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With a pair of offices dealing with claims, billing and payments from two separate services and no way to migrate the data, Orlando Health, based in Orlando, Fla., struggled to create an efficient and accurate revenue cycle workflow for years. One office handled physician accounts receivable; the other handled hospital accounts receivable. These disjointed revenue cycle systems weakened Orlando Health operationally and financially.
A software as a service (SaaS) platform helped the healthcare organization tackle this problem five years ago, and to date has played a significant role in helping the system avoid losing out on $22.7 million a year in patient payments for medical services. The software enables Orlando Health to be able to determine ahead of time which patients may have trouble paying or won't be able to pay at all. Then, based off the data, Orlando Health can decide to either work with the patient to pay the balance, offer the patient charity care or send the patient's account to a collection agency. Jose Rivera, corporate director at Orlando Health, attributes 62% of the $22.7 million a year to the analytics platform.
The challenges began when Orlando Health grew from 70 employed physicians to 5,000 through acquisitions. The physicians and staff acquired from the various practices used a variety of billing systems and revenue cycle processes, causing complications when filing claims to insurance companies.
Rivera explained that if a patient enters the emergency department at one of the system's eight hospitals within central Florida, undergoes a surgical procedure, is later admitted and then discharged, that patient receives not only a hospital bill for all the room charges and ancillary services, but also a separate physician bill. The patient's insurance carrier also receives two separate claims.
"From an insurance carrier perspective, we can't change that. That's the way the industry is and that's what we have to abide by," Rivera said. "From a patient perspective we … as an organization strive to make that as easy a process as possible."
That isn't possible, however, unless the two data sets can be migrated and accessed at the same time.
"That can only be done through a common platform," Rivera explained. "A common platform that will merge those two arenas and allow us the ability to maximize our efficiencies [and] at the same time render a much better service to our patients because we're able to manage both their hospital and physician balances."
Cloud-based analytics help streamline data
Orlando Health solved this problem by purchasing VisiQuate's SaaS analytics platform hosted in the cloud. During that time, Orlando Health had achieved $22.7 million a year in bad debt write-offs, and Rivera attributes 62% of that amount to the analytics platform.
"Instead of having two analytics products, we really have one database, one combined database for physician/hospital analytics and it brings it all into one platform," said Jim Kolmansberger, co-founder and president of VisiQuate.
Orlando Health uses four sets of customized analytics provided by VisiQuate:
- Physician performance analytics gauge the total net revenue for every employed physician.
- Patient-pay analytics provide financial risk scores for all patients on both the hospital and physician sides.
- Revenue management analytics bridge the gap between the back-end central billing office and the front-end physician practice managers and administrators.
- Enterprise management analytics allow the hospital and physician practices to share important information about common patients.
Jim Kolmansbergerco-founder and president, VisiQuate
Rivera explained that Orlando Health sends daily electronic data files of all transactions that occur in both systems to VisiQuate's data analytics platform. The platform then normalizes the data, enabling Orlando Health to more easily interpret the information, analyze it and make business decisions based off the results, which are presented via Web-based dashboards.
"It's through a completely Web-based tool that allows any user within the system to access the information," Rivera said, including from mobile devices. Orlando Health generated about one million transactions last month, he added.
Achieving a "bullet-proof" claim can save money
The ultimate goal, however, is to submit to the insurance companies a "bullet proof claim" so the claim won't be denied once it gets into a payer's system. This goal can be tricky to pull off, and "a significant portion [of claims get] denied because payers change their guidelines every day," Rivera said.
Catching errors beforehand and submitting claims correctly the first time saves Orlando Health money because resubmitting claims is expensive. The transaction fee per claim can cost anywhere from 25 cents to 75 cents. "Multiply that by 300,000 a month, [then] multiply that by 12, and then the [cost of] the labor resources behind the scenes," Rivera said. "It becomes very costly."
Carriers can deny claims due to simple mistakes such as providing the wrong policy number or not including the insurance provider number. Other times, denials stem from more complex situations, Rivera said, such as the need to abide by many different payer guidelines.
"What I mean by that is every payer will pay for every procedure code differently," Rivera explained. "So, in other words, for an appendectomy: Medicare will pay an appendectomy for a certain amount of diagnoses codes. United Healthcare has its own set of diagnoses codes that it considers payable. Blue Cross and Blue Shield has its own set of diagnoses codes that are payable. So there's medical necessity guidelines we have to apply to every payer based on who we're submitting the claim [to]."
Although Orlando Health has internal processes that scrub claims for errors, it's still not enough.
"We needed a system that would allow us to be able to see all of that information, make it meaningful, easier to change -- or to make sure that we have everything correct before it gets out," Rivera said. The system also needs to send back information about the reasons for claim denials and what corrections are necessary to prevent the same errors in the future.
Although VisiQuate doesn't actually calculate or look for those errors, it delivers the information in a way that makes it easy to see and understand the errors, Rivera said.
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