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Proprietary and Confidential. Do not distribute. 1 The Problem Code, click submit, then wait for... –Rejections and denials Manually edit claims and resubmit.

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Presentation on theme: "Proprietary and Confidential. Do not distribute. 1 The Problem Code, click submit, then wait for... –Rejections and denials Manually edit claims and resubmit."— Presentation transcript:

1 Proprietary and Confidential. Do not distribute. 1 The Problem Code, click submit, then wait for... –Rejections and denials Manually edit claims and resubmit Then the entire process starts over –Reimbursement While all of this is taking place... –Cash flow is unpredictable –Rejections and denials increase A/R days –Productivity suffers and costs escalate 15% ► The portion of claims that are rejected or denied, necessitating rework and resubmission $25 ► The average cost per claim for rework and resubmission $68,000 ► The cost per physician per year in time spent interacting with payers* * Medical Group Management Association study: “The Costs to Physician Practices of Interactions with Health Insurance Plans,” Lack of Transparency in Current Physician Workflow

2 Proprietary and Confidential. Do not distribute. 2 The Solution – Advanced Clinical Editing by Optum Reviews claims before submission to payers to reduce claim denial rates, shorten accounts receivable cycles, and increase the rate of collection Helps physician groups –reduce claim denials by pre-screening for billing and coding errors –stay current with new and changing guidelines –comply more easily with Medicare and commercial regulations –realize significant ROI through intelligent automation Unparalleled Clinical Content Continuous Investment Industry Leader Commercial editing Over 9 million Professional coding relationships Over 1 million Facility coding relationships Medicare editing (including LCD and NCD) Over 56 million Part B coding relationships Over 15 million Part A coding relationships Resource and financial investments are made annually to help gather and maintain the content used in our editing and billing products Quarterly knowledgebase update / bi-weekly NCD/ LCD updates Yearly/ bi-annual software new feature releases Medicare Physician Quality Reporting Initiative (PQRI) edits and rules Medicaid Fully prepared for 5010 & ICD-10

3 Proprietary and Confidential. Do not distribute. 3 The Power Behind the Advanced Clinical Editing 81+ million industry sourced coding relationships –Contains 10 million Commercial knowledgebase edits –Contain more than 15 million Part A, 55 million Part B Medicare Knowledgebase edits Sourced at the code relationship level Supported by disclosure statements Date sensitivity at the code relationship level Quarterly knowledgebase update / bi-weekly NCD/ LCD updates ICD-10 Ready Comprehensive Commercial and Medicare Knowledgebase Diverse Team of Medical and Clinical Coding Experts Team of over 40 experts supporting content development Team of Medical Directors, Specialty Panels, RN’s, LPN’s, RHIT’s, RHIA’s, CPC’s, CCS-P and Legal Support Methodology reflects clinical research, comprehensive coding expertise and claims data analysis Clinical, technical and end user customer support

4 Proprietary and Confidential. Do not distribute. 4 Medicare Coverage Data Development Process IdentificationDevelopmentDelivery Tech One reviews the policy end-to-end Changes are updated in the internal development application (ContentManager) Tech Two completes a QA of the entire policy after Tech One and gives final approval OptumInsight Data Operations extracts all policy data Data files are posted on the customer portal for download and utilization in Advanced Clinical Editing Data Driven LCD/NCD rules allow for timely release and implementation of new requirements; updated content delivered biweekly Revision Identification Tool identifies the policy update (processed weekly) Policy is flagged for development Medicare Coverage Data Team recognizes the importance and weight that the National Coverage Determinations carry in the claims adjudication process –Each NCD has been analyzed for coding opportunities by a team of content experts and a written analysis developed and maintained for each NCD.

5 Proprietary and Confidential. Do not distribute. 5 Medicare Coverage Data Development Process - Codifying the NCD/ LCD Policies LCD Policy Text page 24 page 10 page 3 page 26 page 1 of 38 OptumInsight translates to clinical edits

6 Proprietary and Confidential. Do not distribute. 6 Medicare Source Data Mining In addition to LCD/NCD maintenance, extensive data mining is done within CMS published sources to identify any overarching requirements: –Medically Unlikely Edits (MUE); –National Correct Coding Initiative Edits (NCCI); –National Physician Fee Schedule (NPFS); –CMS Manuals; –MLN Articles; –CMS Transmittals; –Federal Register The Medicare Rule Set contains 109 system rules that are reviewed annually to ensure continual compliance with CMS claims processing guidelines.

7 Proprietary and Confidential. Do not distribute. 7 CPT codes to DX to modifier relationships Sequencing of DX codes Appropriate use of modifiers Age, gender, frequency relationships Medicare unbundle (CCI) Medicare edits (MUE, globals, reductions) Non-covered services Commercial unbundle edits NCD/LCD Missing charges Duplicate charges Validation edits (CPT, HCPCS, ICD-9) HIPAA compliance and certification (WEDI SNIP levels 1-7) Presence of a field (provider, provider tax ID, insurance ID) Payer companion guide edits (loop, segment) Claim-level Medicare edits (CCI, MUE) Claim-level LCD Validation edits (CPT, HCPCS, ICD-9) Advanced Clinical Editing is Vastly Different from Typical Clearinghouse Edits Typical Clearinghouse Edits ACE Adds 65 Million Clinical Edits!

8 Proprietary and Confidential. Do not distribute. 8 © Ingenix, Inc. 8 What if There Was a Better Way? The Solution – Value to Medenet & Medenet Clients Q: What if …. Clinical coding edits happened prior to payer claims adjudication –Deliver coding edits back earlier in the process –Clear easy to understand messages Regulatory and payer rules were automatically updated? –Quarterly Knowledgebase release –Bi-weekly LCD/NCD updates The solution was affordable and within reach of even the all physician practice? A:  Lower administrative costs  Increase first pass pay rates  Increase Customer Satisfaction  Increase transparency

9 Proprietary and Confidential. Do not distribute. 9 Benefits for Providers Error detection moves further upstream in the process Lowers A/R days Decreases denial rates Increases staff productivity and workflow Identifies Missed Billing Opportunities Increases Revenue Compliance, Audit Avoidance, and Education Core Value: More timely & accurate claim payments and reduced administrative burden Adding Value for Providers

10 Proprietary and Confidential. Do not distribute. 10 ANSI X12 HIPAA edits Edit correction Sends claims to Payer Advanced Clinical Editing Workflow Encounters/ Charges Remittance Information, Denials, Rejections Charge Entry Charge Entry Work Queue Charge/ Postings/ Claims Processing Practice Management System Advanced Clinical Editing Clearinghouse Clinical Edits Historical Editing Remittance Claims Claims Adjudication Payer Remittance Claims Remittance Information, Denials, Rejections

11 Proprietary and Confidential. Do not distribute. 11 © Ingenix, Inc. 11 Sample Edit Scenario - Medicare Positive Editing Examples Increase Payments for Medicare Services Medicare Venipuncture (mVP) DefinitionValidates that both the venipuncture and lab code was billed Edit TypePositive edit Example It is important to take a Hemoglobin A1C test annually to detect diabetes before symptoms start to manifest. When the lab test is performed, the physician should bill for both the drawing of the blood as well as the hemoglobin test. If only the hemoglobin test is billed, ClaimsManager will flag the missed venipuncture code. The addition of the code will result in increased revenue. Billing Established Codes for New Patients DefinitionValidate that the patient is an established patient and not new to specialty Edit TypePositive edit Example Patient comes into orthopedics office and saw Dr. Anderson 4 years ago when he blew his knee. Now, he is presenting with a shoulder issue. Dr. Anderson remembers this patient and bills him as an Established patient instead of a New Patient. The change between the Established Patient code and New code will increase reimbursement.

12 Proprietary and Confidential. Do not distribute. 12 © Ingenix, Inc. 12 Sample Edit Scenario - Commercial Editing Examples Decrease Rejections for Commercial Payers Pre-Op Procedure One Day Before Surgery (PRE, PRH_ Definition Validate the surgical provider isn’t billing for E/M service one day prior to surgery (if being seen for items related to the surgery) Edit TypeHistorical edit Example Patient comes in for an office visit, one day prior to meniscus surgical repair, for service related to surgery If E/M service was billed on a different claim, then the surgery PRH would trigger If E/M service is on same bill as the surgical procedure PRE is triggered

13 Proprietary and Confidential. Do not distribute. 13 © Ingenix, Inc. 13 Sample Edit Scenario - Medical Necessity Editing (LCD Part B) Examples Decrease Rejections and Stay in Compliance with Medicare Part B Missing or Invalid LMRP Diagnosis (LBI) DefinitionValidate that diagnosis represents the need for nail trimming Edit TypeABN, compliance edit Example The patient presents with an ingrown toenail with an infection. The physician performs a nail trimming to treat the nailed. The patient is also diabetic but when the physician bills the patient, he/she only includes the diagnosis code for the toenail infection ClaimsManager does the analysis of the diagnosis code and determines that the diagnosis doesn’t support medical necessity guidelines to support the payment for the patients foot care. LCD Part B Typical Frequency Exceeded (BFR) Definitio n Validate that the patient hasn’t been seen for nail trimming within the last 60 days Edit Type Historical edit Example Diabetes patients struggle with neuropathy and poor circulation, therefore routine foot care is necessary. Some Medicare Carriers have designated routine foot care to be one session every 60 days. If the patient comes in for additional foot care more frequently than the 60 days, ClaimsManager will flag to indicate that this has been billed outside the parameters of the policy.

14 Proprietary and Confidential. Do not distribute. 14 © Ingenix, Inc. 14 Scenario : Patient is billed for a Prolonged Service CodeCPT DescriptionReimbursement Prolonged physician service in office or other outpatient facility; face to face, 1st hour $ Edit Per CPT guidelines, codes are used when a physician provides prolonged services involving direct patent contact that is beyond the usual service. This services is reported including other services, including E&M services at any level The claim is modified to include the code as noted in the edit. High level Office Visit $ Example Scenario - Advanced Clinical Editing Helps Increase Revenue (Family Practice Scenario) By adding the additional code, the total reimbursement increases by $143.17, for a total of $


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