THIS YEAR’S nationwide launch of Medicare’s Recovery Audit Contractor (RAC) program is forcing healthcare providers to go on the defensive. The old process of preparing a bill and making sure it gets paid has gotten much more complicated, says Paul Pitcher, a financial services analyst for KLAS. Hospitals are now being forced to justify their billing processes or face a loss of reimbursements.
While some of the smaller providers are making do with spreadsheets, Pitcher says most forward-thinking hospitals are looking to claims management software to expedite the process. This, he says, has given rise to the denials management tool, a new subset of claims management technology. Healthcare IT vendors have taken notice as well, and are either adapting their RCM tools to handle RAC audits or developing new solutions to handle RAC and other audits coming down the road.
THREE TRENDS TO WATCH
KLAS analyst Paul Pitcher sees three trends shaping denials management in the coming year:
1. RAC ATTACK: Medicare’s RAC program is forcing providers to justify their billing practices. The most forward-thinking are using healthcare IT tools to create defensible audit trails.
2. STAFFING: Hospitals are bulking up their RCM departments to make sure audits are handled properly.
3. ADAPTATION: Vendors and providers are realizing that the RAC program is only one of many audits expected to affect the healthcare industry in time. With that in mind, new tools are being developed to manage all audits – and help hospitals improve their billing processes to reduce denials.
Alpha II’s RevenueQueue automates the tedious task of auditing claim remittances, turning explanation-of-benefits data into business intelligence and discovering missing revenues for both small and large healthcare organizations. As a collaborative denial management workflow tool, RevenueQueue helps users prioritize tasks – by payer, volume or dollar value, for example – for greatest impact.
Contact: 800.476.8477 (Tallahassee), 888.889.6777 (Montgomery), email@example.com
Claims and Denial Management Solution
MedAssets’ claims and denial management solution improves financial performance throughout the revenue cycle. These products increase net revenue and improve cash flow by identifying and resolving billing and payor errors prior to submission, reducing denied claims, recovering lost revenue on denied and underpaid claims and improving upstream processes. MedAssets’ solutions help ensure that claims are processed automatically, accurately and consistently.
Contact: 888.883.6332, firstname.lastname@example.org
Audit Tracker Online
Certified by the American Hospital Association, MRO’s Audit Tracker Online is an affordable tracking and reporting solution designed to help healthcare providers effectively manage the Recovery Audit Contractor (RAC) process and a variety of other payer audits from initial medical records request through appeals and payment resolution. In addition to tracking all aspects of the process, Audit Tracker Online creates detailed trend analyses, identifying steps that will allow providers to enhance the claims process and improve clinical and financial information in an effort to avoid future audits.
Contact: MRO Corp. Sales Department, 888.252.4146, email@example.com
Navicure Claims Management
Navicure is a leading Internet-based claims clearinghouse that helps physician practices increase profitability through improved claims reimbursement and staff productivity.
Matthew Halkos, 877.628.4287, firstname.lastname@example.org
NextGen Practice Management
NextGen Practice Management offers automated real-time tasking, productivity transparency, eligibility verification, electronic claims/billing, denials and aging management, user generated reporting and more.
Contact: 877.654.9245, email@example.com
Artiva Healthcare improves efficiency and productivity, proactively avoids claim denials and reduces write-offs, thus increasing cash. The denial management solution trends payer denials to support denial/rejection/appeal follow-up and highlights payer trends. Artiva enforces business processes through advanced workflow, prioritizing worklists on numerous criteria, including payer, balance, age and plan code.
PCG Software, Inc.
Virtual Reporter is a workflow management application that serves as the user interface for PCG’s fraud and abuse prevention software. It automatically updates claims on the host system to improve workflow efficiency and flexibility when detecting fraudulent, abusive and wasteful billing practices.
Contact: PCG Software, Inc., 877.789.1291, firstname.lastname@example.org
Billing, coding, auditing and consulting services
Revenue is at risk from declining reimbursement, claim underpayments, greater complexity and the increasing cost of doing business. Through premium technology resources and superior expertise in medical business management, PracticeMax can legitimately increase net revenue by minimizing the costs associated with undercoding while mitigating the risk of overcoding.
Contact: Scott Everson, 480.374.7207,
Denial Management and Decision Support
ZirMed’s Denial Management and Decision Support (DMDS) solution is part of ZirMed’s Analytics services. ZirMed Analytics is an advanced analytic engine that helps healthcare providers of all sizes better understand, correct and receive payments and better organize the business to deal with payer- and patient-related revenue issues. DMDS helps healthcare providers by analyzing vast amounts of claim and payment data to identify errors and areas for increased efficiencies. It also enables providers to collect lost income at minimal cost. Denial Management and Decision Support is a subscription-based service that converts revenue cycle data into actionable information. It also establishes best practices that can be used to pursue continuous improvement.
Contact: 877.494.7633, www.zirmed.com
“Navicure enables us to see where our claims are at any moment and to better manage denied claims. As a result, we’ve been able to decrease A/R days by 18 percent and increase net collections by 16 percent.”
– Tracie Little, insurance manager, Medical & Surgical Clinic Magee (Miss.)
“Between MedAssets Claims and Denial Management solutions and our own outstanding staff, we have addressed systemic issues that were broken in our claims processing, leading to excessive denials. We can address the causes internally, or with payers, effectively and promptly. Our clean claims rate is now more than 90 percent and our cash improvement is significant.”
– Dee Chaisson, vice president of revenue cycle, JPS Health Network.
“After implementing NextGen Practice Management, our clean claim submission rate increased to more than 98 percent. The product also enabled us to enhance revenue through improved collections, which represented an initial gain of nearly $100,000.”
– Suzanne Bruno, practice administrator, Horizon Eye Care
“As we progress from one report to another we can see this (ZirMed) is very beneficial for any clinic. Thank you for a fantastic product! As we continue to experience a decline in reimbursements we have to work smarter and this allows us to do our job with better decision support tools.”
– Tina Cikanek, Kilgore Vision Center.
“Prior to the utilization of Ontario Systems’ Artiva Healthcare system, UNC Hospitals did not have a structured denial management process. Our data was managed at the account level and categorization of denials was dependent upon user interpretation. Because of this, our workflow was limited and reporting was inadequate and inefficient. We are now able to capture, record, respond, analyze and, most importantly, have improved our denials management. In our first three years, we saw a 20 percent reduction in avoidable losses and are now able to better understand our business and where we need to focus our improvement initiatives. We now have a denials management infrastructure that can easily adapt to our changing business needs.”
– Matt Castellano, IT director, revenue cycle systems, University of North Carolina Health Care System.