Electronic Straight Through Billing Service and Software Methodology for Medical Practice

Medical billing complexity and massive volumes of daily claims render manual claims processes incapable of protecting both the provider and the payer from underpayments, overpayments, and billing compliance violations. Straight Through Billing addresses complexity and volume processing problems by automating the majority of the claim flow and focusing the billing follow-up specialists to exceptions only. A Straight Through Billing process flags problems, routes them for follow up, and enables online correction and resubmission. Straight Through Billing methodology implements billing service transparency and focuses management on strategic process improvement opportunities.

Straight Through Billing (STB) integrates billing process within the practice management workflow, automates vast majority of transactions, focuses manual labor on exceptions, and establishes a process for continuous improvement.

First, integrated practice management and billing workflow connects patient scheduling, medical record management, and billing into a single flow. Every participant of the practice management workflow receives a unified and coherent picture of practice workload, patient and provider location, resource availability, and cash flow.

Next, transaction automation streamlines and expedites billing process by automating claim validation, payer message reconciliation, and billing workflow management:

 

• Automated claim validation eliminates errors downstream and reduces processing time because it flags errors before submitting the claim to payer.
• Automated claim-message reconciliation eliminates costly search for the original claim and standardizes message communication, further eliminating the need to decipher the (often cryptic) payer's message.
• Billing workflow management drives the followup discipline required for resolution of claim denial and underpayment incidents and establishes high degree of process transparency for all billing process participants, resulting in full and timely payments.

 

Third, focusing manual labor to exceptions requires timely exception identification, routing to followup personnel, online error correction, and rigorous followup tracking. Again, process transparency, as implemented in vericle-like systems, enables tracking exception followup.

Finally, a process for continuous improvement requires continuous observability of every process attribute and a modification methodology for both automated claim processing and manual exception followup tracking.

STB implements billing transparency by design because billing transparency is an integral attribute of every component of STB process.

Straight Through Billing Architecture

Straight Through Billing systems architecture mirrors the architecture of general Straight Through Processing (STP) systems developed for the financial services industry. Such systems require effective workflow management, knowledge base validation system, connectivity to all process participants, including on-line data reconciliation, and tracking of problem resolution. Therefore, a typical vericle-like STB system has a three-tier architecture:

 

• Back-end processing engine designed for high-volume transaction processing environment
• Middle-tier uses Java Servlet technology
• Front-end is an HTML-JavaScript zero-footprint client

 

An STB system (e.g., Vericle) following the methodology outlined above implements rich functionality, which allows automated

 

• Computer aided preferential patient scheduling
• Integrated electronic medical records
• On-line computer aided coding
• Real-time claim validation and patient eligibility testing
• Electronic claim submission
• Payment posting, reconciliation, and verification of meeting contractual obligations
• Monitoring of audit risk and billing compliance
• Tracking of denial appeal process

 

Quantitative STB Management

STB methodology allows for quantitative management as the likelihood of failure of the entire process can be estimated as the product of such items for each individual workflow steps. A vericle-like STB system tracks the percent of clean claims (claims paid without any manual intervention in full and within the allocated timeframe) and focuses the management on those process aspects that yield the greatest potential improvement. Thus STB methodology focuses on exceptions both at tactical and strategic management levels.

Yuval Lirov, PhD, author of Practicing Profitability - Network Effect for Revenue Cycle Control in Healthcare Clinic and Chiropractic Office: Scheduling, SOAP Care Plans, Coding, Billing, Collections, and Audit Risk (Affinity Billing) and Mission Critical Systems Management (Prentice Hall), inventor of patents in Artificial Intelligence and Computer Security, and CEO of Vericle.net - Distributed Billing and Practice Management Technologies. Yuval invites you to register to the next webinar on audit risk at BillingPrecision.com

Chiropractic Office Billing Software And Patient Relationship Management - 9 Criteria For Best SaaS

Software-as-a-Service (SaaS) pushes the limits of outsourcing and reduces the exorbitant costs of specialized practice management software. SaaS model is available for all aspects of chiropractic clinic management, including scheduling, billing, and SOAP note documentation, which are mission-critical for high quality health care, practice building, and regulatory compliance.

What is Software-as-a-Service?

Software-as-a-Service (SaaS) is a logical step in the progression from build to buy to subscribe and a manifestation of a major software trend towards Service Oriented Architecture (SOA). SaaS is the software industry term for delivery of software product and services over a network (typically the Internet) under subscription business model.

The increasing reliability of the Internet coupled with availability of completely integrated practice management and billing software, create supportive conditions to pay-as-you-go business model. SaaS liberates the users in two significant ways:

 

1. SaaS requires no large upfront investment in hardware and software licenses on the part of the user
2. SaaS shifts the onus of systems management from the user to the SaaS vendor, including
   1. Internet connectivity, bandwidth, and routers
   2. Servers for Web server software, email, firewalls
   3. Capacity management
   4. Redundancy management
   5. Application upgrade management

       

       

    

    

 

In financial management terms, SaaS proposition is equivalent to turning capital expense into operating expense, which translates into

 

1. Better balance sheets
2. Lower risk, especially during the period of rapid technology innovation on one hand and practice-building stages on the other hand

    

    

 

SaaS differs from Applications Service Providers (ASP) in two ways, namely, domain expertise and software development skills. While ASP vendors developed primarily hardware and systems expertise and offered foreign business applications, SaaS vendors are experts in the specific application domain.

SaaS Vendor Selection

For the manager of chiropractic clinic, the main challenge could be the integration of newer applications with the subscribed SaaS application. SaaS Integration Platforms (SIP) is a popular way to handle the integration challenge. A SIP, such as Vericle, offers a suite of integrated applications, such as Patient Relationship Management, Patient Scheduling, SOAP notes, and Billing.

Chiropractic clinic in search of SaaS vendor must focus on the following topics:

 

1. Functionality: Does the application deliver required functionality?
2. Training: Will the vendor provide sufficient application training?
3. Third-Party Application Interface: Does the application work with existing applications already deployed in the office? What requirements must be satisfied if you decide to purchase another application later?
4. Performance: How do you measure application performance? Are formal performance metrics available continuously?
5. HIPAA Compliance: What controls are in place to enable access only on a "need to see" basis? Is every access instance logged using secure mechanism?
6. Service Level Agreement: What minimum service levels the vendor guarantees to the client? What are the penalties for violating SLA?
7. Data Ownership: Who owns the data?
8. Disaster Recovery: How long would it take to recover from a disaster? Is a secondary data center available 24 x 7?
9. Disengagement Procedures: How long is data available upon severing the relationship? Who is responsible for data transfer to the new vendor?

   Yuval Lirov, PhD, author of "Practicing Profitability - Network Effect for Revenue Cycle Control in Healthcare Clinic and Chiropractic Office: Scheduling, SOAP Notes, Care Plans, Coding, Billing, Collections, and Audit Risk" (Affinity Billing) and "Mission Critical Systems Management" (Prentice Hall), inventor of patents in Artificial Intelligence and Computer Security, and CEO of Vericle.net - Distributed Billing and Practice Management Technologies. Yuval invites you to register to the next webinar on audit risk at BillingPrecision.com

Electronic Medical Billing Software and Service Compliance in Chiropractic Office

Over the course of the past two decades, federal and state enforcement agencies have investigated medical billing incidents and brought multiple enforcement actions against healthcare practices. The list of agencies tasked with billing compliance enforcement includes federal Department of Justice, the Office of Inspector General (OIG) at the Department of Health and Human Service, state Medicaid fraud control units, and others.

The number of medical billing fraud investigations and enforcement actions has been steadily growing. For instance, according to BillingWiki, thirteen articles and news items were published on the topic of medical billing fraud during May of 2006. In addition to growing frequency of incidents, the severity of penalties has also escalated from relatively non-adversarial audits and occasional return of payments to fines, suspension or loss of license, and imprisonment.

Six out of thirteen news items and articles about medical billing fraud published in May 2006 involve chiropractors (BillingWiki/Compliance). The remaining items are distributed more or less evenly across such specialties as psychiatry, gynecology, neurology, orthopedics, and aged care. The growing frequency of audits and increasing severity of penalties are symptomatic of inadequate attention to billing compliance at the chiropractic office.

An insurance company typically performs post-payment audit by soliciting medical notes for a random sample of paid claims during the previous year. Next, the proportion of inadequate medical notes defines the overpayment percentage. The total amount of overpayment is then calculated by applying the overpayment percentage to all payments over the past six years.

Billing compliance is doctor's responsibility and ignoring it often results in practice ruin. To avoid billing audit risks, some doctors have elected to work on cash-only basis, collecting cash payments directly from the patients instead of submitting medical claims to insurance agencies. However, such tactics does not help avoid the potential audit because patients submit requests to pay the claim to the healthcare insurance company on their own.

Since the top two reasons for post-payment audits are over utilization of certain CPT codes and hot line calls by patients and staff, the best strategy to manage post-payment audit risk has three prongs:

1. Formal compliance program,
2. Competent management of medical notes, and
3. Continuous monitoring of potential audit triggers.

First, the existence of a compliance program may determine whether the payer can routinely handle the matter as an innocent overpayment mistake or it must be investigated by the OIG as a potentially fraudulent act.

Next, careful management of medical notes is a basis for a successful audit defense, which often reduces the damages significantly and helps avoiding a repeat audit a few years later.

Finally, audit trigger monitoring ensures compliance of both cumulative service patterns across multiple patients and individual treatments. Real-time juxtaposition of histograms of CPT code frequencies between practice and national averages compares service patterns and alerts of potential compliance infringements.

Individual treatment compliance is ensured when no specific CPT code exceeds its monthly limits, such as billing a 9894X on each visit, or billing a 97140 manual therapy in place of a manipulation code because it pays more, or charging for 97149 together with 9894X, while both procedures linked to the same diagnosis. In the latter example, performing both an adjustment and a soft tissue manipulation in the same part of the body for the same complaint is illegal and a repeat submission of such a claim may trigger an audit.

An environment of high volume of patient encounters creates thousands of possibilities to deviate from normal distribution of services and trigger an audit. Therefore, real time analysis requires powerful technology infrastructure and competent legal coverage. Such infrastructure must handle all compliance aspects together, which necessitates modern Vericle-type integrative approach, combining billing, monitoring, and medical record management components in a single and comprehensive system

Yuval Lirov, PhD, author of Practicing Profitability - Network Effect for Revenue Cycle Control in Healthcare Clinic and Chiropractic Office: Scheduling, SOAP  inventor of patents in Artificial Intelligence and Computer Security, and CEO of Vericle.net - Distributed Billing and Practice Management Technologies. Yuval invites you to register to the next webinar on audit risk at BillingPrecision.com