Health care claims and health plan enrollments can overtake operations staff at any time of year, but year-end is peak season for backlogs. Most benefit plans renew at year end and drive this peak activity. Combine this with open enrollment season for federal workers and large corporations and you may well need a health claims backlog reduction intervention, an enrollment backlog reduction intervention, or both.
As health claims and enrollments roll in through out the year, operation managers and executives like you must look at what they are spending to accomplish a health claims backlog reduction or enrollment backlog reduction. Are you staffing to peaks to handle these claims and enrollments? Are you staffing to average and running material hours of overtime? Or are you just letting time-service performance erode and catching up in February or March? Are you just mired in the swamp?
It is always tempting, and possibly just unavoidable, to put your key staff on draining the backlog swamp. Yet these are the exact folks who should be focusing on high impact and chronic illness claims. Routine tasks eat up the time they should be devoting to high value-added activities, not backlog swamp draining.
In evaluating choices to optimize your operation, give thoughtful consideration to outsourcing components of your operation. Outsourcing controls costs and maintains prompt service, which are critical in this industry. Slow claim payment and enrollment delays are high visibility faux pas to your customer and create ill will. Conversely, running high costs, even to satisfy your customers, is no way to impress your boss. Both can be avoided by outsourcing targeted tasks.
More advantages to outsourcing: You can focus on the main operations of your company while reducing overhead. Efficiency increases, making it possible to accomplish both a health claim backlog reduction and an enrollment backlog reduction with speed. When departments have become a challenge to manage effectively, outsourcing allows you to target resources on a situation, and then free yourself of their cost as soon as you catch up.
At a time of year when health claim and enrollment form supplies increase, outsourcing provides the additional resources needed to meet deadlines. With heavy workload, you may find that high employee turnover also results, adding instability to the mix. Outsourcing your health claims and benefit plan enrollment data entry can stabilize your organization while improving customer relations.
Outsourcing has been a key strategy in reducing backlogs and enhancing performance. Any operations manager or executive who wishes to create a well-oiled machine out of their organization needs to give it a serious look. Put a pencil to it and see if it doesn’t please your customers and management simultaneously, not to mention reducing wear and tear on you!
So drain that swamp. Just drain it smartly.
Processing medical claims can be frustrating for both medical office managers and insurance company health claim managers. Paper-based claim forms can get lost or mis-keyed, resulting in delayed claims payments and wasted time tracking down the correct information. However, with end to end medical claims solutions, the entire transaction can be processed through an electronic data interchange (EDI) interface, saving time and trouble.
Instead of working with paper, or keying in explanation of benefits (EOB) forms at the insurance company level, complete end to end medical claims solutions offer a 100 percent EDI interface. This kind of processing means that the EOBs are keyed into an ANSI 835 or other format, then uploaded into the Practice Management System. This reduces delays in posting that can occur when someone is manually entering data or converting it from another format. Using a completely 100 percent EDI interface also curtails the need for unnecessary follow up because the information is right there, as well as preventing errors caused by manually entering data.
Paper does not need to be a part of medical claims. In an era when doctors carry tablet computers into patient exam rooms, using paper seems like an ancient relic of the days when doctors made house calls and accepted payment in bushels of apples. While some would like to return to those days, the reality is that in today’s fast-paced medical billing world, medical offices and insurance companies need fast-paced, end to end medical claims solutions that can go entirely paperless. It’s important to look for a vendor that can offer a 100 percent virtual claims process in order to keep up with the inevitable uptick in claims as the population ages and requires more medical care.
The next big breach may not be as far away as you think. And when it occurs it will tend to stick out like our little friend here.
Stanford University Hospital in Palo Alto, CA, recently found that a spreadsheet containing health data on about 20,000 emergency department patients had been posted on a website unrelated to the hospital for about a year, according to the New York Times. Among items of protected health information (PHI) were patient name, diagnosis codes, admission and discharge dates and billing charges. This illustrates, once again, that the biggest security threat to health information systems is misuse or loss of PHI by employees or business associates, not hacking or malicious attacks. Whether you are dealing with employees or business associates, the same tools are needed: good training, accountability and oversight.
According to the 2010 Annual Study: U.S. Cost of a Data Breach by the Ponemon Institute, training and awareness programs are used by 2/3 of respondents as a post-breach remedy. Are you waiting until a breach to install training on HIPAA? Awareness training is your best first defense in ensuring that your staff understands the law and their role and responsibility in meeting it. Look for training that engages an adult learner and uses techniques for retention. Augment that HIPAA awareness training with period information on ways to improve privacy and security in your environment. Use breaches for discussion and improvement of your processes. Simply put, make sure your training sticks.
If you outsource any part of your process involving PHI, you need to know what training and policies your “business associate” has in place. Business Associates are now held to the same requirements under HIPAA and the covered entity thanks to the ARRA-HITECH Act of 2009, but the Covered Entity is still responsible for their data. Many commentators have seen the Stanford breach as a reason not to outsource, but the fact is that people, whether they are employees or vendor staff, need to be trained, held accountable and have oversight to ensure the proper steps are taken to protect PHI. Working with a vendor who is knowledgeable and actively involved in HIPAA compliance can actually strengthen your overall security and privacy. But, do your due diligence on HIPAA compliance when selecting a vendor and when reviewing the vendor periodically to determine whether the on-going relationship is truly a value add to your process. The Question is not whether to outsource, but to know what questions to ask your vendors and which verification processes to have in place to ensure compliance.
The 1996 Health Insurance Portability and Accountability Act (HIPAA) has seen major updates since its inception - to the privacy act in 2003, the security rule in 2005 and ARRA-HITECH in 2009. Physician practices have worked hard to stay compliant and most do a good job. However, since ‘the only constant is change,’ meet HIPAA Update 2011, complete with newer, more stringent rules. As you study the new rules, make sure too that your staff understands long-standing HIPAA regulations. Here is our HIPAA Update 2011 top ten need-to-know list:
1. Comply with HIPAA Version 5010. This new data transaction standard takes effect January 1, 2012. Talk to your software vendor to verify critical practice management software upgrades and testing with health plans are completed so you meet the government-imposed deadline. If not, expect disruptions in claims processing and other administrative issues.
2. Understand the HITECH Act of ARRA. Described by some as “HIPAA on Steroids,” new regulations of the American Recovery and Reinvestment Act of 2009 (ARRA) expose the practice to increased liability, mandated government audits and even lawsuits for non-compliance. Study the federal government’s Office of Civil Rights website, www.hhs.gov/ocr/privacy.
3. Have a Privacy Officer. Patients have a variety of rights under HIPAA; make sure that someone in your office is in charge of administering and protecting those rights.
4. Know your biggest security threat. By far, the largest number of patient security threats are caused by, or enabled by, internal users, i.e. office and clinical staff. Role-play regularly with staff on patient privacy scenarios and ensure you provide annual HIPAA training for your staff as that is considered a "best practice."
5. Understand security no-no’s. Never allow public e-mail systems; unsecured WiFi; outdated anti-virus and spam software; peer-to-peer sharing applications.
6. Have a secure password system. Protect security by avoiding ‘weak’ or shared user names and passwords. A login such as ‘staff’ invites abuse and patient security breaches.
7. Maintain an incident-reporting process. Someone, usually the office manager, must document HIPAA incidents so you can prove corrective actions were taken. Incidents that affect more than 500 people must be reported to CMS in a timely manner according to ARRA – HITECH.
8. Train and update. Do not let staff become complacent! Regularly review policies and conduct training. This is especially critical given new, more stringent HIPAA requirements, oversight & penalties.
9. Post your Notice of Privacy Practices. Place on your website and have copies at the front desk.
10. Separate myth from fact. Keep current on HIPAA happenings and share information with staff regularly, so your staff is knowledgeable about what’s true under HIPAA and what's rumor.
Are we moving to a pay-for-care-coordination system of health care?
Really?
Are patient-centered medical homes about to spring up like daffodils?
I am not convinced.
Don't get me wrong I am for this approach and many pilot programs indicate reductions in cost, improvements in quality or both. Dr. David Longworth's recent article in the Cleveland Clinic Journal of Medicine, Accountable care organizations, the patient-centered medical home, and health care reform: What does it all mean?, highlights four programs that achieved significant savings.
From the Group Health Cooperative of Puget Sound reducing total cost by $10 PM/PM, to Blue Cross Blue Shield of South Carolina materially reducing hospital days, ER visits and total medical & pharmacy costs, impressive savings are clearly attainable with a patient-centered model.
Yet I wonder how many tests we are going to run on alternate systems before we adjust our treatment of the system.
In his August 24, 2011 Health Care Blog (@healthblawg), David Harlow says:
"The advantages to proceeding with a Bundled Payment for Care Improvement project include the opportunity to participate in CMS shared savings programs while only providing limited commitment of organizational resources, i.e., limited to one or more discrete service lines or episodes of care. Of course, investments in a culture of collaboration must be made, but the system-wide investment in IT and other infrastructure at the level called for in order to qualify as an ACO would not necessarily be required in order to proceed with this initiative."
I agree with David's observations but argue such incremental-ism, while reducing risk to the hospital, does not go far enough fast enough. Our fee-for-service system delivers poor value, and it is getting worse in this regard, not better. We cannot get the change we need and deserve by nibbling about the edges.
Someone please, take a bite . . . a big bite.
After reading the article by Jeff Rowe of HITECH Watch created 8/12/2011, it started me thinking --- "Is there a law of diminishing returns in policymaking?". I say, "Not only is there, but we have far surpassed the point!!!".
You cannot legislate morality and you cannot legislate health. Doing the "right" things for the "right" reasons MUST be the job of every person in the process. Laws and regulations can guide people, but when there is more documentation and explanation that even the paid staffers can read, how can anyone else keep up? The public comment periods are a misnomer since most people do not even know about them and the time it takes to respond is excessive for a small to mid-size player. Hence, most of the comments are made by the "BIGS" and this is not a one size fits all system. When the Federal Government is in the trees or even the weeds, they lose perspective on being the oversight we need to ensure the people in the process are doing the "right" things for the "right" reasons. We have lost oversight and there are fewer and fewer health care checks & balances. When any entity takes on all the roles in a process, it leads to inefficiency and ineffectiveness --- no one --- not even the Feds can be all-knowing and all-doing.
The Federal Government should set the high level objectives and then allow the industry to work together to make that happen. Getting down to "certifying" vendors, defining metadata standards and even designing curriculum at the Federal level for workforce roles that are not ubiquitous is a waste of money and will not be the panacea that we are all hoping for in health care.
Isnt' it time we asked everyone in health care to step up and do their part to address these neagtive effects of healthcare reform. We need to become part of health care checks & balances. Only those closest to the process can effectively identify the changes needed. Only the patients can help ensure they receive the "right" care and treatment. Only the healthcare provider can determine how to minimize errors and maximize efficiency in his/her practice.
So, given our need to control spending at a Federal level, isn't it time to turn process improvement back over to the Process Owners?
Now we have insurance companies buying hospitals and provider practices...didn't we see this before? It did not work last time, why is it going to work this time? Sorry, Yogi, but it is like deja vu all over again!
While there are many faults of the current healthcare system in America, we do, theorectically, have checks and balances. The payers oversee that the providers are performing valid services and charging appropriately for them. The providers "police" the payers to ensure fair and accurate payments (as much as they can given the cloak of darkeness around the reimbursement rules). The Government should be the entity overseeing the whole system to ensure it best meets the American public's needs and the needs of our society.
Unfortunately, over the past 30 years, the blurring of lines between these entities has reduced the effectiveness of all of them. Healthcare is a complex problem/issue/expense and in order to optimize the processes, we need to have clear roles and responsibilities outlined so that entities can work effectively in their space. When payers buy providers or providers become the payer, this reduces the effectivenss of the parts. Can synergies be created through staff model HMOS? Certainly, Kaiser and others have demonstrated an effective way to make this work. But, that does not mean all payers can effectively run the delivery of healthcare.
The Government has also gotten too far into the trees, that they do not see the forest. Both Federal and State Governments has lost their perspective to provide oversight by being actively involved in the payment and delivery of healthcare. While we keep arguing about National Healthcare, with over 50% of our healthcare bill being paid by the Government through Medicare, Medicaid and other programs, the US is the largest Government run healthcare system in the world.
The 25 criteria to achieve meaningful use, edi transactions sets and all the other government regulations will not solve the healthcare crisis in America. Neither will payers buying providers in the search for an Accountable Health Plan. Accountability, like morality, cannot be legislated -- it takes each of us to "do the right things for the right reasons" and to look at the totality of a situation, not just how do I maximize MINE.
Jeff Rowe of HITECHwatch.com tweeted about whether the concept of meaningful use was meaningful and why smaller providers are lagging behind on the effort. In his June 29, 2011 post, the editor of HITECHWatch raises the issues of how long MU will continue in its current form and function.
Well, as in all things perpetuated by the Government, we had the concept and theory way before the detailed requirements. Jeff stated how the Meaningful Use criteria rewarded those already in the lead (i.e., the bigger, "in the know" providers). He quotes Farzad Mostashair's remarks in which he likens the MU process to a race and says "the time frame for clarification, rule making and subsequently for implementation the technologies and process change to achieve the recommendations is very difficult for those beginning the race at the start." Unfortunately, this is classic government -- trying to get too deep into the weeds without understanding what the weeds are. And, further, funding "help" in the form of Regional Extension Centers, without understanding what the smaller providers need. Is this just the blindness of bureaucracy or is it a well thought out attempt to orchestrate a government takeover of Health Care?
Of course, the US is the largest government run health care system in the world, with more than $
The HITECH Incentive payments have not seemed to be enough to motivate most small to mid-size providers to meet the 20 out of 25 meaningful use criteria. Is it because the providers are having difficulty in understanding the meaningful use criteria or is it just apathy on more government regulation?
Consequently, many of our clients, especially small practices and rural areas, are seeking help with implementing Meaningful Use. The guidance from the agencies just isn't enough.
If you are like most medicare supplemental carriers, you have been seeing a number of CMS Mass Adjustments lately. Even if you have Mass Adjustments "turned off" on your COBA ID, you are still getting a fair number. Are these Mass Adjustments impacting your time service?
Adding this unexpected volume of nickel and dime transactions to your already full queues of claims can create a management challenge. Here are what some carriers are doing to alleviate the mess:
(1) Put them in a separate queue on your claim system and have dedicated staff handle them. And, more importantly, have your main team continue to knock out their daily production so that the Mass Adjustments don't throw you out of compliance.
(2) Set a dollar limit for adjustments to minimize the time spent handling the small transactions. Several payers have set thresholds of anywhere from $5 to $25. By aggregating the transactions, you can reduce your cost of handling these claims.
(3) Outsource overflow to highly skilled and targeted staff whether through use of an internal pool, temporary staffing or a BPO firm, be sure that you are dealing with HIPAA trained, experienced claims professionals. By using an additional pool of staff, the task of working these adjustments will not impede your timely handling of daily claims.
By following any of these steps, the CMS Mass Adjustments will not be a healthcare claims processing nightmare for you!!!
Lisa Lechowicz is CEO and Founder of HDM Corp. She has extensive experience in running large health care claims operations.
Health Care is a business like any other. Of course, the mission of the business is to help people get well & stay well, however, hospitals and providers of health care must be sure they keep their business healthy, as well.
What is preventing the healthcare providers from making process changes toward efficient administration?
Let me know your thoughts on what the greatest obstacles are. Is it HIPAA, EDI phobia????
For example, why don't more providers take advantage of the eligibility and claim status transactions electronically? More and more payers are providing good data via this method and a process can be established to use these tools to obtain the information needed more timely and with less effort -- so why are only 20-30% of the providers using them?