Hosted Claims Manager: Your Cure to Rejections, Denials & ICD-10 Teri Cipriano, CPC, Hosted Claims Manager Support and Implementation Analyst Debra Mitchell, RN, BSN, MBA, Children’s Orthopaedic and Scoliosis Surgery Associates. LLP April, 2015

Individual Page Use?: No Are all Uses and Applications Discussed or Referenced in the Proposed Material on Label for the Product?: Yes Relates to a Major new Product/Services Launch?: Includes Product or Service Claims, Features, Benefits or similar information?: Contains Competitive or Comparative Claims?: Includes Return on investment (ROI), quantifiable cost of ownership, reimbursement, or meaningful use claim or reference?: Include References to Market / Segment Share or Market / Segment Leadership?: Include identifiable Patient Information / Data?: If Customer Names are Used, are Necessary and Appropriate Permissions in Writing and on File?: NA Include Customer Testimonials?: If any non-GE Stock Images are Used, are Necessary and Appropriate Permissions in Writing and on File?: N/A Do the Proposed Materials Contain Images of GE Products?: Do all Product Images Depict the Device(s) Being Promoted in the Piece?: This is a Translation of a Previously Approved Piece in Which no Changes Have Been Made?: This is a Revision of a Document Previously Approved for Ad / Promo Use?:

©2015 General Electric Company – All rights reserved ©2015 General Electric Company – All rights reserved. The results expressed in this document may not be applicable to a particular site or installation and individual results may vary. This document and its contents are provided to you for informational purposes only and do not constitute a representation, warranty or performance guarantee. GE disclaims liability for any loss, which may arise from reliance on or use of information, contained in this document. All illustrations are provided as fictional examples only. Your product features and configuration may be different than those shown. Information contained herein is proprietary to GE. No part of this publication may be reproduced for any purpose without written permission of GE. DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCT DIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE A COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITY REMAIN AT GE’S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLE REGULATORY CLEARANCE. GE, the GE Monogram, Centricity, and imagination at work are trademarks of General Electric Company. All other product names and logos are trademarks or registered trademarks of their respective companies. General Electric Company, by and through its GE Healthcare division.

AGENDA What is Hosted Claims Manager? Review features of Hosted Claims Manager Demo Examples of how Hosted Claims Manager can help Debi Mitchell – Children’s Orthopaedic and Scoliosis Surgery Associates, LLP Reports Summary

The best way to REDUCE clinical rejections and denials is to PREVENT them before they occur! Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series (2009)

Hosted Claims Manager One of the best ways to reduce rejections & denials is to prevent them before they occur! Hosted Claims Manager is a pre-claim, clinical editing solution and proactive claim analysis service that identifies and resolves posting errors that would later result in a rejection or a denial. Reduce clinical rejections and denials before they negatively impact financial performance Reduce costs associated with addressing rejected or denial claims Support regulatory compliance by evaluating claims against specified coding rules while detecting Medicare Correct Coding Initiative edits Support regulatory compliance by comparing claims to local payer coding regulations and guidelines

Hosted Claims Manager Features

Optum™ Proven, industry-leading clinical editing engine (with state specific LMRP/LCD/NCD) Includes between 60-90 system edits Near Real time response: Centricity™ Practice Solution & Centricity Business Clinical edits are integrated into the approval process Advanced EDI Management: Centricity Group Management Queues and workflow designed for ClaimsManager edits Payer edits Edits can be created specific to your local payers guidelines Edits can be turned off/tweaked if not needed

ICD-10 compatible Scrubbing will take place on ICD-9 and ICD-10 dx codes For instance the DCM edit will compare ICD-10 to ICD-9 diagnosis codes for historical editing. This edit is issued whenever the current line is an ICD-10 and in the history is an ICD-9 and when the current line is an ICD-9 and in the history is an ICD-10. Another is IMD edit is used to identify diagnosis code and modifier combinations that are not appropriate. Laterality is part of specific ICD-10 diagnosis codes and because of this conflicting laterality modifiers should not be submitted on the same line. PQRS Scrubbing will take place on measures YOU bill for

Why you need Hosted Claims Manager Reduce Clinical Rejections and Denials With the Hosted Claims Manager edits occurring prior to claim submission, allows for clean claims Decrease AR days Help make efficient and optimize revenue cycle Arm yourself with tools to code correctly Payers have specific coding expectations Hosted Claims Manager can help ensure those are billed correctly Aid in coding changes New codes, deleted codes, required new modifiers, etc. ICD-10!

Clinical edits...What are they? DLP Identifies items entered on one or more claims that have identical Dates of Services, Procedures , Modifiers, Departments, and Providers (including previous claim history) NPT Identifies where a new patient E&M was billed and the patient has been seen within 3 years by the same organization and specialty GFP Identifies an E&M that was billed during the global follow up period of an earlier procedure, has the same primary dx and was performed by the same provider IDX Identifies claim lines that contain a diagnosis code missing required digits for appropriate specificity

Clinical edits...What are they? LBI Identifies that no diagnosis on the claim line supports medical necessity for the procedure billed (as specified by Local Medicare Guidelines) MOD Identifies a line item that contains a modifier that is not permitted for use with a particular procedure code MFD Identifies situations where you have exceeded the maximum allowed frequency for a given procedure within a given date range NPD Identifies a line item that contains a diagnosis code that is not appropriate for use as a primary diagnosis code

$25 Think about it…… Average cost per claim for rework* Source: The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series (2009)

Hosted Claims Manager Live Demo

Hosted Claims Manager: Centricity Practice Solution

Hosted Claims Manager: Centricity Group Management

Hosted Claims Manager: Centricity Business

Hosted Claims Manager Edit Examples

Hosted Claims Manager Edit Examples THERAPY FUNCTIONAL DATA REPORTING The goal and the initial level or impairment should be noted in the patients' plan of care. A functional G code needs to be billed with the evaluative procedure. 96372 AND J CODE UNITS MUST MATCH Helping to recover over $20K dollars for a client in an 18 month period. DUPLICATES, REWORK AND UNDERPAYMENTS Client was getting a large volume of duplicate denials. After researching they found they were billing some procedures codes on two separate claim lines with 1 unit each. They should have billed with one claim line using multiple units. One line on their claim paid and one line denied as a duplicate – in essence underpaying them. The Hosted Claims Manager team built an edit to catch when this would happen and allow the client to bill appropriately. STOP ALL DMAP TICKETS High dollar tickets for client need to be stopped to ensure they are billed correctly first time. In 1 month, this hits around 150 times for them. STOP CLIA LABS NEEDING QW MODIFIER When billing associated labs, need to ensure the QW modifier is billed or will deny.

Debi Mitchell, RN, BSN, MBA Children’s Orthopaedic and Scoliosis Surgery Associates. LLP

Located in Tampa Bay Florida www.CHORTHO.com Orthopaedic division at All Children's Hospital John Hopkins Medicine

COSSA’s Days in Account Receivable (DAR) In 2002 (Before Centricity Practice Solution) Days in AR was 35.86 In 2003 Installed Centricity Practice Solution In 2006 – sending paper claims Days in AR was 20.93 In 2008 started Centricity EDI Services 2010 Days in AR was 18.2 In 2011 installed Hosted Claims Manager Days in AR 16.2 2014 Days in AR was 13.85

Days In Account Receivables How to calculate DAR? 12/31/2006 Total AR $960,106.37 Gross Billings past year $8,257,105.92   Days in AR 20.93 MGMA Method Rolling 12 months Days in AR = Total AR/Average Daily Billing Average daily billing = Gross charges for year/365 MGMA best practice Benchmark in 2011 37.11 days 12/31/2011 Total AR $948,072.27 Gross Billings past month $21,199,575.86   Days in AR 16.36 12/31/2014 Total AR $948,072.27 Gross Billings past year $24,984,914.96   Days in AR 13.85

Children’s Orthopaedic and Scoliosis Surgery Associates, LLP 2011 4 Physicians Total Charges $20,719,654. Billing A/R Staff 4 2014 5 Physicians Total charges $24,984,914.96 20.58% higher Billing Staff 4 Over 4 years we have seen an increase in 20.58% more charges A decrease of DAR by 2.51 days And doing this maintaining the same staff levels What’s next? 2015 – 6 Physicians ICD -10

Electronic Revenue Cycle Management 837 Claims 835 ERA (EOB) EFT (Direct Deposit) Denial Management Hosted Claims Electronic Revenue Cycle Management 270/271 Verification & Benefits E-Statements Return Mail Manager

A clean claim decreases your collection cycle Registration/ insurance verification Revenue cycle Patient statement Visit documentation/ coding Payment posted A clean claim decreases your collection cycle Removes the most costly parts Charge entry, Claim scrubbing Secondary Insurance billed (if applicable) the cycle repeats if you don’t send a clean claim – you have to make sure the verification was done right – relook at coding – etc And sometimes can just keep going around without getting paid Claim submission 837 Payment posted ERA/EFT/835, Patient payment

System is based off rules Easy to request rules! Requesting a New Rule or Modification to exiting Rule request sheet Example x-ray codes – new rule all plans 73520 is used for patients over the age of 12 73540 is used for 0-12 Example new rule for an insurance carrier (ID 846) We agreed not to bill established EM codes (99211 – 99214) with code 29450 with the DX code of 754.51 for a certain insurance carrier  To which CPT Code(s) or range of Codes does this rule apply? 29450 and 99211- 99214

Hosted Claims Manager makes it easy to request edits Request new rule Hosted Claims Manager makes it easy to request edits We filled out a form and saved it on the shared file server Request by carrier or group By CPT codes By Diagnosis Define what the flag will say

Example of a request Is this a new rule (Set Flag)? Yes What do you want the flag message to tell the user when this rule fires? In current global period need to attach modifier 58 What denial are you trying to prevent? Included in the global package of the initial procedure Is this a change to an existing rule? No Please provide a short description of the general purpose of this rule: Procedures having a 0, 10 or 90 day global value that are performed during the postoperative period of another procedure having a 10 or 90 day global value are considered included in the global package of the initial procedure unless an appropriate modifier is appended (58). Medicare and commercial insurance companies are following this guideline under their “reimbursement policies” a cast application falls under the “0” day global value when the patient is under a global for a code a modifier 58 need to attached to the cast application code.

CPT in Global Visit Here is an example of a flag. We know we can not bill a casting code without a 58 modifier when we are under a global code In 2014 this edit was hit 338 times!

Rule communicated on note tab inside the ticket Old codes Rule communicated on note tab inside the ticket The system will give edits if you have made the CPT code inactive Hosted Claims Manager will alert you if code is inactive and you have not made the code inactive

Missing higher charges? New Patient vs. Established Over time you will be able to use Hosted Claims Manager to help you code new visits instead of establish visit codes! This edit hit 149 times in 2014! Hosted Claims Manager needs the history before this edit will work.

Primary Diagnosis matters Hosted Claims Manager will tell you if the Dx code is inappropriate or missing, or doesn't matc Hosted Claims Manager hit this edit 145 times in 2014 allowing us to correct prior to batching

This means increased revenue! Missing revenue Missing a supply code This hit 682 times in 2014! This means increased revenue!

This is one of the best products GE offers (in my opinion) Hosted Claims Manager This is one of the best products GE offers (in my opinion) Sending in a clean claim is vital to a our success Having the ability to have custom edit rules will make you successful Allows your collection staff to work on the claims and appeals they need to do Not fixing coding mistakes. ICD-10 is the next road and we are happy that Hosted Claims Manager will be there with us

Hosted Claims Manager Reports

Hosted Claims Manager Reports

Hosted Claims Manager reports

Success Reports

Do you know your overall rejection and denial rate by payer? Summary Do you know your overall rejection and denial rate by payer? Do you know the percentage that are “clinical”? Do you know the magnitude of the cash-flow impact? Do you have an improvement process in place to reduce defects?