Improved revenue cycle management for Epic. Cathrina Caldwell, CPC, CPC-H Director, Sales Product Consulting

Transcription

1 Improved revenue cycle management for Epic Cathrina Caldwell, CPC, CPC-H Director, Sales Product Consulting

2 Agenda OptumInsight Overview Traditional physician claim workflow A better way Claims Manager Professional Knowledgebase edits Additional revenue Deployment options Knowledgebase coding relationships and edits How we are different Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2

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4 Optum businesses One of the largest health information, technology, and consulting companies in the world. The leader in population health management serving the physical, mental, and financial needs of both individuals and organizations. Pharmacy Management leader in service, affordability. and clinical quality. Market leaders within a dynamic health services market Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 4

5 OptumInsight business profile An insight-driven health care solutions company since 1996 A significant footprint in health care communities Enable secure delivery of health claims and clinical information for more than one in seven Americans Proprietary health care databases with 75+ million patient lives; over 15 years of longitudinal health data Supporting one in five emergency department visits Work with 6,200 hospital facilities, 246,000 health care professionals/ groups, and 270 government entities Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5

6 Claims Manager Professional workflow

7 Current physician practice claim workflow Code, click submit, then wait for... Rejections and denials Manually edit claims and resubmit Then the entire process starts over Reimbursement While all of this is taking place... Cash flow is unpredictable Rejections and denials increase A/R days Productivity suffers and costs escalate Clearinghouses provide only limited technical edits primary focus on connectivity 19%* The portion of claims that are rejected or denied, necessitating rework and resubmission $20+ * Hours each week that Doctors offices spend dealing with claim edits $25** The average cost per claim for rework and resubmission $68,000 ** The cost per physician per year in time spent interacting with payers * 2011 AMA National Health Insurer Report Card ** Medical Group Management Association study: The Costs to Physician Practices of Interactions with Health Insurance Plans, Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7

8 What if there was a better way? Q: What if... Clinical claims editing happened prior to sending claims Claim errors identified and edited before they are sent to your clearinghouse Regulatory and payer rules were automatically updated? Medicare and commercial updates on a quarterly basis Missed revenue opportunities were proactively identified? Identify partially billed services The solution was affordable and within reach of even the smallest physician practice? A: Your Practice s... Denials and rejections would decrease A/R days would get lower Cash flow would improve Productivity would increase and reduce costs Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8

9 Claims Manager Review claims before submission in order to reduce claim denial rates, shorten accounts receivable cycles, and increase the rate of collection. Claims Manager can help your practice: Realize significant ROI through intelligent automation Reduce claim denials by pre-screening for billing and coding errors Stay current with new and changing guidelines Comply more easily with Medicare, Medicaid, and commercial regulations Develop your own edits and customize system edits to meet your practice s billing and reimbursement needs St. Vincent Health reduced it s A/R days from 63 to 35 by using Claims Manager *St. Vincent Health, Indiana, the nation s largest not-for- profit and Catholic health care system Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 9

10 Common platform Optum claims processing One common platform across Optum claim editing solutions for providers and payers One common clinical knowledgebase Claims Manager is the provider market solution Claims Manager Professional Claims Manager Facility Claims Edit System is the payer market solution Claims Edit System Professional Claims Edit System Facility Historical editing Global periods, new vs. established Positive editing Identify unbilled services Relational editing Lines within the claim, claim to claim Design emulates payer adjudication process Fits with existing workflow Fully customizable solution Rules-creation manager Design emulates payer adjudication process Fits with existing workflow Fully customizable solution Rules-creation manager One common clinical knowledgebase Medicare, Medicaid, and commercial rule sets Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10

11 Claims Manager: knowledgebase / edits

12 The power behind the Claims Manager Comprehensive commercial and Medicare knowledgebase 81+ million industry sourced coding relationships Contains 10 million commercial knowledgebase edits Contains more than 15 million Part A, 55 million Part B Medicare knowledgebase edits Sourced at the code relationship level Supported by disclosure statements Date sensitivity at the code relationship level Quarterly knowledgebase update / bi-weekly NCD/ LCD updates ICD-10 Ready Diverse team of medical and clinical coding experts Team of over 40 experts supporting content development Team of medical directors, specialty panels, RNs, LPNs, RHITs, RHIAs, CPCs, CCS- P, and legal support Methodology reflects clinical research, comprehensive coding expertise, and claims data analysis Clinical, technical, and end user customer support Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12

13 Medicare coverage data development process Data-driven LCD/NCD rules allow for timely release and implementation of new requirements; updated content delivered biweekly Identification Revision identification tool identifies the policy update (processed weekly) Policy is flagged for development Development Tech one reviews the policy end-to-end Changes are updated in the internal development application (content manager) Tech two completes a QA of the entire policy after tech one and gives final approval Delivery OptumInsight data operations extracts all policy data Data files are posted on the customer portal for download and utilization in Claims Manager Medicare coverage data team recognizes the importance and weight that the national coverage determinations (NCD) carry in the claims adjudication process Each NCD has been analyzed for coding opportunities by a team of content experts and a written analysis developed and maintained for each NCD Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 13

14 Medicare coverage data development process codifying the NCD/ LCD policies page 1 of 38 LCD Policy Text OptumInsight translates to clinical edits page 24 page 10 page 3 page 26 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14

15 Medicare source data mining In addition to LCD/NCD maintenance, extensive data mining is done within CMS published sources to identify any overarching requirements: Medically Unlikely Edits (MUE) National Correct Coding Initiative edits (NCCI) National Physician Fee Schedule (NPFS) CMS manuals MLN articles CMS transmittals Federal Register The Medicare Rule Set contains 109 system rules that are reviewed annually to ensure continual compliance with CMS claims processing guidelines. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15

16 Claims Manager knowledgebase specific types of editing (not all inclusive) Historical-based clinical editing Invalid use of modifiers Modifier 25 may be required Modifier not appropriate with CPT code MUE Medicare MUE Medicaid Unbundling across claims Commercial unbundle Medicare unbundle (CCI) Medicaid unbundle (CCI) Should component codes be transferred to a different code such as a lab panel? Global surgical packages Was a related procedure performed during a global F/U? New vs. established patient Should an established patient be billed vs. new? Duplicate line/claim Historical-based clinical editing LCD/NCD Part B edits CPT to diagnosis appropriateness Sequencing of diagnosis codes Frequency allowed for procedures Age/gender requirements POS or modifier requirements Anesthesia Crosswalk surgical CPT code to appropriate anesthesia code Validate that anesthesia provider is billing anesthesia code Use appropriate modifiers for anesthesia Revenue enhancing edits Complete services were not billed for Were both the injection and injectable material billed? Prolonged service billed but E/M service is missing Is patient really considered a new patient? Was radiology guidance billed with breast biopsy? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16

17 Commercial editing examples Decrease rejections and increase payments for commercial payers Definition Validate the surgical provider isn t billing for E/M service one day prior to surgery (if being seen for items related to the surgery) Pre-op procedure one day before surgery (PRE, PRH) Edit Type Example Historical edit Patient comes in for an office visit, one day prior to meniscus surgical repair, for service related to surgery If E/M service was billed on a different claim, then the surgery PRH would trigger If E/M service is on same bill as the surgical procedure PRE is triggered Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 17

18 Medical necessity editing (LCD Part B) examples Decrease rejections and stay in compliance with Medicare Part B Missing or invalid LMRP diagnosis (LBI) Definition Edit Type Example Validate that diagnosis represents the need for nail trimming ABN, compliance edit The patient presents with an ingrown toenail with an infection. The physician performs a nail trimming to treat the nailed. The patient is also diabetic but when the physician bills the patient, he/she only includes the diagnosis code for the toenail infection Claims Manager does the analysis of the diagnosis code and determines that the diagnosis doesn t support medical necessity guidelines to support the payment for the patient s foot care. LCD Part B typical frequency exceeded (BFR) Definition Edit Type Example Validate that the patient hasn t been seen for nail trimming within the last 60 day Historical edit Diabetes patients struggle with neuropathy and poor circulation, therefore routine foot care is necessary. Some Medicare carriers have designated routine foot care to be one session every 60 days. If the patient comes in for additional foot care more frequently than the 60 days, Claims Manager will flag to indicate that this has been billed outside the parameters of the policy. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18

19 Claims Manager: additional revenue examples

20 Optum Claims Manager Identifying partially billed procedures before claims submission, results in complete payment for all services delivered Identify additional revenue sources average group fails to capture 0.05% of potential revenue Automatically detect missing related procedures If an injectable drug is billed, the associated procedure to administer the drug should be present Add-on codes billed without primary procedure Prevea Health has gained $2,112,859 by identifying Cardiac catheterizations service dollars that were Interventional radiology previously not billed and by making substantial use of Claims Manager's positive editing ability. *Prevea Health, Wisconsin. Results based on five-year study ( ). Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 20

21 Claims Manager helps increase revenue (family practice scenario) Scenario : Patient is billed for a prolonged service Code CPT description Reimbursement Prolonged physician service in office or other outpatient facility; face to face, first hour $ Edit Per CPT guidelines, codes are used when a physician provides prolonged services involving direct patent contact that is beyond the usual service. This services is reported including other services, including E&M services at any level The claim is modified to include the code as noted in the edit. High-level office visit $ By adding the additional code, the total reimbursement increases by $143.17, for a total of $ Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 21

22 What makes Claims Manager different? Unparalleled clinical content Commercial editing Over 9 million professional coding relationships Over 1 million facility coding relationships Medicare editing (including LCD and NCD) Over 56 million Part B coding relationships Over 15 million Part A coding relationships Continuous investment Resource and financial investments are made annually to help gather and maintain the content used in our editing and billing products Quarterly knowledgebase update / bi-monthly NCD/ LCD updates Yearly/ bi-yearly software new feature releases Medicare Physician Quality Reporting Initiative (PQRI) edits and rules Medicaid Industry leader Optum will be fully prepared for ICD-10 Significant financial investments will help guarantee Claims Manager and its content will be ICD-10 compliant by the Oct. 1, 2013 effective date Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 22

23 Claims Manager: Integration with Epic

24 Claims Manager and Epic Long standing Epic Optum relationship Claims Manager Professional real-time interface to Resolute Professional and EpicCare (50+ sites) Claims Edit System (payer market) real-time interface to Tapestry Managed Care Provide data files, Epic multiple integration support Cadence, Epic Care, Resolute (Facility and Professional), Radiant, etc. NCD/ LCD Part A and B (Charge Entry and ABN editing) CCI/OCE (Charge Entry) Epic Resolute Hospital interfaced to Optum Coding and Reimbursement Module (grouping/encoding) at Parkland, Dallas with Resolute Hospital Optum Healthia, primary resource for PM, application expertise Support and attend Epic national meeting Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 24

25 Joint Epic Optum Claims Manager customers Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 25

26 Claims Manager / Epic integration Real-time, two-way interface using bridges End users stay within the Epic screens, providing enhanced productivity and minimal learning curve Many integration points within Resolute and EpicCare Order entry Charge entry / charge review Claims processing / claims edit Edits routed via charge router logic (Resolute work queues, EpicCare work queues) Claims Manager is transparent to users Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 26

27 Charge entry errors

28 Charge entry Enter new charge. If charge has no errors, the session will close and a new charge entry screen will automatically appear. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 28

29 Charge entry Test Test 04/01/10 Kladar GI 22 Enter new charge. If a frontend edit occurs Partial Esopagectomy, distal w or w/o pyloroplasty MCR Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 29

30 Edit message returned to Epic charge entry screen Optum offers enhancing features such as historical claim checks. If Charge hits a Front End Claims Manager Error a message will appear immediately within Epic PRH flag issued because E/M code was billed one day prior to surgical code. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 30

31 Charge router claims processing work queue

32 Editing at time of claim processing claim edit work queue back-end edits Historical checking determines that patient is new to service and new patient E/M should be used. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 32

33 Questions and answers