Patient Access / Financial Clearance
A comprehensive hard-wired approach to pre-encounter processes is key to reducing denials and maximizing reimbursement. Clear lines of accountability during scheduling, insurance verification and pre-registration processes inclusive of:
Patient Access / Financial Clearance
- Selection of correct insurance plan
- Determination of pre-authorization needs
- Obtaining of authorizations and process if not able
- Determination of specific benefits for ordered services versus just verifying coverage
- Determination of patient responsibility
- Pre-service collection (POS Collection)
- Medical Necessity checking and associated ABN process
Collection of past-due accounts, if desired
- Charity care eligibility
Atwater Consultants have helped many Clients improve the patient experience and Staff effectiveness/job satisfaction while delivering measurable financial performance improvement. We deliver results with a seamless combination of IT systems optimization, Staff alignment and training, along with process redesign and implementation.
Using 835i Payer Remittances to properly identify Denials can be a daunting challenge, and the trend of increasing Denials volume is accelerating. Some of the challenges are caused by:
- Billing system mapping of payer remark/denial codes to specific follow-up activities and related worklists are frequently inaccurate; Application-specific expertise, combined with expert understanding of Payer denials coding is required
- Frequently Worklists include denials which would not result in an increase in reimbursement [ex: DRG’s]. Setting up the Application to accurately identify these zero-pay Denials is essential to avoiding unnecessary collections efforts.
- Lack of life-cycle tracking, trending and management of denials can frequently cause an endless and insurmountable cycle. Accurate Reporting and trend-analysis must be used to identify root causes and pop-up payer behaviors, followed by rapid improvement events [RIE] to correct and fend-off increase in denials volume
- Denial Codes assigned by Payers may be distorted causing inaccurate Remit Posting which would cause inaccurate/incomplete Work Listing. Billing system setups must accommodate these payer-specific situations so as to avoid wasted time and inaccurate Reporting
- Take-backs and other credits coming in on the 835i are frequently posted inaccurately, causing lost opportunities to challenge the Payer or re-Bill the encounter.
- Delays in correcting and re-Billing Denials may be causing lost write-offs.
Atwater Consultants have proven track records of improving cash recovery through accurate denial identification and laser-focused collections. From this work, root causes are identified and realistic plans for avoidance are developed
Charge Capture and Charge Integrity
Setting up processes and system settings to accurately identify and trigger Charges at the time of care requires careful attention to detail and continuous monitoring. Developing processes, system settings, and meaningful Reporting are the first step; once baseline data is captured and careful analysis is completed, there is frequently a significant opportunity for improvement.
Atwater Clinical, IT, HIM, and Revenue Cycle experts know these challenges and can help assess, design, and execute on performance improvement programs. Results are frequently significant.
Comprehensive KPI’s [Key Performance Indicators] are essential. The capability to dig into data ranging from enterprise-wide all the way down to Department [and in some cases individual or procedural] is mission-critical. Producing and distributing meaningful reports will infuse the entire organization with accountability and transparency. Often the work of implementing and educating users on daily, weekly, and monthly KPI’s will induce behaviors that yield direct bottom-line results.
Organizations frequently struggle with Reporting and Benchmarking. We work with our Clients to design KPI’s and create distribution strategies so that the right people, at the right time, receive the information they need to run their business. By establishing benchmark KPI’s early in the implementation process the entire team remains focused on measurable outcomes, rather than being distracted by unproductive ‘noise.’
Patient Status Changes
Assigning Patients to the correct status [IP, OP, OBS] then monitoring and adjusting as appropriate: Sounds like a pretty straightforward task: NOT SO!! Almost every Provider struggles with the result they have Compliance issues, Denials, and frequently, lost Revenue. Through data analysis, Chart review and process observations, these opportunities can be identified, and new processes built to avoid risk and possible lost Revenue.
By determining if this is an issue at an early stage of the implementation, processes and system tailoring can be developed well prior to the go live. Our consultants can lead the adoption of new processes and tools that minimize this issue.
Remittance Processing/Cash Reconciliation
Accurately posting Remittances is essential to managing the AR. Commonly found issues include creation of credit balances, mishandling of ‘zero pay’ remits, lost tracking of Denials, inaccurate handling of take-backs, inability to Balance Cash daily/monthly, Vendor anomalies on use of ANSI Coding, mismatched Lock Box cash receipts to Remit batches, and more.
How Claim Payments are posted to the AR, and how Cash is reconciled is often a challenge. Growing Credit Balances, unreconciled Cash, inability to trigger Secondary Payer Billing can result. We work with some of the largest most complex organizations to help them fix these issues. By understanding the current state, Atwater consultants can help organizations prepare for a clean and accurate migration to the new application.
Service Master [CDM]
Service Master [CDM] pricing, descriptions, and assignment can cause lost Revenue or net Cash opportunities. In addition, organizations are increasingly concerned about competition [the $10 aspirin!] A CDM review by experienced professionals can frequently yield optimized Billing and collections.
CDM optimization projects frequently deliver a significant uptick in net Revenue. Having a ‘clean’ CDM with market competitive pricing is an important part of a system migration. Atwater has completed many such engagements.
Managed Care Contract Management
Managing complex reimbursement terms under Payer Contracts requires careful set up of the contract management application and a comprehensive process to accurately calculate expected reimbursement and evaluate all payment variances. Specific areas for review include:
- Review of all payer contracts in effect
- Modeling of contracts to ensure terms are commonly understood
- Review of current system set-up against current contracts
- Determination of adjustment timing (at claim or at payment)
- Development of policies and procedures for variance review
Atwater consultants understand complex Contracts and the technologies and processes needed to drive optimal cash collections. We help our Client’s with accurate system set-up along with staff training, to ensure success.
Analysis of DNFB can include opportunities for accelerated and improved Billing and cash collections. Charge capture, Clinical documentation, Coding throughput, timely filing, and system gaps are commonly found.
Atwater consultants can help quantify DNFB at a detail level, understand root cause, and tailor solutions that take advantage of the new applications’ functionality.
Building and maintaining system settings that trigger Secondary Payer Billing can be challenging. Careful analysis of the AR can identify accounts where the Secondary Payer Claims aren’t calculated or billed accurately. Correcting roadblocks can frequently unlock net new cash.
A quick review of a Client’s current state Secondary Billing processes, AR, and system settings often surfaces issues that need to be made part of an implementation plan.
AR Follow-up and outside AR Collection Agencies
Being prepared to assign Accounts very soon after go-Live is essential. Analyzing the current state and rebuilding them in the new application is mission-critical implementation task.
Atwater consultants understand this process including construction of the many two-way interfaces required to drive SBO processing.
Sitting smack between the clinical world and the Revenue Cycle is HIM/Coding. This essential mission-critical function demands careful attention to implementation details including interfaces, User training, and staffing alignment.
Atwater can conduct short-duration high impact current state/future state analysis and produce fact-based recommendations for improvement. When gaps or roadblocks are identified early, they can be addressed in concert with the implementation, thereby avoiding possible spikes in DNFB and other Billing hiccups post-Live.