The Back Page: Web-based Claims Clearinghouse Eases Billing & Coding Challenges

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Terry Davis is a medical coder with Oklahoma Cardiovascular Associates, Oklahoma City.

With 45 physicians and 14 non-physician practitioners spread across nearly 40 locations, it became increasingly arduous to effectively manage the paper-based billing process for Oklahoma City-based Oklahoma Cardiovascular Associates (OCA). My ability to manipulate data—both to gauge and improve bottom-line metrics—was severely hampered every time a piece of vital information slipped through the cracks and vanished.

Prior to March 2009, for instance, we received paper remittance advice—often up to 200 pages—that had to be manually scanned into our system. This forced me to dedicate two part-time employees solely to making duplicate paper copies, from which they devised appropriate worklists to hand to each biller. That all changed after OCA went live with a web-based medical claims clearinghouse that has streamlined workflow in addition to providing my team with the strategic business intelligence needed to effectively track and manage the revenue cycle.

Improved workflow and A/R days

Regarding billing workflow, appropriate worklists now flow directly to each biller from the solution, and claims can be worked in real-time. Because we chose a web-based clearinghouse, our billers can access a set of up-to-date bundling edits that includes rejections experienced by other users. Overcoming the bundling obstacle is eased, which aids our first-pass rate: Improving from 89 to 94 percent. (Note that we determine error rate based on claim lines. Claim lines not paid due to requests for medical records, invoices for drugs and radiopharmaceuticals and investigation for pre-existing conditions or coordination of benefits are not counted as errors.)

Meanwhile, we also plan to use a crosswalk to identify the appropriate evaluation and management CPT code to replace the eliminated consultation CPT code for Medicare and any other payors that no longer reimburse for them. The goal is to lessen the effect of the change on the physicians, who will still be allowed to indicate that they have performed a “consultation” service.

Overall, the administrative burden formerly caused by the need to spend time organizing work rather than doing work has been cut drastically. The two part-time employees that were devoted to compiling worklists? They became full-time collectors as attrition created job openings. In addition to realizing reduced administrative costs through the elimination of five or six FTEs, the practice benefits from our entire staff’s ability to concentrate on tasks that truly impact revenue generation. Our average days in accounts receivable (A/R), for instance, now rest at 26—well below the 37-day standard for a practice our size as recommended by the Medical Group Management Association. Staff becomes more accountable for progress as managers gain access to accurate data and reports.

Explanations of benefits (EOBs) provide another example of automation benefits. Bringing in revenue from secondary insurance used to be problematic, but we no longer need to tediously copy paper primary EOBs, black out sensitive information, put them into envelopes with the claims and mail them. Electronic filing and tracking eliminates the need for follow-up calls to payors, only to hear, “I’m sorry, we never received the EOB.”

Claims and remittance are the key documents that drive every practice. The more health IT solutions can be used to help coders and billers quickly generate clean claims on the front end, the fewer problems experienced downstream. The end result: Improved cash flow and reduced administrative costs. With reimbursement squeezed as never before, it has become crucial for cardiology practices to evaluate health IT solutions in light of their ability to efficiently and compliantly aid the capture of all billable dollars.

Mr. Davis is a medical coder with Oklahoma Cardiovascular Associates, Oklahoma City.