Ready or not, a change is coming to your Medicare eligibility check process.
The Centers for Medicare & Medicaid Services (CMS) has officially announced the deadline for hospital, home healthcare, hospice and skilled nursing (Part A) eligibility inquiries to transition to a new platform.
On February 1, you must bid farewell to the Common Working File (CWF) and embrace the HIPAA Eligibility Transaction System (HETS) for eligibility verification.
The future for CWF and HETS
Though all eligibility inquiries will transition to HETS, CWF will still exist for claims management functions (entry/status/summary) and other transactions.
For eligibility purposes, the main difference users will notice is that HETS requires slightly different input information and returns more targeted results than CWF. Other differences include once-daily information updates and a limit of 30 eligibility requests per day.
The most important thing to do prior to the deadline is prepare. If you’re already using HETS, there’s nothing you need to do. If you’re currently using both systems, you should start using HETS exclusively.
ABILITY® customers who currently use an application for eligibility verification can expect a seamless transition with no disruption to business as usual. All of our applications with integrated eligibility components are currently HETS-ready/connected. What that means for you is that February 1 will bring no changes or surprises.
To learn more about how ABILITY can provide a stress-free switch, request a demo today.
For additional information about the transition to HETS, visit the CMS announcement page.
“Meaningful and sustainable change to traditional staffing models is a moral imperative that requires urgent collaborative action.”
That call to action from the American Association of Critical-Care Nurses reminds us all that when it comes to staffing in healthcare, the status quo is no longer okay. We now have decades of research and first-hand experience that confirms we can have a positive impact on patient and workforce outcomes by changing the way we think about, model, design, fund and implement staffing policies and practices.
One sure tactic for doing so is adopting new technology, and specifically staffing software and applications, that can dramatically improve how we schedule staff.
For example, modern scheduling tools can enable:
- Better decision making. Staffing managers have at their fingertips the data they need to make quick, accurate decisions when it comes to filling shifts. Leading solutions offer intuitive dashboards that offer full visibility and real-time insights so you can act fast.
- Access from anywhere. Cloud technology and well-designed mobile apps enable managers and staff to access, manage and communicate about shifts from their mobile phones.
- A more collaborative culture. Managers and staff work together to fill open shifts. As a result, manager/staff relationships improve, staff satisfaction rises, and turnover falls.
- Less wasted time. Managers spend less time stressing over, completing and managing the schedule, and more time focused on making improvements that truly impact patient and workforce outcomes — and the bottom line.
All that isn’t to say that we are ignoring the realities of the healthcare industry. Administrators and managers are under intense pressure to control costs, while addressing insurers, changes in payer rules, unions, legislation, labor shortages, rising labor costs and more.
Still, with staffing being such a complex issue, it’s wise to look at solutions that can ease that complexity, while also helping organizations to heed the AACN’s call to action and drive better outcomes through simplified scheduling and improved collaboration.
About the Author:
Award-winning nurse leader Kathy Douglas, RN, MPH, has been in healthcare workforce strategy for over 20 years. She has authored dozens of published articles and presented on all aspects of staffing in healthcare. Kathy is also a filmmaker and directed the internationally distributed film, NURSES: If Florence Could See Us Now.
Is your healthcare organization losing money to inefficient patient billing workflows?
You’re likely all too familiar with the losses that you can incur from write-offs and denials, but you may be surprised at the hidden costs that come with a few very common workflow issues. Read more
How much are your remittances costing you? You may have hidden inefficiencies draining your time, labor and revenue. If any of the following issues sound familiar, you could benefit from a centralized approach.
Wasted time pulling from different places
How many different sources are you using to pull your remits? If your organization is like most, you probably have to access clearinghouses for some, payer websites or PaySpan for others, and some even come on paper.
Just pulling your remits takes time away from your billing staff that they could use in more productive ways.
Scanning, downloading and printing
Staff often have to scan in remits or save them to downloaded files for research and follow-up later on. These tasks are time-consuming and tedious, and they create a lot of inefficiencies in your billing processes.
Inefficient posting processes
How much time do you devote each week to posting remits? When billing staff are forced to retrieve remits from different places, posting takes more time than it needs to.
Challenges keeping up with multiple tax IDs
If your organization handles multiple National Provider Identifiers (NPIs) and tax IDs, your billing staff may have to split remits to post electronic remittance advices (ERAs) back into different electronic health record (EHR) and electronic medical record (EMR) systems. This is just one more way that disparate systems result in wasted time and increased A/R days.
Cumbersome methods for remit searches
Does your platform let you filter and search remits by different criteria — such as adjustment codes, reason or remark codes? If not, billing staff are forced to get creative and scour through potentially hundreds of remits to find what they need.
A centralized approach to remittance management
How can you take these inefficiencies and challenges out of your remittance management workflows? A centralized approach can save your organization significant time and money.
With the right technology, you could bring back all available ERAs into a single portal, eliminating multiple sources and workflows that your staff have been dealing with.
In one centralized location, you could easily download remittances for autoposting. If your organization handles multiple tax IDs, you could split the remits for posting into different systems. And, you could eliminate all scanning, saving and storing of remits. Instead, you would have a digital filing cabinet for all ERAs for printing and research.
Want to learn more about how you can simplify your revenue cycle with a central source for all your claims management needs? Read about ABILITY EASE® All-Payer here.
When you think of patient satisfaction, patient payments is probably not the first thing that comes to mind. But, if you take a deeper look into your patient payment processes, you’ll find a lot of avoidable inefficiencies. These can lead to hassles and inconveniences for your patients. Getting rid of them could be the key to a better overall patient experience.
You already know that accepting patient payments can be cumbersome. Billing staff members spend a lot of time every day on fragmented, manual processes that could easily be centralized and automated.
Let’s dive into a few of the things in your patient payment processes that frustrate your patients and waste staff time — and discuss how to fix them.
Centralize payment processes
Many organizations still use a collection of payment paths and processes. Your patients may pay you with cards, cash and checks at point of service, but they also mail checks to your office that have to be batched or scanned and deposited. If you have an online payment option, it may only accept cards and route payments through another vendor with an entirely separate process.
All those payment avenues should make patient payments more convenient, but they often have the opposite effect. They’re fragmented and confusing, and they leave your staff and your patients in difficult situations.
If you can centralize all your patient payment avenues, you can save time for your staff and give your patients more payment options.
Automate bookkeeping processes
Of course, accepting payments is only the beginning. After you accept patient payments, you have to log everything and ensure that your books are in order.
Daily balancing is a cumbersome and painstaking task. In reconciliation, your front desk staff have to pull data from banks and card processor reports, track cash taken in each day and ensure that all transactions balance correctly.
And what happens when a patient needs a receipt or refund from previous services? With different processes, finding and fulfilling this request can take precious time. Patients feel neglected, and staff are left with unnecessary added work.
If you switch to a single source for payment processing, you can eliminate these inefficiencies and free your front desk staff to focus on your patients.
Offer automated payment plans
How do you handle patient payment plans? Does the burden of monitoring payments fall on your staff? When payment plans aren’t automated, your front desk and billing staff are tasked with keeping track of every patient’s payment schedules, notifying patients when payments are due and following up after payments are made or if payments are late.
Organizations spend a lot of time sending statements and following up on outstanding balances, but that’s not necessary when you automate the process. Payments can be processed automatically each month, and you can greatly accelerate A/R while cutting down on collections. Once claims are adjudicated and accounts receivable are determined, you can charge the correct balance without a lot of extra work.
ABILITY® helps all organizations, from billing agencies to healthcare providers, streamline their patient payment processes every day. With a single platform — ABILITY SECUREPAY® — you can collect more revenue faster while enhancing patient convenience with card-on-file services and automated payment plans. At the same time, you can boost patient satisfaction by offering more payment options for your patients, including online options and check payments.
For more information on how you can streamline your patient payment process and capture 100% of your patient payments in a single platform, read about ABILITY SECUREPAY here.
Healthcare organizations have various metrics that help define and measure success. With so many moving parts, how do you determine what to prioritize?
A strong and efficient revenue cycle is the cornerstone of your organization, so it’s important to start there. It is responsible for paying salaries, buying new equipment and even keeping the lights on.
Are you making the most of your revenue opportunities? Below are three common mistakes that compromise cash flow, and what you can do now to correct them.
Failing to verify eligibility before providing care
Ideally, providers would prefer to verify eligibility for every patient before they receive care. In the real world, this isn’t always possible. Many things can prevent prior authorizations, ranging from unforeseen emergencies to a busy day in the front office that simply doesn’t allow the time.
While you can’t eliminate emergencies, there are ways to cut down on the mountains of paperwork facing your office staff. How many administrative tasks are performed manually? And of those that are electronic, how many different screens do they have to log into to confirm eligibility for just one patient?
Electronic claims management saves a substantial amount of time by enabling batch inquiries and alerts to indicate additional coverage for Medicare beneficiaries. You can verify eligibility for more patients in less time without rejected claims headaches after the fact.
Operating with a fragmented claims management workflow
Speaking of claims, is there anything that requires more time and attention than managing multiple claims with multiple payers? From unique business rules to confusing rejection codes, claims management is usually fraught with long A/R cycles and time lost trying to locate and manage missing claims.
Make your claims submission process more efficient from start to finish with ABILITY EASE® All Payer. With a single platform, you can manage CMS and all other commercial payer claims, verify claims against the most current business rules (as well as customize unique rules for specific payers), and even address eligibility issues up front, prior to claim submission. Most importantly, you can achieve acceptance rates of up to 98 percent.
When rejections do happen, the claim immediately returns to your work queue with a clear message about the correction needed. No more trying to decipher confusing codes while your A/R days pile up.
Writing off denied, low-value claims
In the hustle and bustle of a busy workday, it’s not surprising that low-value, rejected claims become the lowest priority. Billers are stretched thin and their time is better spent working on new, possibly higher-value, claims. But it shouldn’t come down to one or the other. Using the right technology, your staff can successfully handle all types and give a needed boost to a sluggish revenue cycle.
If you don’t find time to settle all of your claims, you aren’t collecting all the revenue you’ve earned. These “low-value” claims add up over time, so what seems like a reasonable write off could result in the loss of thousands of dollars. Not taking the time to resubmit these claims also contributes to poor A/R performance and patient frustration.
Some simple steps you can take to address this issue include:
- Have staff verify coverage and eligibility prior to treatment
- Use historical patient data to create new claims
- Track claims from submittal through payment
The single best thing you can do to strengthen your revenue cycle is to prevent as many rejected claims as possible. This is where electronic claims management systems can have a huge impact.
What do predictive analytics and insights have to do with getting more hospital referrals?
When you brainstorm ways to gain more referral sources, what comes to mind first? You may think of sending your business development team out on more calls, or even hiring more representatives to reach a wider range of hospitals. But putting more feet on the ground is expensive — and it isn’t the only way to increase your market share.
In fact, if you leverage the latest technology, you can do a lot more to get those referrals — without hiring more staff and increasing your overhead. Let’s take a look at some of the ways you can boost your competitive edge with analytics.
Discover untapped referral opportunities
Have you been reaching out to the right hospitals for referrals? Traditional business development strategies lack the insight to see which hospitals need to refer patients to facilities with your strengths. Find out more about patient movement by referral source or destination, and monitor your organization’s performance along the way.
Use analytics to identify your competition
Should you be worried about the facility across the street? Let’s say, for example, that you know of a few post-acute care providers in your area. You know that they serve patients with many of the same conditions that you do, and you know that your target referral sources overlap with theirs. To stand out, you need to know how your care compares with theirs.
With the right tools and the right data, you can see where your quality of care surpasses other post-acute care facilities, where you have room for improvement and where you have a competitive edge. You can then make strategic decisions about which hospitals you should be targeting and how to approach them for referrals.
Analytics can help identify market trends
For years, analytics tools have provided access to past market trends. However, legacy analytics tools could only look back. Their data inevitably lagged and couldn’t accurately project what was to come.
Next-generation analytics tools give you an up-to-the-minute view of market trends with accurate projections. You can use this data to make effective improvements to your quality care, target the right hospitals at the right times and improve your messaging to stand out as the top choice for referrals.
With the analytics in ABILITY INSIGHTTM Referral Mapper, you have the power to improve your business development strategy and significantly increase your market share.
The Patient-Driven Payment Model (PDPM) that goes into effect on October 1 is the largest financial change the industry has seen in 20 years.
The Centers for Medicare and Medicaid Services (CMS) changed the fee-for-service reimbursement model to a fee-for-performance model, also known as value-based care.
CMS’ objective with PDPM is to remove the financial incentive to provide routine therapy to patients regardless of their unique characteristics, goals or needs. Instead, PDPM classifies patients into payment groups based on specific, data-driven patient characteristics.
When the new structure goes into effect later this year, all skilled nursing facilities will be expected to comply immediately. How you fare during the transition depends on how well you plan ahead. Read on for four smart ways to prepare for PDPM.
Prioritize staff training
The implementation of PDPM will make it more important than ever to complete accurate and detailed Minimum Data Set (MDS) assessments. The initial diagnoses will set the bar for payments going forward and must be supported by clinical documentation each step of the way.
An application like ABILITY CAREWATCH® can help ensure accuracy by catching inconsistencies in your assessments before they are submitted. Providers can also analyze this data to improve care plans and locate reimbursement opportunities that may have been missed.
One such opportunity that PDPM incentivizes is accepting more medically complex patients, since reimbursement will be more closely aligned with their elevated care needs. Your staff must be equipped to deliver that level of care.
Expect that some staff training will be required prior to meeting the updated requirements for both the MDS assessments and the needs of patients requiring enhanced care.
Become or enlist an ICD-10 coding specialist
CMS’ FAQs note that ICD-10 codes will be used in two ways: First, providers will be required to report the patient’s primary diagnosis on the MDS. The diagnosis will be mapped to a clinical category and then further classified into therapy components.
Second, ICD-10 codes will be used to capture additional diagnoses and comorbidities of the patient, which factor into further classifying them into speech-language pathology and non-therapy ancillary components.
Many skilled nursing facilities don’t have certified coders on staff. Coding will be even more demanding under PDPM, and providers have a choice: either train key staff on the new requirements or consult with a certified coder.
Prepare to step down therapy use
One of the largest changes in the shift to PDPM is that reimbursements will no longer pay per therapy minute. Skilled nursing operators might consider renegotiating with their current therapy partners.
The new rules also limit group and concurrent therapies to no more than 25 percent. CMS considers this an important step to help ensure that patients receive the highest level of personalized care.
Don’t forget about your vendors
Skilled nursing facilities rely on many other service providers to run smoothly. Therapy providers, electronic health record vendors and others should be knowledgeable of the upcoming changes that PDPM will bring. Check in and make sure these providers are preparing diligently and sharing their progress and insights along the way.
One of the best ways to succeed under PDPM is to stay informed and prepare, so that when October comes, your facility can hit the ground running.
Claims denials happen throughout the revenue cycle, but often their origins are at the very beginning, the moment a patient seeks treatment.
What’s driving the denials?
According to the Journal of Healthcare Information Management, 86 percent of healthcare industry mistakes are administrative[i]. It’s not surprising when you consider the volume of paperwork faced by front-office staff, and what in many organizations is still a heavily manual workflow.
The Technology CEO Council found that patient charts cannot be found on 30 percent of patient visits[ii]. Without this vital information, basic patient data and benefit eligibility information are missing, leading to claims mistakes and denials.
Unfortunately, eligibility questions aren’t the only problem. In order for claims to be accepted and paid promptly, they must legible, accurate and complete – a tall order considering the number and complexity of diagnostic codes and the pace of regulatory changes.
Denials cost more than you think.
Trying to recover lost revenue can be a lengthy and expensive process, but worth the effort for providers. In the second quarter of 2016, the average automated claim denial from Medicare’s Recovery Audit Program was worth $714. And complex denials that required medical record review averaged $5,418[iii], according to the American Hospital Association.
With so much at stake, preventing mistakes from happening in the first place and avoiding denied claims is the best approach. But how? First, identify the real reason claims are denied:
People make mistakes.
We are human, and sometimes we make mistakes, no matter how good we are at our jobs, or how great we are as people. When you mix our humanity with a very complex healthcare system that is constantly changing — it’s no wonder errors happen. But it doesn’t excuse us from seeking a better way to complete this process.
It’s an easy fix.
Here’s the good news: most revenue lost along the revenue cycle is preventable through automation. And the majority of claims that are denied don’t have to be.
An automated system with a built-in claims scrubber, custom business rules and pre-submission eligibility checks can help ensure the cleanest claims possible. It can also keep up with current diagnostic codes so your staff doesn’t have to.
Imagine having a first-pass acceptance rate of 98 percent. It’s possible with ABILITY EASE® All-Payer, a software application that also helps eliminate the administrative burden of submitting secondary claims.
When it comes to revenue cycle management, it really pays to do it right the first time. Advanced technology makes it possible.
[i] Journal of Healthcare Information Management, Volume 17, Number 1, Winter 2003, https://www.himss.org/jhim/archive/volume-17-number-1-2003.
[ii] Technology CEO Council, A Healthy System Report, 2006, http://www.techceocouncil.org/clientuploads/reports/A_Healthy_System_Final.pdf.
[iii] Jacqueline LaPointe, Hospitals Still Facing Medicare Claims Denial Management Issues, October 17, 2016, https://revcycleintelligence.com/news/hospitals-still-facing-medicare-claims-denial-management-issues.
Revenue cycle management should be a priority throughout the patient’s journey — from the moment a patient walks in to receive healthcare services, to the moment that patient pays their final bill. There are many opportunities along this journey for healthcare providers to make their revenue cycle more efficient and productive.
These “big-picture” tools help along the way: clear communication, top-notch staff training, superior organization and state-of-the-art technology. But this high-level, simplistic view of revenue cycle management just scratches the surface when it comes to Medicare claims.
When your revenue cycle management journey includes Medicare, you’ll often experience detours, obstacles, errors, stalls and redirects. (And sometimes you have to do it all over again.)
The job of advanced technology is to make this journey as smooth as possible. Simply put, technology’s main goal is to improve revenue cycle management. This includes such things as: eliminating redundancies, reducing or removing human error, easing frustration and getting that final bill paid quickly and correctly.
What are the best ways to get your Medicare claims to the finish line? Are there ways to save time and money along the way? Here are three tips to help simplify Medicare claims:
Tip #1 Use your time wisely.
It seems like every week there is a new rule or regulation from CMS. Keeping up with these changes is a job in itself. When preparing documentation for Medicare claims, who has time to do anything more than once?
CMS continues to toughen its claims scrutiny, and organizations could see an increase in post-payment reviews. Plus, changing payment models are boosting the number of denials and the need for appeals.
Your time is important. Automate your most time-consuming processes: submission and tracking of ADR responses, RAC audit information and appeals.
Tip #2 Pass on paper.
These days, stationery stores have all but disappeared, but the healthcare industry still loves (and uses a lot of) paper. Did you know 50 percent of healthcare claims are filed are on paper? This can result in errors and wasted time.
Paper wastes a lot of money, too. A recent CAQH Index® report shows a staggering $8.5 billion is being wasted on medical providers’ manual transactions.
Reduce your overhead and save time by eliminating paper, printing and mailing costs. Instead, submit your Medicare documentation using secure, HIPAA-compliant electronic delivery.
Tip #3 Let technology do the heavy lifting.
Technology plays a critical role in successful claims management. It can streamline your process for secure submission, tracking, and reporting for Medicare claim review programs, and even help ensure proper reimbursement.
Medicare claims offer unique challenges that only the most adaptable, comprehensive and robust application can handle. Applications like ABILITY AUTOMATETM esMD manage Medicare claims and make the process a whole lot simpler for you.