[MT-L] Claims Cleanup : Reimbursement Mangement

[James A Purvins]

Happy Friday Meditech L,

Are others out there struggling with the number of claims on your system ? My question are for those folk that are utilizing Meditech claim features to the maximum. This would include secondary and supplementary claims (yep, I just found out those two terms are not synonymous). Also, those facilities that use reimbursement rules and Step Magic to full advantage. Claims upkeep and keeping your reimbursement rules current is a constant maintenance effort.

 

It becomes an incredible effort, especially when you have a block of insurances or insurance types that new and exclusive rules apply. New claim forms, new reimbursement rules, it just complicates things immensely.

 

That’s not even taking into consideration how long a facility has been on Meditech, migrating from UB to 837 to 5010, that is a LOT of claim forms on the system to manage, of course you would try to inactivate any legacy claims as you are bringing your claims through the update process.

 

I’m just wondering how facilities are managing this process ? Do you have claims and proration rules according to your contracts ? To restrict the reimbursement rules, you can program your write offs in Step Magic to restrict by insurance. I like to stay clear on putting in insurance logic into the reimbursement rules since page one has the insurances defined. But the two edge sword of copying your reimbursement rules when specific insurance auto adjustments come into play becomes a nightmare.

 

How about those folk that move into a new implementation ? Is that an opportunity to clean up and streamline your claim forms ? I’m a believer in doing less edits in the host claim system (be it DSG or whatever claim clearinghouse you are using) and the claim coming out of Meditech should be exactly what is being submitted to the Clearinghouse or insurance company.

 

I’m just curious how others are grappling with this maintenance nightmare.

Meditech offers such flexibility, its hard to keep that flexibility under control.

Thank you for any feedback, I know this is Friday, so I probably will send a follow up message next week with some further items of interest.

Jim Purvins

[Taylor, John]

Many “claims” issues are not really claims issues at all, but problems that start and are not addressed up stream of the Business Office.  Missing subscriber information, missing authorizations, etc.  Claim checks are designated as either UR, Pre-Bill, or Claim with responsibility falling to Patient Access, HIM, and the Business Office respectively.  Accounts are available on a daily work list via the Biller Desktop, with representatives from each of these designated areas working those accounts.  Additional work lists are created for special issues, such as missing occurrence codes.

 

We have an extended Revenue Cycle team consisting of Directors from HIM, Patient Accounting, Business Office, and Revenue Cycle that meet weekly.  The team addresses high-value issues affecting cash flow, timeliness, etc.

 

Changes to claims, dictionaries, etc., are presented to the extended Revenue Cycle team and approved, deferred, or not implemented depending on the merits of each request.

 

And I wholeheartedly agree that claims should be as clean as possible before going to the clearing house Jim.

 

 

Thanks,

 

John Taylor

Systems Analyst, Information Technology

Augusta Health | Office:  (540)332-4882

[David Summers]

Not to beat a dead horse hear, but I thought this would be a good group to defer to.

Is it the responsibility of the information systems department to develop the proration rules?  We're having a department conflict in getting this sorted out.  Getting a decisive opinion on this would help steer our view.

Thanks,

Dave

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Dave Summers, RHIA

Financial Analyst | IS

Bethany Methodist Corporation

773.989.1417 work

312.290.0004 pager

CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify Methodist Hospital of Chicago immediately by telephone at (773) 989-1407 and destroy all copies of this communication and any attachments. 

[Sandy Oliver]

Hi, Dave.  All were good questions/comments.

Here at our facility, we have a Billing Analyst who works in the Billing Dept to support our Billing/Collections Dept, and me.  I work in the Information Services Dept and I support Billing/Collections as well as a few other areas.

Proration rules are done by both the Billing Analyst and me.  At present, she handles the simpler ones, & I handle all else.  It's a team effort as we continue to learn & move forward. 

Yes, you are absolutely correct.  Claim and proration maintenance alone is a full time job.  Our Hospital has been on Meditech for many, many years & I am fairly new here...just over a year, so I am cleaning up many of the BAR dictionaries.  The Claim dictionary in particular is in need of much maintenance because as you stated, there have been many versions of claims, claim programs, etc.  Right now I am trying to clean up the invalid claim checks.  On top of all else, payers consistently continue to change the billing rules so that adds a whole new level of maintenance.

We do have a Revenue Integrity Dept and our Manager has been here for a long time & has a wealth of knowledge.  That area handles the charge master & all related maintenance, as well as other things, of course.

I hope that this information is in some way helpful to you.

Merry Christmas,

Sandy Oliver, Sr. Application Analyst, Information Services Dept.

Holyoke Medical Center

575 Beech St.

Holyoke, MA  01040

413-534-2873

>>> David Summers <dsum...@bethanymethodist.org> 12/23/2015 2:38 PM >>>

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[Gary Ring]

David:

 

I don't think the issue is which dept or cost center has responsibility from a budget standpoint, since I've seen and been involved with both:  the BAR resource is an I.T. resource; or the BAR resource is imbedded/part of the PFS dept. I think the question is what type of talent/knowledge base is required.  BAR support, like LAB, can be somewhat technical depending how far you push the envelop. Proration Rules, for example, could need someone with Magic coding/programming experience if you use the Step Magic function to deal with complicated rules/contracts.  It also certainly helps when you're trying to communicate specific logic to MEDITECH for things like Claim Checks, 837 5010 Claim files/formats, and 835 5010 Remit files/formats. 

 

But specifically for Proration Rules, it really depends on whether you're using the Rates/Hooks "table" function or whether you are using Step Magic. If you use Step Magic with Magic code, and you don't have a programming-type resource in PFS with Magic coding experience, then it probably makes sense to relegate that function to I.T. or make it a dual I.T./PFS responsibility. 

Gary J. Ring
President
RINGCONSULTING

11 Jones Road
Peabody, MA 01960
978-807-1573
www.ringconsultinginc.com

www.linkedin.com/pub/gary-ring/7/741/43b
 

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From: "David Summers" <dsum...@bethanymethodist.org>
To: "John Taylor" <JTa...@augustahealth.com>
Cc: "James A Purvins" <jpur...@comcast.net>, Medit...@mtusers.com
Sent: Wednesday, December 23, 2015 2:38:02 PM
Subject: Re: [MT-L] Claims Cleanup : Reimbursement Mangement

[Taylor, John]

I tend to favor the IT side since I’ve seen hospitals not having implemented well and really struggling.  Poorly implemented proration can lead to a myriad of problems including misstated Operations Summary, higher touch rates on claims, staff making too many manual adjustments, problems in reimbursement and contract management, financial loss, etc.

 

Regardless of who is responsible, core competence is key. 

 

Thanks,

 

John Taylor

Systems Analyst, Information Technology

Augusta Health | Office:  (540)332-4882

 

[David Summers]

Sandy, Gary, and John,

I really appreciate your insight into this matter.  Extremely helpful in where our organization should go in regards to these pursuits.  Hope you all have a wonderful New Year and thank you for your time.

-Dave