The manual claim production process had a cost that wasn’t sustainable. With a high-need community, quality care is at a premium and anything that can streamline processes means more resources for programs that need support.
At one time, Peak Vista Community Health Centers needed nine full-time employees to process charges from the EMR to the PM System.
The task of manually reviewing charges was tedious and time consuming, especially during the administration of vaccines—one employee would process charges for vaccines for the entire day.
"Roll-up of admin codes for vaccines is a difficult job,” said Christi Garriott, Senior Vice President of Business Intelligence and Revenue at Peak Vista. “The manual work to process 27,000 vaccines a year required a significant amount of employee time. It’s a major effort to fix the admin codes to meet billing rules for vaccines."
RCxRules, which was adopted in 2019 to improve billing workflows and save staff time, became operational in four months.
Before implementation, staff had to manually review charges and use more than 200 rules as a reference to identify issues. With these rules automatically programmed into the rules engine, the evaluation process achieved a whole new level of efficiency.
“Now out of 3,000 tasks a day, we probably have to manually review about 100. Everything else automatically posts. Clean claims go out the first time without the need to review them.”
Providers were often a day late with their charge submissions. Adjustments were made in the rules engine to prevent these late submissions from generating errors. “Just by listening and learning to how we operate, RCxRules helped us save numerous hours by eliminating unnecessary charge corrections,” said Garriott.
The rules engine provided immediate educational opportunities. It helped the staff better understand coding rules and sharpen their skills to comply with the Coding Correction Initiative (CCI)—a CMS program designed to prevent improper payment of procedures that should not be submitted together.
“Reimbursement is increasingly based on quality instead of counting beans. In the long run, pay-for-performance value indicators are going to be based on coding. I think the rules engine has prepared us for significantly positive outcomes going forward," said Garriot.
The ROI with RCxRules became evident when the health center reduced its charge review team from nine to four FTEs.
The health center transferred four staff members to the accounts receivable department. One staff member was reassigned to help administer a grant-funded dental care program for seniors. As a result, more underserved seniors receive vitally needed dental care.
With charges becoming more standardized, the rules engine facilitated a greater understanding of accounts receivable. Because information about claims was more consistent, staff could answer patients’ questions in real-time over the phone instead of having to respond after a lengthy investigation of an issue, thereby improving customer service.
Because Peak Vista produces clean claims, payer reimbursement is faster. Patients have a better idea of what to expect with regard to their out-of-pocket costs, and estimates of these costs are more accurate.
As providers caught on to changes in coding rules and requirements for referrals, the amount of time it took to obtain authorizations from third-party payers decreased. Given that some authorizations could previously take up to six weeks, the time savings significantly increased patient satisfaction.