©2016 experian information solutions, inc. all rights ... · all our va therapy recurring claims...

©2016 Experian Information Solutions, Inc. All rights reserved. Experian and the marks used herein are service marks or registered trademarks of Experian Information Solutions, Inc.Other product and company names mentioned herein are the trademarks of their respective owners. No part of this copyrighted work may be reproduced, modified, or distributed in

any form or manner without the prior written permission of Experian. Experian Public.

2©2016 Experian Information Solutions, Inc. All rights reserved. Experian Public.

Introducing:

� Melanie BetancourtSharp HealthCare

� Rob StuckerExperian Health

©2016 Experian Information Solutions, Inc. All rights reserved. Experian Public.

The Quest for Clean Claims

A High Reliability Journey with Experian Health ClaimSource®


Perfection is not attainable.

But if we can chase perfection, we can catch excellence.”

- Vince Lombardi

Reflection


� Not-for-profit serving 3.2 million residents of San Diego County

� Grew from one hospital in 1955 to an integrated healthcare delivery system

Fully integrated information technology systems and infrastructure

► Centralized system support services

► Largest healthcare system in San Diego with highest market share

� Largest private employer in San Diego

► 17,000 employees, 2,600 affiliated physicians, 3,000 volunteers

Sharp HealthCare


To improve the health of those we serve with a commitment to excellence in all that we do.

Our goal is to offer quality care and services that set community standards, exceed patients’ expectations and are provided in a caring, convenient, cost-effective and accessible manner.

Sharp HealthCare’s Mission


To be the BEST place to work, BEST place to practice medicine, and BEST place to receive care

In the Universe

Sharp HealthCare’s Vision


� HROs are high-performing organizations that have:

► Highly Trained Personnel

► Continuous Training

► Effective Reward Systems

► Frequent Process Audits

► Continuous Improvement Efforts

� High reliability means getting things right each and every time by:

► Building and sustaining a culture that places safety and reliability as the basis for all of our work

► Preventing failure – in processes, policies, technology, and people

► Reducing the probability of error through interventions determined by our diagnostic assessment

� An HRO focuses on zero events of preventable harm to patients, families, and employees.

What is an HRO?


Managing the Expected – Process Reliability

� Standardization

� Standard work

� Automation

Managing the Unexpected – System Resilience

� Thinking

� Thinking in teams

� Information systems + adjustments

Two Types of Reliability


� Separate platforms, processes, and reports for Medicare and Medi-Cal

� Direct submission or through Emdeon or PostNTrack for most other payers

� Data fragmented and segmented

� Reports were not user-friendly and no Clean Claim Rate for direct to payer submission

� No actionable edits for commercial payers – relied on rejects and denials

� 835 remittance advices picked up directly from each individual payer

� No electronic claim system for skilled nursing claims – all hand keyed

Revenue CycleCatalyst for Change


It was Time for Change….


� Improved Cost Management & Revenue Cycle Intelligence

� Opportunity to align GE Centricity Business functionality with Experian Health ClaimSource® claim scrubbing capability

� HRO centric – with low touch, standardized workflows

Decision to Migrate to a Single Billing Platform


� Web based user interface – It Looks Like a UB04/1500!

� Hosted solution thus no server maintenance and low demands on in-house IT resources

� California based – Understood quirky rules and demonstrated ability to perfect a Medi-Cal claim

� Robust compliance edits

� Scalable to multiple lines of business

� Normalized 835 remittance advice data and Denial Manager

Why Experian Health ClaimSource DIRECT


The Road to Implementation


Clean Claim Rate Trend


� Standardized workflow as staff utilizes the same system across payers

� Reduced 14 GECB claim forms and queues to 5 claim forms and 1 queue

� Clean Claim Rates improvement in all sectors

� Use of 837/NTE segment to create very specific edits and bridge routines

� Remittance Advice pick-up and transfer

� Custom routine for posting Medi-Cal proprietary SCPI remittance advice

� MEA and Jopari for claims attachments

Process Improvement Efforts


� Transition of Sharp Managed Care/internal capitation claims

� NDC/UD Modifier custom process with both 340B vendors

� Automated collating of printed UB04s and EOBs for secondary billing

� Cloning of statistical claims to Medicare on transmission to Medicare Advantage plans

� The use of Denial Manager to monitor and trend denials

� Medi-Cal TAR Verification

� Secondary claims submission

� Claims available in history for resubmission

� Medi-Cal Bad Debt Module

Process Improvement Efforts Cont’d


� We had to manually rebill all claims that had multiple units for 360 and 762. Automatically changing units for 360s and 762s to 1 for billing BSC…. The bridge routine automatically changes the claim fso we were saving our follow up reps from manually changing at least 60-100 accounts per week.

� All our VA therapy recurring claims with bill type 132/133 were being denied because VA does not recognize this bill type. The bridge routine transforms the bill type for this payer from 132/133 to 132Claims are billed correctly and not denied for incorrect type of bill.

� The Aetna NRC roll up into the R+B charge. Aetna denies payment for NRC 460 as inclusive to R+B. ClaimSource® rolls the charges for NRC 460 into the R+B. Prevents denials and/or manual corrected claims.

My Favorite Bridge Routine


� Claims Reconciliation –

► 999, 277CA

► Missing files, load errors, communication disconnects

► Payer EDI resources

� Medi-Cal remittances/SCPI

� Newborn Hearing Screening Claims

� 340B Requirements for Medi-Cal and Medi-Cal Managed Care

Rough Terrain…


� KPI Dashboard

� Improved Line of Business reporting for SNF, Home Health, & Ambulatory

� HIM/Coding working coding edits directly in ClaimSource®

� Cold-feed of scrubbed claims and remittances in to document imaging system for better

� Enhanced 277CA

� Integration with Sentry/340B

Roadwork & Uncharted Territory


� “It is great to be able to pull up a claim that was sent in a matter of seconds and see exactly what was sent to a payor instead of having to physically print a claim. Also, it has allowed us to identify trends that can be fixed on our end so future claims can go out clean which will enable payment to come in from the payors sooner. I LOVE IT!”

-Kara, Commercial Team Lead

� “The Experian ClaimSource system is very user friendly. With Experian ClaimSource we have changed processes that have a great impact in meeting our goals.”

-Cindy, Medicare Team Lead

Testimonials


Ta Da…

©2016 experian information solutions, inc. all rights ... · all our va therapy recurring claims...

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