Home health care providers want to improve their patients’ lives and create a care experience that is patient-centered and second-to-none. They also want to get paid. And today, with rising patient volume and increased regulatory requirements — including Electronic Visit Verification (EVV) and the forthcoming implementation of the Patient-Driven Groupings Model (PDGM) — the challenges to timely reimbursements have never been greater.
This landscape has deepened the importance for providers to unify their systems in a comprehensive technology platform, one that can account for specifications that come with a multitude of payers, patient diagnoses, federal laws and state regulations. Proper technological support will help payers meet the goal of maximizing their claims reimbursements in a timely fashion.
Getting to 99% claims acceptance — in four steps
As regulation, patient volume and patient categorization all increase, successfully handling billing and claims reimbursement under old norms — namely manual entering and monitoring — will cease to work. According to Scott Brashears, a senior vice president of health care compliance technology company Complia Health, the shift from manual entry to automation is the key step that helps providers “get to 99” — maximizing claims acceptance rate on the first attempt and ideally reaching 99% success.
“In layman’s terms, getting as many if not all of your claims paid in a timely fashion,” Brashears said in a recent webinar.
In the webinar, Brashears explains the complexities of the modern reimbursement system and the risks and pitfalls of continuing to bill manually in an automated world. While manual work brought risks under the prospective payment system (PPS), those risks multiply exponentially under PDGM, he said.
“What gets your path to 99 is billing efficiently, with as [few] interactions as possible, and as timely as you can,” he said. “The closer you get [to 99], the more cash flow you have, the better efficiency you have — and the more you can add to your business.”
What Brashears sees is an interwoven web of four areas that health care providers must navigate in order to maximize their claims reimbursement:
— The billing and claims process
— Payer mix
— State laws
— Patient diversity
The complexity comes not simply from those four categories, but from their respective branches, and the way they all interact. Take the six-step billing and claims process. Health care providers must evaluate a patient’s eligibility for service and their own authorization to perform the service, ensure the accuracy of their documentation, validate their billing with each payer, meet filing timelines and anticipate denials.
Each of those six steps then contains a multitude of options based on how the other three items — payer, patient, state laws — affect a given step. Bill validation, for instance, changes with the state and the payer.
“It’s not as simple as saying, ‘Susie went and saw Jon and got paid,’” Brashears said. “If you’re in Wisconsin, you might need to split two visits a day out with multiple modifiers. If you’re in Ohio, you might need to roll them up and bill it under a tiered rate. Or if you’re in Colorado, for example, the first hour has to bill separately than the second hour.”
With a technology platform, such as Complia Health’s ContinuLink, health care providers can use an automated system of checks and balances to ensure that bill validation is successful in each state and with each payer. But not everyone is using that sort of a system.
“In today’s systems, a lot of that is a manual process,” he said. “And the more you put a manual processes in front of this, the harder time you’re going to have. If I have to do something 100 times and it gets repetitive, there is a good chance — statistics prove — that I’m going to mess some of those up. So the validation should be as automated as possible in order to ensure that you’re actually getting paid for all of the services you’re providing.”
With provider consolidation continuing to reshape the industry, companies will have to know how to navigate this complex web of systems that touches multiple states, multiple payers and different patient care needs. The right technology platform helps providers manage these needs and lets them focus on health, Brashear said.
“Our values are pretty straightforward: we want to help you take care of your patients, and help you get paid,” he said about ContinuLink. “We want to enhance the health experience. There is nothing wrong with wanting to get paid for the services you are providing.”
ContinuLink by Complia Health helps home health and home care agencies deliver quality of care without compromise. No compliance gaps, the right information at the right time and the best care available at your fingertips. To learn more about maximizing claims reimbursements, view the webinar “Your Path to 99.”
Companies featured in this article:
