Payer-direct claims: for a Pennsylvania health system, the key to claims efficiency was a combination of technology and a do-it-yourself attitude. (What works: claims processing).

Even the best technology is still only a tool to help healthcare organizations move forward to achieve objectives. Our organization wanted to transmit claims directly to as many payers as possible and to acquire claims-editing software that would help us simplify our billing process. We were willing to make the IT investment upfront, provided we could capture gains for the organization's long-term future.

PROBLEM

Lehigh Valley Hospital and Health Network (LVHHN) is a 750-bed teaching facility that serves as the major clinical campus for Penn State University's College of Medicine at the Milton S. Hershey Medical Center. The network has a professional staff of more than 1,100 physicians.

Three years ago, we were transmitting Medicare claims through the Capital Blue Cross system, and using NEIC and Independence Blue Cross on a stand-alone basis. However, when Capital Blue Cross announced that it would no longer process Medicare claims through its system effective October 2001, we needed to find an alternative.

Our accounts receivable (A/R) days were moving upward from the low to middle 60s, but we remained reluctant to resolve the situation by employing clearinghouse services. We wanted to avoid the per-claim fees of a clearinghouse and, at the same time, increase internal efficiency by billing directly to payers. We looked for other vendors that could easily meet our deadlines to get us up and running to pass Medicare claims through electronically, but we found few that met our requirements.

SOLUTION

In fact, our short list of candidates was very short--only two vendors. In the end, we chose The SSI Group, headquartered in Mobile, Ala., with its ClickON electronic claims tools that operate on Windows NT, client/ server and SQL platforms. We were impressed with SSI's ability to write specific rules to accommodate a multitude of variations and distinctions among payers' requirements, and we anticipated seamless integration issues with our clinical and financial systems. A critical part of our decision was SSI's ability to transmit directly to a large number of our payers.

SSI's billing software streamlines the billing process with its combination of payer-specific, provider-specific and system edits. The billing process begins with a download of data from the provider's information system, usually in the form of a print spool file containing the UB-92 or HCFA 1500 claims, and then the billing application analyzes each claim for completeness and accuracy of data. Whenever possible, information is automatically added or manipulated to be compliant with payer requirements. The resulting claims data is either valid and ready for transmission to the payer or requires follow-up by the billing staff.

Achieving ROI was another significant factor in our decision. LVHHN viewed the purchase of the SSI system as a long-term investment. Our precontract ROI analysis showed that following an initial outlay of investment, we could expect a return on investment within three years, and we deemed this to be reasonable.

Within 60 days--as opposed to the usual 90--we were up and running with ClickON technology, and we met our Oct. 1, 2001, deadline. By January 2002, the system was fully operational.

The 29-member LVHHN billing staff is accustomed to changing processes and procedures, so we encountered no training obstacles or learning curves with the employees who used the SSI system. In only a few cases did we encounter a little resistance to learning the ClickON technology, because these employees preferred the old Blue Cross system. Fortunately, it didn't take much hands-on experience with the SSI system for them to see it could produce cleaner claims in shorter turnaround times than the previous system.

RESULTS

We began with Capital Blue Cross claims, then followed with Medicare claims. Within two to three months, our staff had all payers coming through the SSI system. Since 40 percent of our claims are Medicare and another 20 percent are Blue Cross, that's a significant portion of our business.

SSI wrote rules to accommodate the quirks of individual payers' systems, and that has contributed greatly to our efficiency. Today we can pass all clean claims through their scrubbers and directly to payers, with the exception of payers whose claims are processed via a clearinghouse.

We have reduced A/R days at Lehigh Valley Hospital from 68 days to 50 days, and at Muhlenberg Hospital from the same level to 47 days. While this 25 percent to 30 percent reduction might not seem astonishing, it is significant in terms of net dollars to the organization, given the complexity of our healthcare network.

LVHHN is a multihospital facility. Our services include a huge trauma center, a burn unit, a cancer treatment facility .and a large psychiatric unit--services rendered according to complex treatment plans where multiple services are billed and episodes of treatment are ongoing and extensive. Achieving a 25 percent or 30 percent A/R reduction in such facilities represents a significant improvement and a return to the bottom line, and it would be considered commendable by peer facilities.

In addition, we stopped printing a lot of paper claims and achieved savings in not running so many UB-92s. Billing staff who use the SSI technology no longer need to review most claims; now they review only the exceptions.

The SSI scrubber is on everyone's PC. Our IDX LastWord system passes information to the SSI system through the scrubber; billing staff edit and correct claims, and they are sent electronically via SSI directly to payers.

Installation and implementation of this system were streamlined and required little help from our IT department other than a few staff hours for lines and wire connections. We had a person internally in patient accounts who could champion the implementation. Any time we can avoid using the already stretched resources of our IT department by doing it ourselves, we improve the efficiency of the entire Lehigh Valley enterprise.

The SSI Group positions ClickON technology as a set of tools--and that's exactly how we view it. In addition to using new tech tools, we also have engaged in considerable self-evaluation as an organization. We have revisited and realigned internal processes to make better use of tech tools and better use of staff time.

SOURCE
Sandra Colon
Director of Patient Accounts
Lehigh Valley Hospital and
Health Network
Bethlehem, Pa.

PRODUCT/COMPANY

ClickON Claims Processing Tools
The SSI Group Inc.
Mobile, Ala.
www.thessigroup.com

For more Information on ClickON technology from The SSI Group, www.rsleads.com/305ht-200 or Circle 200