibility electronically HETS supplies information to prepare an accurate claim, determine beneficiary eligibility and confirm patients can receive treatment IVANS Has Seen A 115% Growth In Real-Time Eligibility Verification Use From 2008 to Data is based on social security information, merged from the common working file and secondary payer systems The system is updated nightly from the Medicare claims processing system (common working file) Information available to a variety of provider types including hospitals, Part B, home health, hospice, and skilled nursing 8

Growth In Real-Time Eligibility Verification Use From 2008 to 2009.

9 Access to HETS Increases Visibility into the Patients Medicare History Example of a basic data set: Name Date of birth/death Gender code Type: A, B Eligibility: Active Coverage Beginning and termination of coverage HMO Data Other program entitlements Service type: Hospital, Skilled Nursing, Hospice, Outpatient, etc. Benefits remaining Date of earliest billing action/date of latest billing action 9 HETS Companion Guide

coverage HMO Data Other program entitlements Service type: Hospital, Skilled Nursing, Hospice,

10 Additional Data Returned by the HETS System Via an Eligibility Response Part A Hospital days remaining SNF days remaining Inpatient deductible remaining Date of earliest/latest billing action Home Health Part A/B entitlement/termination date HMO Data Secondary payer data Hospice data Part B Most recent Part B year Cash deductible remaining Physical/speech therapy limit remaining Occupational therapy limit remaining Hospice Period number Start date 10

entitlement/termination date HMO Data Secondary payer data Hospice data Part B Most recent Part B year Cash

11 Conducting Real-Time Medicare Eligibility Checks Takes Three Simple Components Healthcare Providers will need: Credentials from Medicare to access the HETS system Secure connectivity to the HETS system Medicare eligibility verification software 11

from Medicare to access the HETS system Secure connectivity

12 Component 1: Enrolling with Medicare to Access the HETS Eligibility System Complete the trading partner agreement for HETS transactions this outlines security to access the Medicare Beneficiary database Submit the connectivity form a copy will go to the Medicare Eligibility Integration Contractor (MEIC) for security authentication Receive your HETS credentials MEIC authorizes access to Medicare s HETS and will provide you with a submitter ID The forms can be found at cms.hhs.gov/accesstodataapplication/03_medbeneliginq.asp Contact CMS at the MCARE Help Desk at or by at MCARE@cms.hhs.gov 12

(MEIC) for security authentication Receive your HETS credentials MEIC authorizes access to Medicare s HETS and will provide you with a submitter ID The

HETS Securely process Medicare transactions with a single solution

13 Component 2: Secure Connection to Medicare s HETS System IVANS offers access to Medicare s network and HETS CMS approved connection to access HETS Securely process Medicare transactions with a single solution Supports the complete Medicare workflow including eligibility verification 13

14 Component 3: Medicare Eligibility Verification Software IVANS offers Medicare Inquiry Pro Generates a properly-formatted Medicare 270 benefit eligibility inquiry Reads and displays the 271 benefit eligibility response in seconds Run inquiries either by entering specific patient information or by importing a 270 file Creates logs of transactions for reference, audit purposes or resubmittal 14

benefit eligibility response in seconds Run inquiries either by entering specific patient

15 Hospice Family Care Streamlined Medicare Claims and Eligibility Checks with IVANS LIME Challenge: Hospice Family Care (HFC) was increasingly challenged with processing high volumes of Medicare claims in a timely fashion, while reducing their denial rate. Solution: Cost-effective, secure Medicare connectivity via IVANS LIME. HFC could check eligibility, process claims and receive payment quickly. Since we ve switched to IVANS LIME, the stress level of producing Medicare claims and performing eligibility checks is no longer there. Penny Carlton Medicare Billing Manager Hospice Family Care Results: Reduced risk by leveraging Medicare eligibility verification via a high-speed Internet connection, HFC ensures that patient services are approved at the time of visit, significantly lowering denial risk. Improved bottom line hundreds of hours saved each month, freeing up the company s resources by 50% by eliminating costly, time-consuming manual searches, reducing denied claims and resolving backlogged claims. 15

Since we ve switched to IVANS LIME, the stress level of producing Medicare claims and performing eligibility checks is no longer there.

16 We Look Forward To Working With You In 2010 Quick Links to Get Started Credentials from Medicare to access the HETS system cms.hhs.gov/accesstodataapplication /03_MedBenEligInq.asp Paul Yauger Director of Sales, Healthcare Secure connectivity to HETS system & Eligibility Verification Software ivans.com/medicareaccess Dianne Houtz Product Manager, Healthcare Resources for Healthcare Providers ivans.com/healthcare/providers 16

Yauger@ivans.com 203-698-7205 Secure connectivity to HETS system & Eligibility Verification Software ivans.

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