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1 © Passport Health Communications Inc. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions
2 © Passport Health Communications Inc. The Importance of Eligibility in the Revenue Cycle
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 © 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 © 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 © Passport Health Communications Inc. Revenue Cycle begins at the Front What used to be simple data entry now includes:
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 © 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 © 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 © 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 © Passport Health Communications Inc. Some Examples of Available Options…
12 © Passport Health Communications Inc. More Examples…
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 © 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 © Passport Health Communications Inc. Batch Examples…
16 © Passport Health Communications Inc. Batch Examples…
17 © Passport Health Communications Inc. Batch, Web-based Post-back…
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 © 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 © 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 © 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 © 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 © Passport Health Communications Inc. Spring Revenue Cycle Meeting Max Carter Vice President, Corporate Solutions
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