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When Cathy Snell changed claims clearinghouses in early 2009, she was simply looking for a few more "bells and whistles" than her prior service partner could offer Oklahoma Cardiovascular Associates. But Snell wound up with more powerful claims management tools, resulting in significant revenue cycle improvements for the 88-provider group practice, based in Oklahoma City. Prior to switching to Navicure for claims processing services, the practice's average AR stood at 35 days. One year later, they have dropped to between 25 and 27 days, says Snell, the business office manager at Oklahoma Cardiovascular. "We got a better handle on rejections and improved our productivity," she says.

Like most group practices, Oklahoma Cardiovascular must contend with a number of different payers and corresponding claims submission guidelines. Filing with as many as 1,600 payers over the course of a year, Oklahoma Cardiovascular submits about 25,000 claims per month, Snell says.

As of last June, the group's net collection percentage stood at 97 percent, or 2 points higher than it had been with its former clearinghouse. Snell attributes the improved financial performance to more powerful data management tools offered by Navicure-as well as persistent training of front-end staff, where many claims rejections originate.

Snell cites two features offered by Navicure as being critical to the improved revenue cycle. First, the group can conduct electronic batch eligibility checks through Navicure, helping the practice identify those patients whose insurance has either elapsed or changed-and sidestepping a potential landmine of bad debt. "If a patient's insurance has termed, we're catching it before they walk in the door," she says.

Here's how the batch eligibility feature works: First, the group's practice management system, from PCIS, reviews the appointments for the upcoming week. Snell's crew builds a report and uploads it to the Navicure Web site. In turn, Navicure distributes the list to its payers that conduct batch eligibility checks. These include Medicare, which insures about 60 percent of Oklahoma's patient volume. The payers send back a report to Navicure, which in turn parses the data back to Oklahoma Cardiovascular. The report includes basic information, such as whether or not the patient is still covered by insurance, and also includes information about deductibles and co-insurance. "If you find out they don't have insurance, you collect when those patients come in," Snell says. "It's easier to get payment when they are face to face then it is from sending out a statement."

Snell's crew of 50 business office staff includes half a dozen who work the eligibility report thoroughly, contacting the patients before the appointment takes place. It's especially helpful for the Medicare patients, says Snell, who adds that many of them opt for so-called Medicare replacement plans, or managed care alternatives to the standard federal plan.

"They change plans often," Snell says. "They can switch and we wouldn't know. Some of these plans have timely filing requirements. If you don't get the claim to them within 90 days, they won't pay. The same thing for pre-authorization requirements. So we get the pre-certs done before the patient walks in."

Handling rejection

The other big component of Oklahoma's improved revenue cycle metrics is improved claims rejection management. Navicure's system spits out two types of reports for rejected claims. The first report contains outgoing claims that fail to pass a payer "edit" or requirement before moving into adjudication. These claims may have missing data fields, or may include incorrect provider numbers.

The second report includes claims that have passed to the payer, but have been rejected for other reasons, such as the wrong diagnosis. The front end-end rejections, those returned prior to being received by the payer, average between 2 to 3 percent of all claims. Payment rejections, those received from the payer after the claim has been processed, average between 7 to 8 percent of claims, Snell estimates.

Navicure's detailed reports on claims rejections have facilitated revenue cycle process improvement by the billing staff. Navicure's reports organize the rejections into major categories, including eligibility issues, provider numbers, and coding errors. In addition, the clearinghouse breaks out the group practice's claims by payers, enabling Snell to route the reports to various specialists assigned to work the given payers.

In contrast, Oklahoma Cardiovascular's former clearinghouse could only provide a large report which encompassed all claims, both paid and rejected. To work rejections, Snell's crew had to print out the report and sort through it manually to analyze the various rejections.

"We can get to the denials quicker now," Snell says. "We can fix the problem and get the claim back out the door quicker. You can click on the report, go to an individual claim, and go right to the claim. It is a big time saver."

Snell cites one example of how a claim can go wrong. One day, she noticed a huge jump in the number of rejected claims. After studying the report, Snell determined that Medicare had inappropriately rejected a major batch of claims.

Two claims in the file had errors, but the payer inadvertently assigned the error message to the entire batch of claims. Snell called Navicure, then Medicare, and resolved the problem within an hour. "The key is being persistent," she says.

Snell is ready for her next big claims challenge-the forthcoming conversion to the HIPAA 5010 claims standard. Oklahoma Cardiovascular has updated its practice management system and will begin its first round of testing before the end of spring.