There has arguably never been a time like this before in healthcare—when receiving maximum reimbursement for every patient is critical.
A few weeks into the COVID-19 pandemic, the Medical Group Management Association found that COVID-19 had a negative financial effect on 97% of the 724 medical practices it surveyed.
And in an online survey conducted in early May 2020, the Texas Medical Association found that 68% of practicing physicians in that state had cut their work hours because of COVID-19, while 62% had their salaries reduced.
States and local jurisdictions have eased stay-at-home orders, and the Centers for Medicare & Medicaid Services (CMS) has lifted some restrictions on non-emergent, non–COVID-19 care, so business has recently picked up in physician practices. But physicians report that it is still well below pre-pandemic levels and is expected to stay that way, at least as long as social distancing is required.
In our many discussions with healthcare providers throughout this pandemic, we’ve repeatedly heard the same four challenges. Here is how we help them (and you) thrive.
Challenge 1: Managing payer (particularly Medicare and Medicaid) changes
Modifiers and coding are frequently changing and providers are spending a lot of time researching these changes to avoid denials and rejected claims. If your staff is spending a lot of time manually updating these changes, you could be wasting resources.
Quadax monitors payer information regarding COVID-19 as it is published, and updates standard edits within Xpeditor—our claims management platform—to ensure our clients’ claim submissions continue uninterrupted and are transmitted as efficiently as possible. For example, we recently added newly-created COVID HCPCS codes U0001~U0004, CPT 87635, diagnosis code U07.1, and updated edits, based on CMS COVID changes, to allow clients to bill telehealth codes (99421~99423 and G2061~G2063) without having the claims stopped in Xpeditor.
We have also reacted quickly to the recent news that CMS will be rejecting claims using modifier CS billed with any services other than those identified by CMS as appropriate for the waiving of cost-sharing. As a result, we are creating a new edit that will stop claims in Xpeditor to prevent these potential rejections and avoiding manual re-work of claims.
XpressBiller, the heartbeat of Xpeditor, is a powerful, self-service rules engine designed to enable our clients to create and manage their own custom logic that they are unable to make in their core systems. With the help of user-defined conditions, XpressBiller is able to raise custom edits, automatically convert claim data, auto-correct or suppress clearinghouse edits, and automate revenue cycle workflows—all without custom coding in order to rise to the challenge of ever-changing payer requirements.
We can also help ensure your Medicare and Medicaid claims are accurate and correct before submission. Our Integrated Coverage Validation (ICV) for Medicare and Medicaid allows staff to correct preventable errors up-front. By submitting cleaner claims the first time, providers avoid payment delays and the extra work often required to follow up on claims.
Before a claim is submitted, ICV by Quadax validates the patient’s eligibility. For Medicare claims, ICV checks the HIPAA Eligibility Transaction System, and for Medicaid claims, ICV checks eligibility with the appropriate state-specific Medicaid portal. This real-time check rapidly evaluates the payer’s response and compares it to the data on the claim to determine if any errors or issues are found so staff can correct and submit a clean claim. Your first pass, clean claim rate is more important than ever before and ICV edits help you avoid preventable denials, which is a key capability especially if your staff has been downsized.
Challenge 2: Scrambling to be in compliance with the CMS Price Transparency Rule
On November 15, 2019, CMS finalized policies requiring hospitals to disclose standard charges for items and services in an attempt to create market competition and drive prices down. As we are in the middle of a global pandemic, many hospitals thought CMS would delay this ruling. However, last month a federal judge dismissed a challenge by hospital groups claiming the rule would force them to disclose private negotiations with insurers, undermine competition and violate their First Amendment Rights.
Offering an online estimation tool that is consumer-friendly, free and prominently displayed on your website and accessible without having to create an account or password, will put your hospital in compliance with the shoppable services requirement.
Many groups are scrambling to find a tool that creates patient responsibility estimates that are also easy to use, and work well with their EMR system while adhering to government requirements.
If your team is looking for a solution, look no further! Our configurable Patient Access Management software and automated workflow ensure successful outcomes at each patient touch point: insurance verification, patient pay estimates, medical necessity and propensity to pay, while merging front and back end functions, leveraging data and collecting payments upfront. And, our patient-facing estimation tool ensures you’re in compliance with the new CMS transparency requirements.
Quadax also offers a Payer Price Transparency tool, enabling clients to rapidly deploy secure, compliant and user-friendly web pages where patients can interactively explore shoppable services and create personalized estimates.
Challenge 3: Proactively identifying issues in rev cycle processes to maximize reimbursement
At this critical point in healthcare, with patient volumes at historically low levels, having the necessary tools available to identify bottlenecks in your rev cycle processes so you can address them and avoid future issues is vital.
Intelligence by Quadax provides detailed reports, dashboards, performance snapshots and advanced visuals to help inform your decisions regarding resource allocation, process improvement and revenue cycle management strategy.
Monitor changes over time or in rolling time increments, forecast claim reimbursements and anticipate claim denials with the ability to identify root cause by payer, denial category, denial reason, physician, procedure code and more. These actionable insights will empower your team to prioritize claims that need to be reworked. While these insights will always be valuable, they’re even more important now.
Challenge 4: Decreasing vendor support
Healthcare is certainly not the only industry suffering from reduced revenue and job loss. Many of the folks we’ve been talking to have been struggling to receive the support they need from their vendors. As quickly as things are changing during this pandemic, healthcare providers need support from their vendors more than ever and faster than ever.
Quadax revenue cycle experts provide routine, on-site visits (when permitted) to assist with event creation and resolution, continued training, reporting needs, best practices and general issue resolution. Quadax provides the perfect blend of sophisticated technology with reliable, expert, personal support. We have maintained our support team during the COVID-19 pandemic in order to ensure our client’s continued success. We’ll never leave you hanging.