Presentation Transcript

1. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions
2. The Importance of Eligibility in the Revenue Cycle
3. History of Electronic Eligibility Industry Birth of electronic credit card industry 1986 Credit card verification pre-1986 was all manual Three options: trust cardholder, call, or check “the book” Birth of electronic eligibility industry 1989 Eligibility verification pre-1989 was all manual Two options: trust cardholder or call payer Eligibility Trivia Question: Which 3 healthcare payers were the first of offer electronic eligibility in the U.S., or world for that matter?
4. Why is Eligibility Verification Important? With respect to eligibility verification, what is the single biggest problem or issue providers face with scheduling, pre-reg and registration staff? TIP: The exact same problem has existed every year since 1989… Why is this continually an issue? Confirm Coverage Is that all? Are we done? Other considerations: Demographic verification Managed care Coverage types Co-pay /deductible Frequency-related issues Authorizations And many more
5. Front-end Challenges… Environment Fast-paced High pressure Very Complex Typically handled by entry-level personnel High turnover Train, train and retrain Concerns about patient Human nature The classic mandate: I want every patient registered quickly and ____________.
6. Revenue Cycle begins at the Front What used to be simple data entry now includes:
7. Addressing the Interpretation Dilemma… Best option is to automate Implement rules-based system that automatically triggers, programmatically interprets response, flags users on data discrepancies and other issues, and has quality assurance features – including management reporting. Dsffdsd Sfdf sfdsfdsfdsfds
8. Other Lower Cost Options… Don’t lose sight of the key requirement – facilitation of accurate response interpretation Otherwise you are throwing good money at the bad If you will allow the expression, what you want is “in your face eligibility” Rule #1: Don’t let best get in the way of better Three basic eligibility verification platforms: Browser-based, Batch-based and Integrated. Different costs, features and benefits associated with each approach
9. But Data is Data. Right? Initially yes. Eligibility data is truly a commodity. The key differentiator between commoditized eligibility data and an “eligibility system” is determined by: Quality of the user interface or experience, Capability to programmatically evaluate the response and apply actionable intelligence to potential issues discovered, including data “enrichment”, How consumable the data is for downstream processes, Degree of interoperability between downstream systems, including disparate systems.
10. Payer Websites Versus Vendor Browser… Vendor Browser System Multiple payer access Fewer security concerns Facility controls access Daily upload capability Auditable Multi-function Highly customizable Data enrichment Costs less Payer Websites Single payer access Greater security concerns User controls access No daily upload capability Not easily auditable Limited function Not customizable No data enrichment Costs more
11. Some Examples of Available Options…
12. More Examples…
13. The Power of Batch… Multi-payer, single file Medicaid, Medicare, Commercial & Self-pay Echo’s back all input data Patient type, plan type, plan code (bad plan detection), address, etc. Complete search cascading capabilities Multi-payer and other database cascading Payer to MCO/HMO Medicaid to Medicare to Comm. Address verification, etc. If % of Scheduled or Pre-Reg encounters is high then batch may be ideal… Look for these capabilities: Multiple input & output format options 270/271, Excel/CSV, other delimited, Access, and custom Additional output files User-friendly XML Import ready files (271 or custom for HIS, indexed for HIE, etc)
14. The Power of Batch, Continued… Multi-function in single file, continued… Medical necessity Authorizations Propensity to pay Credit reporting & scoring Notice of Admission Coverage Discovery Claim status Uniform output format for all payers Facilitates data import File or web-based view Data validation Member ID Social Security Number Name First, Middle & Last Date of birth Group number All highlighted if discrepancy Custom rules Multi-function in single file Eligibility Address verification Self-pay review
15. Batch Examples…
16. Batch Examples…
17. Batch, Web-based Post-back…
18. Integrated Eligibility Options… Vendor Controlled UI Key for “in-process” is existence of trigger X12 Scripting-based Out-of-process HL7 Vendor controlled UI is generally most robust HIS Controlled UI Straight EDI Examples Epic X12 Cerner X12 Meditech X12 QuadraMed X12 Siemens/HDX Enhanced EDI Epic
19. Transactional Intelligence… Content enrichment Captures discrete data elements New payer responses or data sets Payer website snapshot via hyperlinks Dynamic environments Static Environments
20. Content Enrichment… Leveraging content enrichment to add a discrete data element to the traditional payer response. Multiple data elements may be added, in real-time or batch.
21. Scraping Entire Payer Data Sets… Content enrichment can literally create a payer-specific EDI response from data previously available via payer website only, whether the payer is local, regional or national in scope.
22. The Importance of Eligibility in the Revenue Cycle Eligibility plays a very significant part in the healthcare revenue cycle. Moreover, the process involves much more than just verification of coverage. The absolute key is to find an affordable, cost-effective solution that facilitates accurate response interpretation. And remember, don’t let best get in the way of better!
23. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions