Presentation is loading. Please wait.

Presentation is loading. Please wait.

1 © Passport Health Communications Inc. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions.

Similar presentations


Presentation on theme: "1 © Passport Health Communications Inc. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions."— Presentation transcript:

1 1 © Passport Health Communications Inc. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions

2 2 © Passport Health Communications Inc. The Importance of Eligibility in the Revenue Cycle

3 3 © Passport Health Communications Inc. History of Electronic Eligibility Industry  Birth of electronic credit card industry o Credit card verification pre-1986 was all manual + Three options: trust cardholder, call, or check “the book”  Birth of electronic eligibility industry o Eligibility verification pre-1989 was all manual + Two options: trust cardholder or call payer  Eligibility Trivia Question: Which 3 healthcare payers were the first of offer electronic eligibility in the U.S., or world for that matter?

4 4 © Passport Health Communications Inc.  Confirm Coverage  Is that all? Are we done?  Other considerations: o Demographic verification o Managed care o Coverage types o Co-pay /deductible o Frequency-related issues o Authorizations o And many more  With respect to eligibility verification, what is the single biggest problem or issue providers face with scheduling, pre-reg and registration staff? o TIP: The exact same problem has existed every year since 1989…  Why is this continually an issue? Why is Eligibility Verification Important?

5 5 © Passport Health Communications Inc.  Environment o Fast-paced o High pressure  Very Complex  Typically handled by entry-level personnel o High turnover o Train, train and retrain  Concerns about patient  Human nature Front-end Challenges… The classic mandate: I want every patient registered quickly and ____________.

6 6 © Passport Health Communications Inc. Revenue Cycle begins at the Front What used to be simple data entry now includes:

7 7 © Passport Health Communications Inc. Addressing the Interpretation Dilemma…  Best option is to automate o Implement rules-based system that automatically t riggers, programmatically interprets response, flags users on data discrepancies and other issues, and has quality assurance features – including management reporting. Dsffdsd Sfdf sfdsfdsfdsfds

8 8 © Passport Health Communications Inc.  Rule #1: Don’t let best get in the way of better  Three basic eligibility verification platforms: o Browser-based, o Batch-based and o Integrated.  Different costs, features and benefits associated with each approach  Don’t lose sight of the key requirement – facilitation of accurate response interpretation o Otherwise you are throwing good money at the bad  If you will allow the expression, what you want is “in your face eligibility” Other Lower Cost Options…

9 9 © Passport Health Communications Inc. But Data is Data. Right?  Initially yes. Eligibility data is truly a commodity.  The key differentiator between commoditized eligibility data and an “eligibility system” is determined by: o Quality of the user interface or experience, o Capability to programmatically evaluate the response and apply actionable intelligence to potential issues discovered, including data “enrichment”, o How consumable the data is for downstream processes, o Degree of interoperability between downstream systems, including disparate systems.

10 10 © Passport Health Communications Inc.  Payer Websites o Single payer access o Greater security concerns + User controls access o No daily upload capability o Not easily auditable o Limited function o Not customizable o No data enrichment o Costs more  Vendor Browser System o Multiple payer access o Fewer security concerns + Facility controls access o Daily upload capability o Auditable o Multi-function o Highly customizable o Data enrichment o Costs less Payer Websites Versus Vendor Browser…

11 11 © Passport Health Communications Inc. Some Examples of Available Options…

12 12 © Passport Health Communications Inc. More Examples…

13 13 © Passport Health Communications Inc.  If % of Scheduled or Pre- Reg encounters is high then batch may be ideal…  Look for these capabilities: o Multiple input & output format options + 270/271, Excel/CSV, other delimited, Access, and custom + Additional output files - User-friendly XML - Import ready files (271 or custom for HIS, indexed for HIE, etc) o Multi-payer, single file + Medicaid, Medicare, Commercial & Self-pay o Echo’s back all input data + Patient type, plan type, plan code (bad plan detection), address, etc. o Complete search cascading capabilities o Multi-payer and other database cascading + Payer to MCO/HMO + Medicaid to Medicare to Comm. + Address verification, etc. The Power of Batch…

14 14 © Passport Health Communications Inc. o Data validation + Member ID + Social Security Number + Name - First, Middle & Last + Date of birth + Group number + All highlighted if discrepancy o Custom rules o Multi-function in single file + Eligibility + Address verification + Self-pay review o Multi-function in single file, continued… + Medical necessity + Authorizations + Propensity to pay + Credit reporting & scoring + Notice of Admission + Coverage Discovery + Claim status o Uniform output format for all payers + Facilitates data import o File or web-based view The Power of Batch, Continued…

15 15 © Passport Health Communications Inc. Batch Examples…

16 16 © Passport Health Communications Inc. Batch Examples…

17 17 © Passport Health Communications Inc. Batch, Web-based Post-back…

18 18 © Passport Health Communications Inc.  HIS Controlled UI  Straight EDI o Examples + Epic X12 + Cerner X12 + Meditech X12 + QuadraMed X12 + Siemens/HDX  Enhanced EDI o Epic  Vendor Controlled UI o Key for “in-process” is existence of trigger + X12 + Scripting-based o Out-of-process + HL7 o Vendor controlled UI is generally most robust Integrated Eligibility Options…

19 19 © Passport Health Communications Inc.  Content enrichment o Captures discrete data elements o New payer responses or data sets o Payer website snapshot via hyperlinks + Dynamic environments + Static Environments Transactional Intelligence…

20 20 © Passport Health Communications Inc. Leveraging content enrichment to add a discrete data element to the traditional payer response. Multiple data elements may be added, in real- time or batch. Content Enrichment…

21 21 © Passport Health Communications Inc. Content enrichment can literally create a payer-specific EDI response from data previously available via payer website only, whether the payer is local, regional or national in scope. Scraping Entire Payer Data Sets…

22 22 © Passport Health Communications Inc. Eligibility plays a very significant part in the healthcare revenue cycle. Moreover, the process involves much more than just verification of coverage. The absolute key is to find an affordable, cost-effective solution that facilitates accurate response interpretation. And remember, don’t let best get in the way of better! The Importance of Eligibility in the Revenue Cycle

23 23 © Passport Health Communications Inc. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions


Download ppt "1 © Passport Health Communications Inc. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions."

Similar presentations


Ads by Google