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Transcript of Changing the denials management paradigm with advanced ... EDI: Centricity EDI...

  • Imagination at work

    Changing the denials management paradigm with advanced analytics A GE Healthcare presentation

    1

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    ©2016 General Electric Company.

    The results expressed in this document may not be applicable to a particular site or installation and individual

    results may vary. This document and its contents are provided to you for informational purposes only and do not

    constitute a representation, warranty or performance guarantee. GE disclaims liability for any loss, which may

    arise from reliance on or use of information, contained in this document. All illustrations are provided as fictional

    examples only. Your product features and configuration may be different than those shown. Information contained

    herein is proprietary to GE. No part of this publication may be reproduced for any purpose without written

    permission of GE.

    GE, the GE Monogram, Centricity, DenialsIQ, and imagination at work are trademarks of General Electric

    Company.

    All other product names and logos are trademarks or registered trademarks of their respective companies.

    General Electric Company, by and through its GE Healthcare division.

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Introduction of speakers

    3

    Sr. Product Marketing

    Manager

    GE Healthcare

    Andrew.Slotnick@ge.com

    Mike Monahan

    Director Solutions Enablement

    GE Healthcare

    Michael.Monahan@ge.com

    Andrew

    Slotnick

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Goals of the presentation

    4

    1. Insight into big data and analytics and their

    applications to operations

    2. Introduce you to UC Irvine Health (UC Irvine)

    3. Detail UC Irvine’s challenges related to denials

    management

    4. Demonstrate how we applied technology, process

    and people to help UC Irvine drive improvement

    5. Review results

  • See tutorial regarding confidentiality disclosures. Delete if not needed. 5

    Big data is a broad term for data sets so large or

    complex that traditional data processing

    applications are inadequate.

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Data Actionable Insights Outcomes 6

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Understanding the Healthcare specific challenges

    7

    Using healthcare expertise to

    translate specific sciences to solutions

    People-intensive culture requires

    change management …

    Empowering administrative workflows with

    insights from end to end

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Outcomes

    8

    Clinical Quality

    Operational Efficiency

    Financial Performance

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Platform

    Algorithms

    Data

    Clear understanding of a complex problem

    Maximizing value from big data

    9

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Focus on areas of action to deliver targeted outcomes

    10

    Eligibility Prior Auth Coding Timely filing

    Demographic /

    Technical Errors

    Medical Necessity

    Eligibility

    Authorization

    Demographic /

    Technical Errors

    Medical Necessity

    Eligibility

    Authorization

    43%

    28%

    6%

    23%

    Denials Write Offs

    61%

    12%

    16%

    11%

    Initial Denials

  • See tutorial regarding confidentiality disclosures. Delete if not needed. 11

  • See tutorial regarding confidentiality disclosures. Delete if not needed. 12

    Denials…

  • UC Irvine Case Study

    13

  • See tutorial regarding confidentiality disclosures. Delete if not needed.See tutorial regarding confidentiality disclosures. Delete if not needed.

    UC Irvine Health

    14

    Physicians Billing Group (PBG)

    Manages billing for 85% of the physicians at the School of

    Medicine

    30 Billing and Accounts Receivable (BAR) groups

    • 800+ physicians

    • $500M claims submitted per year

    • Patient mix:

    Commercial Contracted 28%; Medicare 26%; Medi-Cal/ CalOptima 22%

    Discover. Teach. Heal.

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    UC Irvine core financial technology footprint

    15

    RCM: Centricity™ Business (8yrs.)

    • Task management (non-insurance follow-

    up)

    • TES

    Insurance follow-up: Huron TRAC™

    EDI: Centricity EDI

    • OPTUM Claims Manager ™

    Contract management: Experian®/

    Medical present value (MPV)

    Business Intelligence: Centricity

    Informatics

    • DenialsIQ™

    Other: Non-PBG* Centricity

    Business users represent 18% of

    users

    Electronic Medical Record:

    Allscripts™

    *PBG – Physicians Billing Group

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Billing performance is the lifeblood of UC Irvine’s ability to deliver patient care

    “We are the only source of revenue for the

    school of medicine. If we do not perform we

    won’t be able to pay our doctors or treat our

    patients”.

    16

    - Elizabeth Burrows

    IT Director Physicians Billing Group

    UC Irvine Health

  • See tutorial regarding confidentiality disclosures. Delete if not needed. 17

    KPI dashboard did not include key profitability metrics

    Metric UC Irvine PBG Non-PBG

    Days A/R 52 69

    Lag time 13 21

    Net collections

    Self-pay

    Non self-pay

    40%

    96%

    57%

    94%

    Denials Unclear Unclear

    Depth of data and insights was only directional, making effective action difficult

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    ~20% of invoices were denied monthly, indicating room for improvement

    18 UC Irvine ~$40m in claims submitted/month

    $ o

    f d e n ie

    d c

    la im

    s

    $835,577

    $1,531,101

    $1,773,035

    $821,392

    $1,216,865

    $396,921 $318,037

    $153,044

    Coding Contractual Duplicate Eligibility Misc NonCovd PriorAuth TimelyFiling

    Industry top performers average ~ 4%

    % o

    f b ill

    e d d

    o lla

    rs d

    e n ie

    d

    1 %

    2 %

    3 %

    4 %

    5 %

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Limitations within denials management workflow created friction

    19

    Denials received Claim re-worked/ submittedOpportunities identified Fix executed

    Workflow

    How technology

    can help

    By unique billing specialty

    • Department

    • Payer

    By role & access to technology

    Result Silo’d knowledge resulted in

    false positives and valuable

    opportunities missed

    Pre-assigned work lists

    updated nightly to collectors

    Could not manage

    resources based on

    demand or value of problem

    Collectors escalate issues

    to manager or coder,

    process reviewed, fix

    implemented

    Improvements were made

    in isolation; missing ‘big

    picture’ for organization

    Insights without human

    intervention; making the

    volume more manageable

    Assign resources based on

    value in near real time

    Technology helps confirm

    we are solving the right

    problems

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Challenge

    • Data was still directional, showed what

    ‘buckets’ were overflowing but not why

    Ex: pointed towards front end or back end

    or categories of denials

    Result

    • Struggled for cross-functional buy-in

    (especially with medical center staff),

    needed more concrete data about how

    • Initiatives often lacked the right resources

    o Budget

    o Time

    o Human and tech resources

    20

    Limited data and KPI depth impacted ability to drive meaningful improvement

    Level of detail added too much risk to process improvement initiatives

  • See tutorial regarding confidentiality disclosures. Delete if not needed.See tutorial regarding confidentiality disclosures. Delete if not needed. 21

    UC Irvine selected DenialsIQ™ to get more concrete insights from their data

  • See tutorial regarding confidentiality disclosures. Delete if not needed.

    Making directional data actionable

    22

    15% Eligibility

    10% Coding

    5% Prior Authorization

  • See tutorial regar