Claims management in a new era of CMS scrutiny

Manisha Sharma is a senior product manager at ABILITY Network, and is responsible for managing and defining ABILITY | EASE®, our Medicare revenue cycle management application. We recently talked with Manisha about the industry trends that are affecting healthcare billers and executives, and how better analytics can help organizations stay on top of their revenue streams.

What changes by CMS are challenging RCM professionals right now?

Medicare payment policy is evolving from the cost- and charge-reimbursement approach to value-based payment. In addition, Medicare is looking at claims more carefully to make sure claims are paid appropriately, and as a result, payments can be delayed or unpaid. Claims are getting audited both pre-payment and post-payment, which has increased the work for RCM professionals considerably.

How are billers and executives responding to these challenges?

We know that being able to spot trends is important, particularly at the executive level. Organizations need to be able to figure out the answers to the big questions—what is causing underpayments? What is causing denials? Why are they seeing more ADRs?

EASE customers have told us how they use the application to get answers to questions like this, which led us to look for ways to make it work even better for these purposes. Healthcare organizations need a solution that will help them maintain a consistently high collection rate, reduce A/R days, and protect against revenue leakage. That’s what drove the development of the new Analytics capability.

Medicare is a major payer for most of our EASE customers; it’s a huge revenue generator and it really needs special attention. EASE Analytics reports display every aspect of claims processing, highlighting critical information and Key Performance Indicators (KPIs). This data lets billers identify the smallest errors and gives them actionable insights, and it also consolidates to a high-level view of total outstanding A/R.

What kind of KPIs should organizations be looking at?

There are three particular KPIs we recommend to help customers optimize their workflow.

  • The first is Date of Service (DOS) to DDE—claims submission to Medicare. Organizations can measure from the time they completed patient treatment to the time it takes to submit the claim to Medicare. It’s very important to measure this part of the process, as delays here affect revenue collection time, so you can watch for any variation from month to month and continue getting claims out quickly.
  • The second KPI we like is DDE to Paid—basically, the time it takes for Medicare to pay the claim. Typically, it takes 14 days, but if you’re seeing a trend of claims taking longer than average, you can make appropriate plans for your cash flow. More importantly, you can look at what steps you need to take to reduce the average number of days.
  • Finally, there is a DOS to Paid measurement, which gives organizations a full-cycle look at the time between when service is rendered and when the claim is paid. This provides a really useful high-level look at the efficiency of the revenue cycle.

With this kind of data, organizations have more insights into what’s really happening with their revenue cycle, and the KPIs can be tracked from month to month to identify and resolve any issues quickly. This is the kind of data that RCM professionals need to thrive in this changing Medicare climate.


Want to see a demo of the new analytics capabilities? Click here to view a recent webinar.

Look for part 2 of our conversation with Manisha soon. We’ll cover how healthcare organizations are handling the tactical challenges of increased ADRs.