The Keys To Successful Collections

Edited by Erin Harris, Editor, Health IT Outcomes

By implementing a new medical claims clearinghouse, Pee Dee Orthopaedic Associates’ past-due claims outperform MGMA (Medical Group Management Association) standards.

Pee Dee Orthopaedic Associates (PDOA) provides full-service orthopaedic care and is a multispecialist practice that handles foot, hand, spine, and general concerns. Kathy Crawley, billing manager at PDOA, explains why implementing a new medical claims clearinghouse has increased users’ productivity and has reduced administrative burden and denials due to eligibility errors.

Q: What challenges facing PDOA drove you to research a new technology solution?
Crawley: GE provided both our practice management system and clearinghouse. I had moved into the role of billing manager unexpectedly, and I needed a great deal of help learning both systems. The clearinghouse did not meet our needs. As a result, we decided to change clearinghouses but kept the practice management system intact.

Q: How does your new clearinghouse benefit your organization?
Crawley: We switched to RealMed for our medical claims clearinghouse. RealMed runs eligibility checks on every claim. If an ID number is incorrect, it is flagged, and we have the opportunity to fix it before it is sent. That way, it does not go to the insurance company, where we would otherwise have to wait on a paper denial for 60 days only to find out that the front desk mistyped the number, and now we have to wait 60 additional days for our money. RealMed’s up-front edits prevent most denials. I do not know how many edits the solution actually has, but it catches coding errors, modifier errors, eligibility errors, date-of-birth errors, etc. Our new clearinghouse has improved our days in AR. In fact, the month that we went live was PDOA’s most successful month.

Q: What factors were most influential in driving your clearinghouse solution decision?
Crawley: A salesperson contacted me and conducted a demonstration. At first, I was very reluctant to change, given the issues I’d had with our previous clearinghouse. However, after the representative outlined the advantages, including claim error edits, correcting them online, its ease of use, and strong support, we decided to make the change.

Q: Who was involved in the purchasing decision? Do your physicians have input, or is it strictly an admin function?
Crawley: Our administrator and I were involved in the purchasing decision. The physicians rely on our administrator for these decisions.

Q: How was the solution deployed?
Crawley: RealMed consists of many different features, and we implemented them one at a time simply because changing clearinghouses is a major undertaking. Because I was the only person doing the testing, we completed the integration in stages.

First, we integrated claims management followed by remittance management. We integrated claims management first, as it is the component that all the other features rely on. Then we implemented eligibility management followed by statements. Each stage took a different amount of time to complete. I don’t care how well you know your practice management system. Every practice is set up differently, and when you start implementing a new clearinghouse, there will be bumps in the road.

I handled the implementation and the testing, and I handled all the claim edits for the first year. Because we had experienced so many internal changes, I wanted to make sure that the issues were worked out before training others. I trained the entire billing department, which includes 16 people. The entire billing department uses RealMed, because the employees are assigned different doctors as well as the claims associated with those doctors. All of the front desk associates use it as well. Anyone tasked with processing payments had to be trained on the solution, as it handles credit card authorizations. The vendor sent two representatives to assist me during our go-live.

As a result of the implementation, we all are more productive in our day-to-day job responsibilities. Editing the claims up front saves both time and money. We receive payments sooner, because we’ve sent out clean claims rather than error-ridden claims. The insurance eligibility that the batch sweeper posts back in our system cuts down tremendously on having to call insurance companies for verification.

Q: How did your job/workflow change as a result of this implementation?
Crawley: Our billing staff now has the ability to correct many of the claims before they are filed. Before RealMed, we were unable to automatically edit the claims. Each claim was sent even if it had problems, because we simply weren’t aware of the mistakes. The editing function keeps our money flowing faster. Our workflow has improved tremendously, because our claims are not lost in “EDI land.” With RealMed, every payer provides a receipt number, which provides proof that the claim has been accepted. This stops incorrect timely filing denials. The fact that we are correcting the claims up front has cut down on having to work on them from the back end after they have been denied. Before implementing RealMed, we did not have the eligibility posting back. The front desk had to visit many different websites (Blue Cross, United Healthcare, etc.). The sweeper helps the flow of the front desk.

Q: What implementation best practices and lessons learned would you share with other practices?
Crawley: I learned that the implementation was best handled in stages, because of the scope of the project. I had to learn the product myself before attempting to train our employees. Breaking down the implementation into stages allowed me to learn each feature at the most efficient pace possible as opposed to learning the entire product at once.

Q: What kind of results have you seen as a result of the implementation?
Crawley: Our +120 [claims that have not been paid in 120 days] is well below the MGMA standard. In other words, our +120 numbers are lower than they have ever been. The more claims that are processed within the 0 to 30 day, 30 to 60 day, and 60 to 90 day time frames, the sooner revenue is generated. You need to strive to keep your +120 numbers as low as possible. MGMA sets standards based on best practices across the nation. It is very important for PDOA to strive to meet these standards, because we must remain a highly professional and quality organization. We also have to work extremely hard to keep our revenue cycle turning around as fast as possible to achieve these goals. Due in part to the RealMed implementation, we have generated the highest revenue ever for the past nine consecutive months.

Q: Does your clearinghouse solution integrate with other systems you use?
Crawley: The GE practice management software, RealMed, and FIG (Featherstone Informatics Group), a workflow manager platform for interfacing, gathering, normalizing, and indexing health information, are integrated and are used in conjunction with each claim. FIG developed and maintains the claims sweeper, the eligibility sweeping, and the remittance downloads. Our claims are swept out of our system and sent to RealMed automatically every day. The eligibility sweeper runs every 30 minutes to pick up new appointments and verify insurance. All files are swept out of RealMed every 30 minutes so that we can receive and post electronic payments during the day. FIG integrates all of this sweeping and posting to and from GE and RealMed so that these functions are automatic and worry-free.