Presented by: Ann Silliman SCC Dan Holsinger Genova Diagnostics Realizing Possibilities Presented by: Ann Silliman SCC Dan Holsinger Genova Diagnostics

Tools for Hog Tying Your Work Bulk Utility RBS Rules Redirections Payor Redirection Rules Grouping Rules Hierarchical Order of Rules Billing Rules

Bulk Utility Bulk Utility is a module within SoftA/R that was designed as a query tool. It can be used to qualify visits and invoices meeting a user defined set of criteria for the purpose of creating worklists or applying actions or transactions to a qualified set of invoices.

Bulk Utility Bulk Utility is accessible from the A/R Desktop and offers a wide variety of search criteria. Rework ‘Bulk’ slides if needed due to time constraint

Bulk Utility Within each frame of the search criteria, there is an ‘Other’ box in which sql expressions can be entered to further customize the qualifying set of criteria.

Bulk Utility Bulk Commenting to Drive Processes Collections Letters Medical Records Patient Requests for Information (A1) Bulk Re-classing to Group Claims Re-class to Collections Payer Bulk Adjustments/Repeat Jobs Small Balance Bad Debt Adjustments

Bulk Utility – Using an SQL in 'Other' Format of the SQL List – Auto e -Mail with Instructions TypeOfBU SQL Comment Payor AdjType TechID Instructions1 Instructions2 Commenting INVTINTN In('12345' , '12345' ,'12345 , '12345 , '12345 , '12345678' ,'12345678' , '12345678' , '12345678'' ,'12345678' , '12345678' , '12345678' ,'12345678' , '12345678' , '12345678' ,'12345678', '12345678' , '12345678' , '12345678' , ''12345678' , '12345678' ,'12345678' , '12345678' , '12345678' , '12345678') Sent COLL LETTER C Click on the Invoice Section Other Button and paste the code in the SQL field into the small pop-up box. Click the OK button, and also click the OK button on the main form Move all accounts down to the lower pane. 4.)On the Menu select Transaction then Comment 5.)Populate the Short description and Comment boxes with the contents of Comment field (in this document). 6.)Click the Submit button. INVTINTN In('12345' , '12345' ,'12345 , '12345 , '12345 , '12345678' ,'12345678' ,' , '12345678' , '12345678' , '12345678') Sent Ltr to Pt Rqst EOB-Ltr A1 1.)Click on the Invoice Section Other Button and paste the code in the SQL field into the small pop-up box. 2.)Click the OK button, and also click the OK button on the main form 3.)Move all accounts down to the lower pane. INVTINTN In('12345' , '12345' ,'12345 , '12345 , '12345 , '12345678' ,'12345678' , '12345678' , '12345678'' ,'12345678' , , '12345678' , '12345678' , '12345678') PATHA Coll LtrA6-Final-(Dy75)  

Bulk Utility – Using the 'Other' Criteria Using the 'other' criteria allows you to use lists of invoices developed from your own criteria to perform bulk functions.

Bulk Utility – Bulk Commenting Collections Letters Collection Letter Cycle Used to manage collections and Bad Debt Process

Bulk Commenting – How to Managing the Medical Records Process

Bulk Commenting – How to Managing the Medical Records Process Cont’d

Bulk Commenting – Managing Medical Records Medical Records Process using Bulk Commenting

Bulk Commenting – A1 process Using Transactions Comments to Manage EOB from Patient Processes

Bulk Re-classing & Write Off– Collections process Bulk Utility to Reclass to Collections and do Bulk Write Off to Collections

Bulk Adjustments– Small Balance Repeat Job Created in Bulk Utility -Repeat Job

RBS Rules The Rule Based System is accessible from within the Setup module and provides the ability to define rules that trigger automated actions based on a user defined set of conditions.

RBS Rules – Trigger Points Trigger points provide flexibility to automate an action at a predetermined stage of processing. Available Triggers After Posting Before Invoicing After Invoicing During Invoicing On Demand After Inbound Message On Update

RBS Rules – Database Tables Database fields from the following tables can be updated using RBS rules: Item Visit Procedure Procedure Component Visit Visit Diagnosis Stay Person Invoice

RBS Rules – RBS Types Update Business Line Duplicate Procedure Rule Custom Transaction

RBS Rules – Update RBS rules that update a database field based on a user defined set of conditions are the most widely used type of rule.

RBS Rules – Business Line The Business Line RBS rule is executed at the end of the Invoicing process and assigns a Business Line to the Invoice which then propagates to any transaction added to that invoice.

RBS Rules – Duplicate Procedures The Duplicate Procedure RBS rule is executed during the Invoicing process and creates 'duplicate' procedures, based on a user defined set of criteria. This type of RBS rule is most commonly used for intercompany billing. A common condition for intercompany billing is 'test performed at a location other than the one at which it was ordered.'

RBS Rules – Custom Transaction The Custom Transaction RBS rule allows the system to automatically add a transaction to an invoice that meets a user defined set of criteria. This logic was developed for a client that performs high volumes of toxicology testing and wanted a way to automatically add an adjustment to an invoice for any uninsured patient so that no more than $100.00 was billed out for toxicology services.

RBS Rules We use an RBS rule to assign bill classes to bill orders performed at different Genova facilities as a single invoice, per Medicare guidelines.

Redirections – Payor Setup 'Branch of' redirection propagates to all other redirections.

Redirections – Price Schedule 'Price Schedule' redirection stores the price schedule to be applied for this payor. 'Price Schedule Ratio' allows a premium or a discount to be applied to the redirected price schedule.

Redirections – Acceptable Prices 'Acceptable Price' redirection stores the acceptable price schedule to be applied for this payor. 'Acceptable Price Ratio' allows a premium or a discount to be applied to the redirected acceptable prices.

Redirections – Billing Rules 'Billing Red' stores the payor whose billing rules should be applied for this payor.

Redirections - Reports 'On Reports With' stores the payor grouping that allows like payors to qualify together on reports.

Redirections - Payment 'Payment' redirection stores the payor code that should be recognized as “one in the same” with this payor.

Billing Redirection

Payor Redirection Payor Redirection rules enable an automated change of payor based on any combination of the below criteria available in the grid. Payor Type System Patient Type Clinic/Ward Type Region Facility Test Type (Tech/Prof) Bill Class Patient Info

Payor Redirection Managing PECOS Managing multiple Medicare payers PECOS status 'Unknown' = MCHLD PECOS status 'Application in Progress' = MCPND PECOS status 'Refused Enrollment' = CLIN Managing multiple Medicare payers Asheville lab billed to Medicare NC (Palmetto) = MC Atlanta lab billed to Medicare GA (Cahaba) = MCGA ATL facility – MC moved to MCGA

Payor Redirection

Grouping Rules User defined bundling rules can be created with two steps. Create a “Group” that contains any number of tests that are likely to be ordered together. Add a grouping rule that defines what happens when tests in the “Group” co-exist on a visit.

Grouping Rules , Step 1: Create a Group All tests from Setup appear in the ‘Available Tests’ window

Grouping Rules , Step 1: Create a Group Select tests to include in the ‘Group’

Grouping Rules, Step 2 Add a Grouping Rule In the below example, the rule states that anytime between 1 and 13 tests from group G0431 co-exist on a visit, the resulting test will be G0431.

Grouping Rules - New fields The addition of the ‘Quantity From’ and ‘Quantity To’ fields eliminates the need to create multiple grouping rules to address all possible combinations of tests in a group.

Grouping Rules - New fields The addition of the ‘Price Multiplier’ eliminates the need to create multiple “resulting procedures” in order to extend the price based on the number of tests in the ‘Group’ that co-exist on the visit.

Grouping Rules – Price Setup The Price Setup grid contains a column labeled ‘Comp’ with the following options: Empty (=default): The price defined for the test will be applied during invoicing. Sum of Comp.: When ‘Sum of Comp’ is selected, invoicing assigns a price for this test based on the sum of the prices defined for the tests from the group that were used to execute the grouping rule. Example: If 5 tests from the group, each having a price of $10.00, co-exist on a visit and result in billable test G0431, the system assigns a price of $50.00 to test G0431. Use Lower: When ‘Use lower’, is selected, invoicing assigns the lower of: The price explicitly defined for this test (=$25.00) The sum of the prices defined for the tests from the group that were used to execute the grouping rule.

Grouping Rules

Hierarchical Order of Rules There are many rules throughout the system that can be defined at the test level, payor level or system level. During the invoicing process, the system first tries to locate the rule at the test level. If a test level rule is not found, the system then tries to locate a rule at the payor level. When neither a test level nor payor level rule is identified the global rule from the System Parameter or global setup dictionary is used.

Multi-Level Setup Options Action on Canceled Components: Instructs the system how to react when some components of group test are canceled Test Level: Billing Rules Grid, Column Label = “On Canc Comp” Payor Level: “Flags" tab, “On Canceled Components” System Parameter: ActionOnCanceledComps

Multi-Level Setup Options Invoice When: Identifies the test status that must be reached before the system will allow invoicing to complete. Test Level: Main Dialog > ‘Test’ Frame > “Invoice When” Payor Level: “Flags” tab > “Invoice When” System Parameter: InvoiceWhenDefaultValue

Multi-Level Setup Options TestRepeatOptions : Instructs the system how to assign modifiers for repeat tests. Test Level: Billing Rules Grid > Column Label “Test Repeat” Payor Level: “Flags” tab > “Repeat Modifier” System Parameter: TestRepeatOptions

Multi-Level Setup Options Professional /Technical Splits: Instructs the system how to react when professional and technical tests co-exist on a visit. Payor Level: “Split and Hold Flags” tab > “Tech/Prof” System Parameter: DefaultTechProfSplit

Multi-Level Setup Options Repeat Modifier and CCI Modifier Defines the modifier to be appended when repeat modifier logic or CCI logic is invoked. Test Level: Billing Rules Grid > Column Label “Rep” (Repeat Modifier Override); “CCI” (CCI Modifier Override) System Level: Dictonaries > Modifiers > Modifier Type column

Repeat Units Settings Payers may want multiple units billed differently: Single line for each unit with 91 modifier All units one line with 91 modifier One unit on one one, all other units separate line with 91 modifier Major reimbursement impact.

Billing Rules The Billing Rules table determines how a test is billed based on contributing factors that exist on the visit. Common attributes used to define billing rules: Who should be billed for the service Where the test was ordered Where the test was performed Patient type Bill Class (Can be user defined, assigned by RBS)

Billing Rules Managing Medicare exceptions Statutorily Non-covered test GY Modifier added

Billing Rules Setting to Free to get Paid Claims with both 86001 and 86003 results in Medical records requests and ends in denial by a single payor. Billing claim without 86001 results in payment for 86003 without denial.