GeBBS Healthcare Blog

Billions of Dollars Flow into Private Medicaid Plans with NO Cost Oversight or Efficacy of Treatment Determined

Posted on Wed, Nov 07, 2018 @ 10:52 AM

Cost containment has become a leading factor in the delivery of healthcare. What are some of the issues that are contributing to these burgeoning costs? One of them is Medicaid. We spent over $576 billion on Medicaid programs in 2017, as reported by the Kaiser Family Foundation.

A recent article in Kaiser Health News noted that 75 million low-income Americans rely on private Medicaid managed care programs. These programs have grown rapidly since 2014, boosted by the influx of new beneficiaries under the Affordable Care Act (ACA). Many states eagerly tapped into the services of private insurers as one way to cope with the expansion of Medicaid costs under the ACA, which has added 12 million people to the rolls. Outsourcing these government-payer programs to private insurers has become the preferred method for handling Medicaid in 38 states.

In return for their fixed fees, these private insurers provide treatment within a limited network -- in theory -- allowing for more judicious, less expensive care. States contract with health plans as a way to lock in some predictability in their annual budgets. Participating states in these private programs are funneling nearly $300 billion annually into private Medicaid insurers.

Are these private Medicaid insurance companies -- who are now receiving hundreds of billions in public money — earning their fees?

Hard evidence is lacking that these private contractors improve patient care or save government money. When auditors, lawmakers and regulators examine the records, many conclude that private Medicaid insurers fail to account for the dollars spent, document the care delivered, or provide access to a sufficient number of doctors. Oversight is sorely lacking and lawmakers in a number of states have raised alarms even as they continue to pay billions. Another “fly in the ointment” is that these private plans get to keep what they don’t spend. That means profits can flow from greater efficiency -- or from skimping on care and taking in excess government payments.

What is the solution to cost containment on these government-funded private payer programs?

Independent outsourced auditors who have deep experience in auditing insurance claims and determining the efficacy and quality of medical treatments can be utilized to monitor these privately managed care plans.

These independent outsourced auditors will have the information technology solutions to deliver highly skilled professionals, robust audit processes, proprietary workflow engines, and world-class IT infrastructures.

They can deliver immediately audit workflow and operations management to ensure consistency throughout the managed care plan audit process that will monitor and report the true cost of medical treatments and the quality of care being provided to patients.

Let’s get the “fox out of the henhouse” and move toward a system that will contain costs, and more importantly, improve the patient care being delivered.

GeBBS Healthcare Solutions is a leading technology-enabled provider of revenue cycle management (RCM) and Government Payer solutions. GeBBS’ innovative technology, combined with its over 6,000-strong global workforce, helps clients improve financial performance, compliance, and patient satisfaction. Visit our website to see how our services can work for you.

 

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Tags: RCM Solutions, Revenue Cycle Solutions

Improving Revenue Cycle Management with Point of Service Collections via Estimation and Eligibility Checking

Posted on Tue, Sep 25, 2018 @ 09:00 AM

A significant share of today’s hospital and doctor reimbursements now come from patients rather than commercial payers, yet many providers haven't updated their collection practices. As charge amounts on medical bills continue to rise, healthcare providers are increasingly challenged to collect the high deductible amounts owed them. Patients are also more conscious of how much they spend on healthcare services as medical costs consume an increasingly large portion of their paychecks.

Ten years ago, high deductibles were an innovative way to reduce employer healthcare spending and encourage policyholders to shop and compare costs when choosing healthcare services. Now, the recent popularity of high deductible health plans has caused many patients to experience difficulty paying medical bills, causing a significant consumer medical debt problem downstream.

There is a definite link between high deductibles and bad debt. Medical bills are the highest cause of bankruptcy in America according to multiple studies. The Kaiser Family Foundation and The New York Times found 20 percent of insured patients reported having difficulty paying for their medical care within the past year.

What can be done to ameliorate this financial challenge?

GeBBS Healthcare Solutions provides a suite of self-pay collection solutions that can help healthcare providers cope with this new phenomenon. We start with a remotely-hosted Centralized Eligibility Unit for hospitals, faculty practice plans, PMS/EMR vendors, and billing companies. The solution consists of GeBBS staff, technology, management and expertise that delivers high-quality, cost-effective patient insurance eligibility and related services. We then follow-up with proven self-pay collection solutions.

A 2009 McKinsey study found that 74 percent of insured consumers indicated that they are both able and willing to pay their out-of-pocket medical expenses up to $1,000 per year and 90 percent would pay for medical expenses up to $500 per year.

Reasons for a rise in self-pay bad debts are due in part to inefficient and ineffective collection practices followed by billing companies and physician practices. Providing the patient with easy access to patient statements that are easy to understand will help drive higher patient collections.

The GeBBS self-pay collections team uses technology-enabled practices to maximize patient contact using:

  • Automated dialers
  • Digital messaging campaigns
  • Mobile technology to drive text messaging campaigns

 

The GeBBs Self-Pay Collections team leverages analytics to arrive at the best time to contact and propensity to pay scores to create outbound campaigns that are patient experience-oriented, non-obtrusive, and drive higher patient connect ratios

We work with the patients and offer them flexible payment options and easy access to payment and capability for capabilities for web, phone, credit card, and e-check payments.

 

Expert Coding Can Ensure You Are Maximizing Your Revenue Cycle

Posted on Tue, Sep 11, 2018 @ 06:00 AM

Declining reimbursements are one of the biggest challenges healthcare providers face today. Ask any physician or hospital and they will tell you about the daily struggle of getting paid for their services. However, many healthcare providers are leaving a significant amount of money on the table by under coding.

To be correctly reimbursed for their services, providers have to code procedures accurately so insurers will pay them the agreed-upon amount. Over coding and under coding both occur when providers aren’t coding correctly and both can result in serious consequences. While over coding can lead to an audit, under coders risk being charged with Medicare noncompliance.

Studies have found that around one-third of visits were under coded according to accompanying written documentation, and about half were under coded based on documentation of medical decision making. An astounding 80% were under coded based upon the number of problems presented by the patient during the visit.

Evaluation and management services in family medical practices are often under coded compared to the actual services provided. Under coding can occur when doctors don't consider problems mentioned by patients, and when they don't document additional work done with patients.

Under coding may forestall an audit, but it also causes practices to leave thousands of dollars on the table every year.

GeBBS Healthcare Solutions with our 2,000+ coders can assure you do not leave money on the table with one of our FlexSource-final-logo-RGB solutions. Our experienced and certified coding team will provide a customized coding solution to meet your specific needs. You can pick the delivery location that meets your specific scope, preference and budget. Whether you need coders onshore or offshore or in both locations the choice is yours. In addition to that you get access to our technology and best practices as part of the solution.

GeBBS coders use our proprietary iCode_Workflow_Logo coding software, which enables faster and more accurate coding. In addition, coding quality is monitored and improved using our proprietary iCA-logo-300dpi-01 coding audit software.

iCode_Workflow_Logo (iCW) is an intelligent coding workflow software that enhances coder performance and improves the overall coding process. iCW accepts any kind of input source with built-in functionalities of customizing and mapping incoming data fields. It creates and supports business rules based on client requirements and generates output into a customized format compatible with client systems. As a one-stop coding solution, iCW provides a single platform with integrated coding quality assurance built in to the workflow, exception management tools, and a platform that helps communicate a variety of standard and configurable reports at the aggregate and individual levels with providers and other stakeholders.

To ensure you are always coding at the exact appropriate level, GeBBS’ iCA-logo-300dpi-01 provides a comprehensive, customizable medical coding audit SaaS solution. With built-in workflow, interactive audit management dashboard, detailed scorecards, and robust reporting, it optimizes and accelerates the coding audit process. For hospitals and providers, it improves overall coding quality and compliance while providing the ability to access audited and scored records for education, review and process improvements. Based on OIG audit methodology and AHIMA’s best practices standards, it supports accurate and compliant coding for both facility and professional fee records.

Trust GeBBS Healthcare Solutions to ensure you are not leaving any revenue – that you deserve – on the table.

 

Pre-authorization as a Service Requires Both Technology and Human Components

Posted on Tue, Aug 21, 2018 @ 09:00 AM

Most claim denials are due to the lack of verifying benefit information prior to services being provided. Insurance verification process is crucial for all hospital encounters, whether inpatient, outpatient or ambulatory care. It will ensure that the hospital or physician receives payment for services rendered and will help determine the patient’s share of the charges referred to as the patient’s responsibility.

Eligibility verification is the process of checking a patient’s active coverage with the insurance company and verifying the authenticity of his or her claims. In order to avoid claim rejection, the verification process must be done before the patient is admitted into a hospital, sees a physician or gets services by a medical professional.

Coverage and eligibility benefits should be verified for all new patients and hospital admissions. Coverage and benefits will also be verified for any patient who indicates a change to their coverage and for all high dollar procedures. Pre-authorization is required for many non-emergency medical procedures and services.

GeBBS end-to-end, comprehensive revenue cycle management (RCM) solutions provide this pre-authorization as a service using both technology and human elements. With 12+ years of RCM experience, our billing experts are well versed in all Medicaid state plans, managed care plans, government-funded programs, third-party insurance, and Medicare billing rules. We follow industry-standard key performance metrics to measure success and integrate best practices, so that you get the value of our proven experience and expertise.

Our solution includes:

  • Scheduling, Eligibility Verification, and Pre-Authorization
  • Customer/Patient Contact by knowledgeable healthcare professionals

The solution renders many benefits including:

  • Reduce overhead costs and streamline staff workflow
  • Improve overall yield by reducing denials
  • Improve patient satisfaction scores (no more turning patients away or rescheduling)
  • Improve referring doctor relationships
  • Focus on patients not paperwork

 

Among the major trends affecting healthcare payments are the new high-deductible insurance plans. As a result, both patient liability and bad debt are on the rise and healthcare providers are experiencing unprecedented revenue and margin pressure. Hospitals and clinics have become like retail organizations, which need to provide their consumers with access to payment capabilities at point of service, via the web, through pre-authorizations of services covered, payment plans, and more. GeBBS patient access management solutions make it easier for patients to stay on top of their new responsibilities, lowers your costs and increases revenue.

 

Transforming the Business of Healthcare

Posted on Fri, Jun 15, 2018 @ 02:09 PM

The overall theme of this year’s HFMA Annual Conference is “Transforming the Business of Healthcare,” and it is right on target. No other industry is experiencing more evolution and transformational change than healthcare. It seems that the only thing we can count on is change -- this is even more true for the business side of healthcare delivery.

Managing change is all about handling the complexity of the process. It is about evaluating, planning and implementing operations, tactics and strategies. It is never a choice between technological or people-oriented solutions, but a combination of both. This is certainly true when it comes to revenue cycle management (RCM).

This period of transformation is precisely the time to engage with a partner who brings a deep understanding of revenue cycle management to the table. GeBBS Healthcare Solutions provides tailored revenue cycle management solutions that cut through the complexity with expertise, operational excellence, and a sophisticated approach. We deliver solutions specific to the clients’ needs and work with their legacy systems, using their tools. GeBBS builds efficient workflow processes with higher output through the use of hybrid solutions that employ both automated technology and the expertise of qualified people.

Serving thousands of hospitals and healthcare organizations nationwide, GeBBS provides end-to-end, comprehensive revenue cycle management solutions from payer credentialing to complete billing and collections services. With many years of RCM experience, our billing experts are well versed in all Medicaid state plans, managed care plans, government-funded programs, third-party insurance, and Medicare billing rules. We follow industry-standard key performance metrics to measure success and integrate best practices, so that you get the value of our proven experience and expertise. Our comprehensive range of revenue cycle management solutions, include:

  • Accounts Receivable (A/R) Management -- Lack of skilled resources can lead to a backlog of claims that need to be processed. It is critical to success to have access to a large pool of qualified resources that can work with your organization and understand how to quickly and correctly analyze account history, appeal denied claims, and get timely turnaround to recover on and close out A/R.
  • Credit balance resolution -- HFMA calls credit balances the “stealth aircraft of hospital patient accounting.” GeBBS maintains a team specialized in credit balances resolution. Our team is comprised of highly-qualified individuals with hospital accounting backgrounds and strong analytical skills.
  • Denial management – The key to success in denial management is having access to a large pool of qualified denial management resources that can work with healthcare organizations and understand how to quickly and correctly analyze account history, appeal denied claims, and get timely turnaround to recover lost revenue.
  • Extended business office-- GeBBS offers comprehensive extended business office (data entry) solutions that take the worry out of the RCM process by improving your efficiency and collections while reducing costs.

Let us help you transform your business side of healthcare delivery. With GeBBS as your partner, there is no reason to fear change – we can help you embrace it and make change work for you!

The Importance of Eligibility Verification and Pre-authorization

Posted on Thu, May 31, 2018 @ 10:30 AM

In medical billing terminology, eligibility verification, pre-authorization, prior authorization and pre-certification are terms that may be used interchangeably to mean that for certain situations and procedures, providers have to contact insurers in advance and obtain a certification number in order to be reimbursed properly (or at all) for services. Insurance verification and insurance authorization services play a vital role in revenue cycle management. In fact, most claim denials happen when a patient is ineligible for services billed by the provider.

Depending on what the patient's coverage documents and the provider's contract with the insurer specifies, neglecting to obtain pre-authorization can result in reduced reimbursements or lower benefits for the patient. If a provider neglects to obtain pre-authorization and payment is denied by the insurer, it may come down to absorbing the cost of the treatment or trying to collect it directly from the patient.

GeBBS Healthcare Solutions, with our Eligibility Verification and Pre-Authorization services, specializes in next generation revenue cycle management to help increase cash flow and speed medical billing processes.

With today’s high-deductible insurance policies, insurance and eligibility verification are absolutely critical. Identifying patient responsibility upfront, prior to the visit, is critical to managing the receivables. In the absence of proper eligibility and benefit verification, countless downstream problems are created — delayed payments, reworks, decreased patient satisfaction, increased errors, and nonpayment.

A McKinsey Quarterly survey of retail healthcare consumers showed that 52 percent of consumers would pay from $200 to $500 or more by credit or debit card when they visit a physician, if an estimate was provided at the point of care.

To avoid these problems, GeBBS provides a remotely-hosted Centralized Eligibility Unit for hospitals, faculty practice plans, PMS/EMR vendors, and billing companies. The solution consists of GeBBS staff, technology, management and expertise that delivers high-quality, cost-effective patient insurance eligibility and related services.

GeBBS Eligibility Verification/Pre-authorization Services can:

  • Improve A/R cycles (reduce A/R days)
  • Increase cash collections by reducing write-offs and denials
  • Receive schedules from the hospital via EDI, email or fax
  • Verify coverage on all primary and secondary (if applicable) payers by utilizing sites like WebMD, payer web sites, interactive voice response systems, and phone calls to payers
  • Contact patients to get updated insurance information
  • Provide the clients with the results, which include eligibility and benefits information such as member ID, group ID, coverage end and start dates, co-pay information
  • Obtain pre-authorization number
  • Obtain referral from PCP
  • Enter/update patient demographics
  • Remind patient of POS collection requirements
  • Inform client if there is an issue with coverage or authorization
  • Process Medicaid enrollment

 

The Age of Revenue Cycle Management Outsourcing Has Arrived

Posted on Thu, May 17, 2018 @ 02:13 PM

The RevCycle Intelligence e-newsletter reported recently that 80 percent of hospitals are vetting full revenue cycle management (RCM) outsourcing. The demand to outsource full RCM is up 86 percent from 2015 among hospitals and inpatient organizations. Approximately 80 percent of hospital leaders in a new Black Book survey of 709 C-suite executives, board members, and senior managers at hospitals and other inpatient organizations said they were vetting or considering outsourcing full RCM by 2019.

The survey revealed the demand for RCM outsourcing is significantly up because hospitals and inpatient organizations are looking to reduce costs and focus on value-based care initiatives. Nine out of ten hospitals are also considering partnering with a third-party vendor to allow hospital leaders and providers to prioritize value-based care implementation.

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The complexity of value-based care reforms and their impact on revenue have put pressure on hospitals to decrease inpatient volumes, achieve financial outcome goals and provide cost-effective care. RCM outsourcing is growing because it offers struggling hospitals immediate results.

This is precisely the time to engage with a partner who brings a deep understanding of the revenue cycle. GeBBS Healthcare Solutions provides tailored revenue cycle management solutions that cut through the complexity with technology, service capability and operational excellence.

GeBBS provides a broad portfolio of HIM and RCM solutions to thousands of physician and healthcare organizations nationwide. As hospitals and physician practices look for ways to contain costs and increase their revenue, RCM outsourcing is a valid strategy to achieve a financially healthier organization. It’s just a matter of finding the right partner with the right expertise and technology.

Revenue Cycle Management Is More Than Just Managing Your Cash Flow

Posted on Tue, May 01, 2018 @ 07:43 AM

Many healthcare providers are under the impression they can assess their financial health by evaluating cash flow only. However, cash flow is just one factor in revenue cycle management (RCM). To maintain a healthy revenue stream, healthcare providers need to understand the other important metrics that should be calculated and reviewed when evaluating their revenue cycle.

The American Academy of Family Practice (AAFP) association has identified five key metrics in RCM that are critical to maintaining a healthy revenue stream:

  • Days in Accounts Receivable
  • Days in Accounts Receivable Greater Than 120 Days
  • Adjusted Collection Rate
  • Cost to collect – your total billing expenses as a percentage of revenue.
  • Denial Rate
  • Average Reimbursement Rate

GeBBS provides end-to-end, comprehensive revenue cycle management solutions for all of these metrics, including, complete billing and collections services. With 12+ years of RCM experience, our billing experts are well versed in all Medicaid state plans, managed care plans, government-funded programs, third-party insurance, and Medicare billing rules. We follow industry-standard key performance metrics to measure success and integrate best practices, so that you get the value of our proven experience and expertise.

Our Solution includes:

  • PMS/EMR System and RCM Process Implementation
  • Scheduling, Eligibility Verification, and Pre-Authorization
  • Medical Coding
  • Claims Submission (Use your clearinghouse or partner with ours)
  • Accounts Receivable (A/R) Management
  • Credit Balance Resolution
  • Customer/Patient Access Solutions

Our A/R Management solution provides a large pool of qualified resources that can work in any practice management system and understand how to quickly and correctly analyze account history, appeal denied claims, and get timely turnaround to recover on and close out A/R. GeBBS analysts can trend denials and look for patterns of deficiency that will increase cash flow and reduce aging A/R.

As a partner to our clients, GeBBS serves as a direct RCM extension to hospitals and physician practices by leveraging our healthcare expertise, technology and qualified resources to offer comprehensive extended business office (data entry) solutions that take the worry out of the RCM process by improving your efficiency and collections while reducing costs. With improved first-pass rate, a 97% accuracy level, and guaranteed turnaround times, you can focus on growing your business and keeping your patients

healthy. GeBBS end-to-end RCM provides a complete solution to help you maintain a healthy revenue stream.

Rising Costs in Healthcare Lead to Increased Demand for Outsourced Solutions

Posted on Thu, Apr 05, 2018 @ 09:00 AM

Healthcare IT News reported recently that nearly three-quarters (73 percent) of health systems with more than 300 beds -- and 81 percent of providers with fewer than 300 beds -- are shifting their focus to IT outsourcing for development and complex infrastructure services. Their data was based on Black Book Research that surveyed 1,030 hospital CIOs and IT leaders and 243 CFOs and financial executives from 266 hospitals and the business managers from 1,400 outpatient, alternative care and physician practices for their insights on technology and outsourcing services options.

The Black Book study’s overwhelming conclusion was that immediate access to a fully-trained staff and its technology, in combination with a positive return-on-investment, are the driving forces behind the turn toward IT outsourcing, especially as the demand on healthcare organizations grow in complexity.

Doug Brown, managing partner of Black Book, said, “Our research found that most hospital leaders see no choice but to evaluate and leverage next-generation information and financial systems as an outsourced service in order to keep their organizations solvent and advancing technologically."

GeBBS Healthcare Solutions provides a comprehensive suite of outsourced revenue cycle management (RCM) and health information management (HIM) solutions. Our in-depth healthcare industry expertise enables us to provide end-to-end solutions to successfully resolve our clients’ billing challenges, while embracing their overall business operations.

GeBBS delivers a world-class infrastructure of highly skilled professionals, robust processes, and proprietary workflow engines. This makes us an ideal outsourcing partner for our clients. By leveraging our people, processes and technology, we enable clients to reduce operating and capital costs, recover revenue, improve patient satisfaction, and increase productivity. With a current staff of over 5,000+ professionals, GeBBS is one of the nation’s fastest growing companies, as recognized by Inc. 5000.

Walmart Reportedly in Early-stage Talks to Buy Humana

Posted on Mon, Apr 02, 2018 @ 02:00 PM

Here we go again! In my last blog I mentioned how companies like Amazon, Google, Apple, Uber, etc. will be driving innovations in healthcare delivery and costs over the next 10 years. Today, the Wall Street Journal (WSJ) reported that retail giant Walmart is in preliminary talks with health insurer Humana about developing a closer partnership, with one possibility being that Walmart might acquire Humana.

If you are a Humana customer right now, they strongly suggest that you use Walmart for your prescription coverage. If this deal comes to fruition it will have a significant effect on the healthcare industry and it could be good for consumers/patients, since Walmart seems committed to its “always the lowest price strategy.

Here are five interesting facts that the WSJ reported:

1. The two companies are discussing a variety of options, and it is not certain they will strike a deal. If they do reach an agreement, it would be Walmart's largest deal ever. Humana's current market value is about $37 billion.

2. If the potential deal, which would require regulatory and shareholder approval, closes, Walmart would be one of the largest health insurers in the country.

3. The talks between Walmart and Humana come amid a flurry of deals that could transform the business of managing healthcare, including CVS Health's proposed acquisition of Aetna for $69 billion and Cigna's proposed acquisition of Express Scripts for $54 billion.

4. Humana shares jumped 10 percent in after-hours trading March 29 after WSJ reported the preliminary talks. Shares of Walmart dropped 1 percent.

5. Walmart, which is a major drugstore operator in addition to being the world's largest retailer and has a current market value of $260 billion.

America’s largest companies continue “to think outside the box,” and they have their eye on the healthcare industry.