Projects Archive

THE RULE

Under the Meaningful Use program, CMS (Centers for Medicare and Medicaid Services), an agency within the Unites States Federal Government, provides financial incentives to eligible professionals and hospitals for adopting certified electronic health record (EHR) system and demonstrating EHR usage in accordance to the standards specified by the government.

PROBLEM

After having successfully demonstrated Meaningful Use (MU) compliance for three years, two physicians of an east-coast based ambulatory surgery center were selected at random by Centers for Medicare and Medicaid for compliance for the fourth year. The group was at the risk of losing financial incentives and facing up to 4% of reimbursement cuts across all Medicare payments.

PROCESS

Based on requirements specified in the auditor’s letter, we helped the surgery center gather documents to build the case for compliance. These involved the group’s CEHRT license and vendor agreements to prove the use of a certified EHR, required for attestation. We extracted security and risk assessment reports, an integral part of the program, to further demonstrate compliance.
The EHR program used by the group had a software update during the reporting period, which led to a mismatch between the version numbers used for certification and after the update. We worked with the vendor to work around this problem through version reports. We provided user logs and system screenshots to supplement proof of compliance. Additionally, we worked with the State and specialized case registries to gather supporting information for individual measures and double-checked compliance data.

RESULTS

In the end, the auditing agency passed all measures and the physicians were considered for complete financial incentives.

BACKGROUND

Through its open architecture, enki Health IT platform connects with various systems, hardware equipment and medical devices using standard protocols such as HL7. We have evaluated enki’s interoperability readiness with over 30 vendors.

INTEGRATIONS

‣ Clinical Systems: Communication and interfacing capabilities using HL7 v2.3 and above. This covers clinical documentation for more than 18 medical specialties.
‣ Billing and Practice Management Systems: enki integrates with billing systems such as AdvancedMD.
‣ Lab Information Systems: enki connects to national labs such as Quest Diagnostics as well as private labs and their information systems.
‣ Radiology Information Systems: Lab and radiology devices can be integrated using standard interfaces provided by the device manufacturers.
‣ Medical Equipment: Through connectivity devices such as Capsule, enki integrates with over 700 old and new medical machines.
‣ ERP Integration: Third party software system for HR, payroll, inventory management, accounting and book-keeping modules.
‣ Medical Devices: enki integrates with digital health devices such as Fitbit.
‣ DNA Testing: We integrated enki with DNA testing services such as 23andMe.
‣ Head-up Displays: We integrated enki with Google Glass.

TYPICAL WORKFLOW INVOLVING INTEROPERABILITY

TYPICAL LAB INTEGRATION

TYPICAL RADIOLOGY INTEGRATION

TYPICAL ERP INTEGRATION

ABOUT

The client split from a larger dermatology group to setup a practice in her hometown.

CHALLENGES

After a larger dermatology group dissolved, our client setup a practice in her hometown. However, setting up a new practice involves several challenges in billing, leave alone the challenges of establishing oneself with patients. The doctor preferred using EMA EHR from Modernizing Medicine and required it to be integrated with AdvancedMD, the practice management system that we use. Further, it was imperative that the doctor is not only compliant with her billing but also accurate enough to get paid correctly and in time.

WHAT WE DID

We stepped in after the doctor had completed her credentialing. From that point on, we developed various processes that resulted in streamlined billing operations. We started by establishing the interface between the EHR (EMA from Modernizing Medicine) and the practice management system (AdvancedMD). Our coding team worked in streamlining modifier usage for dermatology and CPT-ICD coding compatibility. We did “same-day billing” that resulted in faster payments required for the nascent practice to sustain itself.

LIFE WITH NEXTSERVICES

Our work resulted in 100% growth in collections after the first year. We continue to work with the client to develop strong systems that can withstand continuing growth.

ABOUT

This is a New York based specialist center dedicated to the research and treatment of gastroenterology diseases.

DURATION

10 months

AREAS FOCUSSED

• Process understanding
• Inventory understanding
• Reimbursement trend
• Expense/cost analysis

RECOMMENDATIONS

• Process re-engineering
• Inventory management
• Charges vs. payment analysis
• Resource management
• Expenditure management
• Collection optimization

STAFFING

Three specialist physicians, two nurses, four front desk personals and one medical technician.

PRE-VISIT AND CHECK-IN

1. Pre-visit and check-in procedures were completed by the front office staff. The appointments mainly scheduled were follow-up visits, only a handful of patients’ scheduled prior appointments via phone.
2. There was no fixed personal designated to attend calls by patients, checking patients’ eligibility, verifying patient charts, etc. All these activities were carried out by anyone present at time on the desk.
3. For all established patients the demographics were verified at the time of service.
4. Patients with invalid insurance information were flagged and insurance / patient information was collected at the time of visit or over the phone.
5. A concrete eligibility verification and prior authorization process was not devised which led to ineligible patients getting services.

BILLING

1. The physicians themselves entered the charges into the practice management software.
2. The claims submitted were not “clean” due to the lack of co-ordination between the clinical and the billing staff.
3. The most common and persistent errors encountered were as follows:
‣ Duplicate billing.
‣ Incorrect units billed on certain claims.
‣ Lack of monitoring on the submitted and un-submitted claims.
‣ Inconsistencies with the use of modifiers.
‣ Delayed claim submission resulting in backlogs.
‣ Incomplete/unsigned charts.
‣ The claims were not submitted as the Local Coverage Determination guidelines.
4. The accounts receivable activities were undertaken at the central billing office of the medical center.
The process was not clearly laid out at fundamental levels which lead to inconsistencies.
‣ Insurance follow ups on claims were not regular.
‣ Patient receivables were not monitored and tracked.
‣ The claims which had been paid to patient went uncollected.
‣ Patients received incorrect statements.

INVENTORY MANAGEMENT

1. The practice had a substantial volume of patients being treated for inflammatory bowel disease (IBD). A common drug administered as a plan of treatment was remicade.
2. The stocking of drugs was done on a monthly basis with no accurate mechanism to track the inventory vs consumption ratio. This disturbed the process of drug procurement and payments.
3. As the authorization and benefit process was not laid down there were certain uncovered drugs being prescribed leading to lost payments.

RECOMMENDATIONS: PRE-VISIT AND CHECK-IN

1. Organize a workflow. The current front desk process flow was unorganized where no definite responsibilities were assigned to anyone. Process reorganization was suggested.
2. Correct capture of information. Suggested a process to train the front desk on correct and complete demographic capture.
3. Co-ordination between processes. Conduct eligibility verification on all claims and coordinate between the billing and the AR services.

RECOMMENDATIONS: BILLING

1. Be selective and efficient in claims submission. An option to correct the billing process suggested was to be extra cautious while submitting higher dollar value claims. Under no condition the claims submitted should be incomplete.

2. Make healthy comparisons. Analyze the global flow of charges submitted and payments received and compare with previous months, quarter averages.

3. Post payments on date of receipt. Flag for denials and secondary submissions for non-crossover claims. Compare payments against contractual allowed amounts and flag underpayments.

4. Follow up on AR. Run an aged AR report on weekly basis. Map the average payment turnaround time for insurances and identify records that exceed average payment duration

5. Collecting outstanding balances from the patients upfront. Alert patients on the types of statements they are likely to receive. Make attempts to collect when patient arrives for the service. Send balance statements within a week of service and follow-up with a call.

6. Recover paid to patients. Based on insurance, alert patients that they would receive check on behalf of the non-participating physicians and have patient sign an acknowledgement form for the same. Follow-up with insurances and procure the check number of the issued check and send a reminder letter about the check. Partner with patient to collections agencies for un-retrieved checks

7. Negotiate with insurances. For non-participating providers, negotiate aggressively with insurance companies and third-party administrators to extract maximum percentage of fee schedule. compare and analyze payments from different insurances, different plans and use the information during negotiations.

RECOMMENDATIONS: DRUG INVENTORY MANAGEMENT

1. Tracking and evaluation. Discard paper-based tracking. Utilize a software-based system to track the following:

‣ Drug usage by patient, physician, practice, insurance
‣ Payments of drug usage by patient, physician, practice, insurance
‣ Unpaid drugs in any given month by patient, physician, practice, insurance
‣ Expense of drug based on usage.
‣ Estimate of drug requirement based on previous average usage

2. Negotiations with existing and new vendors to get better deals on drugs.

3. Perform profitability analysis at a drug-level.

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ABOUT

The client is a clinical pathology lab setup within a larger multi specialty group in New York.

CHALLENGES

As a newly setup lab, it was difficult to get insurances to open doors to a contract. Even though the lab was rapidly expanding, claims that were submitted without contract were denied by the insurance companies. Further, billing required that we access software used by the multi specialty group and segregate lab payments for our clients.

WHAT WE DID

We persistently followed through with insurances resulting two major contracts for our client, this resulted in rapid changes in revenues. The secret of making insurance companies open their closed doors was to knock again and again.

We also coordinated with the software vendor used by the multi specialty group to submit lab claims and receive payments without disrupting rules setup by the umbrella organization.

LIFE WITH NEXTSERVICES

We continue to persist with opening other insurance doors for our client. Meanwhile, the lab enjoys steady growth month upon month with the assurance that our team is taking care of getting them paid correctly for their work.

ABOUT

The client is an established multispecialty surgery center in New York.

CHALLENGES

When the surgery center had staff attrition, they quickly required us to step in and stop financial disruption.

1) Overhead costs ballooned over the years impacting profitability of the surgery center.

2) Operating on a server-based system required that billing be coordinated remotely with minimal disruption to office staff on the front-end.

3) Claims dating back to two years were not submitted to insurance companies.

4) The surgery center faced denials due to lack of timely authorizations. Procedures were performed on patients who were not eligible for service resulting in further financial loss.

WHAT WE DID

Our billing team stepped in to rapidly take control of the situation in less than a month when the center had staff attrition. This required us to quickly grasp the nuances of multiple specialties that the center was billing for, circumvent technology challenges of billing through remote desktops and curb losses due to old claims that were not correctly submitted. Here’s what we did.

1) We established remote desktop connectivity with the center’s existing systems. This minimized transition time but required us to quickly learn how to bill on their system. Operating in a different time zone from New York, allowed us to use the same computers that the center used during their downtime.

2) We analyzed their entire billing and identified a number of old claims that were not submitted or incorrectly submitted. We resubmitted and appealed on required claims – bringing in lost revenues from the past.

3) We established an eligibility and benefits verification process that required capturing patient copays and deductibles. This helped avoid losses through procedures done for patients whose insurances did not cover them.

4) We implemented a process to identify procedures that require authorizations and alert the center so that authorizations can be obtained in time.

5) We setup a separate team to work on the client’s old Accounts Receivable so that revenues from previous billing can be recovered.

LIFE WITH NEXTSERVICES

The center’s primary objective in working with NextServices was to control their overhead costs. Not only did we increase their profitability through a variety of initiatives but also implemented a rigorous billing process that would help stay compliant in the years to come.

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ABOUT

The client is an anesthesia and perioperative services provider based in Michigan with 16+ anesthesiologists working in the field and centralized administration.

CHALLENGES

1) Missed updating CAQH compliance information. The group missed updating their information with the Council for Affordable Quality Healthcare (CAQH), a non-profit alliance that streamlines the business of healthcare. This resulted in ongoing denials.
2) Inconsistent billing submission. As the anesthesiologists kept traveling, it was difficult for them to regularly submit billing information. This increased the risk of timely filing denials.
3) Paper EOBs delayed reconciliation, including secondary balances. Most of the payment information received from insurances was via paper. This delayed reconciliation resulting in late secondary submissions.

WHAT WE DID

The NextServices billing team streamlined the billing process for this group of anesthesiologists, despite various constraints. Here’s what we did:

1) Closing gaps with compliance. We regularized the process of physicians updating information to CAQH and other channels with defined periodicity. This simple process correction resulted in a dramatic drop in compliance related denials. It also helped the group stay compliant with the authorities.
2) Same day billing submission. To control the delays in billing, we submit claims to insurances immediately after receiving them. This reduces lag in submissions and payments. We maintain an insurance Accounts Receivable (A/R days) of 5-7% above 90 days, which is greatly lower than industry average of 14%.
3) Digitizing EOBs. We set up Electronic Remittance Advice (ERA) and other digital systems to get the group reconcile payments electronically. This not only helped them get paid quickly, but also resulted in timely secondary submissions and reimbursements.

LIFE WITH NEXTSERVICES

The anesthesiologists continue to enjoy what they love, the practice of medicine without worrying about getting paid correctly for their work. We take care of that. The administrator does not worry about the challenges of operations because of various systemic constraints. We customized the billing process by circumventing the constraints and maintain outstanding results such as weekly zeroing out of claims and keep A/R 90+ days at 5-7%, much below industry averages.

ABOUT

The client is an established pathology lab in Michigan.

CHALLENGES

1) Medicare partial payments. For certain lab claims, Medicare paid partially on the total units billed resulting in significant under-payments.
2) CLIA issues. Medicaid denied all claims due to expiration of Clinical Laboratory Improvement Amendments (CLIA) certification.
3) Insurance specific billing. Blue Cross Blue Shield Medicare Advantage Plan had different rules compared to other carriers and expected unique codes to process claims correctly.
4) Paid to patient collections. Insurance companies sent checks directly to patients whenever the lab had a non-participating status with them. Collecting from patients was a big challenge.

WHAT WE DID

Not only did our team work towards organizing the billing workflow for the lab, we specifically addressed the challenges faced by them.
1) We incorporated regular appeals to Medicare as part of the regular billing process, which resulted in complete payments for all partially paid claims.
2) We discovered the problem for Medicaid denials and coordinated with the lab to update Medicaid on the lab’s new CLIA status. This resulted in payments from all previously denied claims.
3) We worked with Blue Cross Blue Shield Medicare Advantage Plan to fully understand their coding guidelines and incorporated correct coding practices into the billing process. This resulted in the lab getting paid accurately on all previously denied claims.
4) We established a patient check collection protocol together with the lab, so that the patients were aware of any checks that would be sent to them and would promptly mail them to the lab upon receipt.

LIFE WITH NEXTSERVICES

The client enjoys the financial benefit of a methodical and rigorous billing process that continuously tracks problems and incorporates insurance feedback into daily operations.

ABOUT

The client is a newly established cardiology and wellness center in New Mexico.

WHAT WE DID

The client came to us with the intent to setup a new practice. We first started with credentialing the doctor for all major insurance companies in New Mexico. We then worked with the practice staff and the physician to setup entire billing operations. This involved creating a software office key for the practice management system (AdvancedMD), setting up electronic remittances (ERAs) and electronic fund transfers (EFTs). After billing operations were stabilized, we implemented enki EHR, our cloud/mobile based electronic health record platform.

LIFE WITH NEXTSERVICES

A client and her staff can simply call us with the desire to startup on her own and we will make it happen. Establishing a well-honed billing process requires discipline and experience, which we bring. This offers the financial stability required to run a medical practice. Rolling out an EHR does not have to mean hundreds of thousands of dollars in costs and disruption of workflow. Our enki EHR platform is beautifully designed so that it’s simple for users to train themselves and it’s easy for the practice to implement. Our ability to hand-hold doctors and their staff through successful transition into seamless billing and a rollout of an advanced EHR platform helps in thriving independently in a challenging business environment.

ABOUT

The client is a gastroenterology group and surgery center.

CHALLENGES

After years of frustration, the client decided to transition from their billing company of over 15 years. Little did they expect that the transition would be full of challenges.
1) The billing company did not cooperate in providing required data for billing.
2) As credentialing status was not properly maintained, Medicare revalidation application had expired resulting in a hold on Medicare payments, which formed the bulk of overall payments.
3) Previous billing had several coding errors resulting in many denials.
4) Finally, the client-server based EHR that the group was on crashed unexpectedly disrupting the entire workflow.

WHAT WE DID

When the previous billing company was not cooperative, it became our responsibility to quickly figure out billing nuances of the group on our own and avoid any financial disruption. We addressed the challenges in several ways:
1) We worked independently to transfer all available data into our practice management system. To ensure that the transferred data is accurate, we implemented quality control steps involving records of patients who were scheduled for the next day.
2) We completed Medicare applications and re-initiated contract with Medicare, directly addressing a major problem faced by the group.
3) We flagged several coding errors that resulted in major denials and worked rigorously to implement sound coding practices in the group.
4) After the client’s workflow was disrupted through the EHR software crash, we transitioned them to enki EHR, which is a cloud/mobile EHR that can never be subject to loss of data.

LIFE WITH NEXTSERVICES

Navigating the business of medicine can sometimes be tricky for doctors – from dealing with difficult vendors to operational issues to technology challenges, as was the experience with this client. What NextServices does is shoulder these responsibilities for doctors so that they can get back to practicing medicine. We earned our stars over the years through hard work, dedication and with a work ethic that demands transparency so that we do our bit to make healthcare delivery simpler.

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