Northeast Health Systems Takes Control of Medicare Denials
Northeast Health Systems (NHS), Beverly Hospital:
- Full service community hospital
- 221 Beds
- Services include maternity, pediatrics, surgical, cardiology, orthopedics and other specialties
- More than 570 physicians serving 13 communities in and around Beverly, Massachusetts
- Large Medicare population
Challenge:
- Significantly improve Medicare claims performance
- Ensure compliance with changing Medicare requirements, especially unpublished edits
- Screen for medical necessity more effectively
Results:
- Reduced days in A/R by up to 3 days translating to $2 million in cash flow
- Decreased labor costs by $100,000
- Significantly decreased overall number of denied Medicare claims
- Streamlined claims compliance process
Solutions:
Northeast Heath Systems (NHS), a 350-bed, integrated healthcare system in Massachusetts, is comprised of a network of hospitals, behavioral health, long-term care and human service affiliates. These include three acute-care hospitals – Beverly Hospital, Addison Gilbert Hospital in Gloucester and BayRidge Hospital in Lynn – and an outpatient facility, Beverly Hospital at Danvers, Medical and Day Surgery Center. As its population of patients covered by Medicare and Managed Medicare plans (including Tufts Medicare and Harvard Pilgrim Medicare) began to increase in 2001, NHS Beverly Hospital realized it needed to significantly improve its Medicare claims performance, and sought expert help screening for medical necessity, tracking Medicare edits and repairing invalid coding and denied claims. Complex Medicare requirements made it difficult to generate 100% clean claims and Beverly’s legacy billing systems just could not keep up with changing and unpublished edits. As a solution, Beverly decided that instead of hiring full time employees with the sole purpose of tracking CMS changes and monitoring claims, it would implement InSight Compliance and InSight Medical Necessity at its 221-bed hospital in May of 2001.
Deploying a Medicare Expert
Craneware InSight’s web-based solutions were selected to alleviate Beverly’s Medicare claim denials because of their ability to automatically identify invalid claims prior to submission to Medicare and all other payors.
Using a complete, up-to-date library of edits, including guidance from Medicare fiscal intermediaries and plan-level edits for commercial payors, the Craneware InSight solutions were able to ensure claim accuracy and completeness before the claim even went out the door. The clinical editing capability of the solution created alerts for Beverly staff so they were warned of valid charges missing on claims, creating new revenue from within the existing revenue cycle.
Using this solution, coupled with InSight Medial Necessity, a tool used to deliver the most extensive set of payor medical necessity requirements available, Beverly was finally able to guarantee complete, clean claims. “Using Craneware InSight, we were able to not only catch, but also repair our broken claims before they were even sent out the door,” said Marsha, director of patient accounts, Northeast Hospital Corporation.
Clean Claims, Clear Communications and Reduced A/R Days
Since first partnering with Craneware InSight in 2001, Beverly has seen tremendous improvement in its revenue cycle department. The efficiency that Craneware InSight tools provide has allowed Beverly to reduce its total days in A/R by up to 3 days, translating into $2 million in cash flow savings. “Our revenue cycle processes are streamlined now and so much smoother,” says Barb, Medicare Patient Account Representative “In addition to resolving internal operational procedures, these tools have perfected our ability to update and track our Medicare claim compliance accuracy.” Beverly has also seen tremendous savings on its labor spending since implementing Craneware InSight’s tools. “By not having the burden of editing claims, researching and investigating new, unpublished edits and resubmitting denied claims, I was able to save over $100,000 a year in labor costs alone,” said Marsha.
Additionally, using these tools, Beverly has seen the communication processes between the revenue cycle departments and its clinicians improve as the Craneware InSight tools create reports on recurring problems. These reports highlight medical necessity errors, lost revenue trends and department-level coding issues and failed edits with cost assessments for any specified time period. “Using these drilled-down reports, we are able to educate other departments and individuals about the billing process,” said Diane, Medicare Team Leader. “Before, we didn’t always know why certain claims were accepted and others denied, and we definitely could not trend any recurring issues. Now we are able to assess these reports and make constructive adjustments throughout our organization.”
Given the vast successes Beverly has realized using Insight Compliance and InSight Medical Necessity with Medicare, it plans to expand deployment and continue to roll these products out for additional commercial payors in the next phase.
