The task was laborious but had to get done. Each day, charges would pour in from no fewer than 6,500 patient visits. A team of 35 charge entry staff carefully reviewed each charge/line item. Overall, they immersed themselves in the world of coding, concentrating on the coding guidelines, CCI edits, bundling, unbundling, and modifier usage.
“Despite the high volume of tedious work, our success rate was high. Our first pass rate at the clearinghouse was always above 98 percent, which was a solid number, but it was also directly related to a high volume of staff reviewing the data. We did a good job, but our goal was to do a great job.”
Charges were entered each day by the physicians. Claims were scrubbed through an automated process by an outside vendor which also provided a kick-out report. The billing team had to manually go through the kick-out reports to find problems and modify the charges to fit Crystal Run specific insurance guidelines. The entire process took about two-and-a-half days to get the clean claims out the door.
“We had to go in and make the corrections to the charges on our own. The charges may have to be voided and re-entered, as well as have modifiers added,” said Michelle Stohner, Revenue Cycle Project Manager for Crystal Run Healthcare. “For example, something as simple as attaching a well diagnosis code to a ‘sick’ office visit CPT code is going to cause a rejection or a denial on a claim.”
Crystal Run was in the process of hiring five additional FTEs for charge review and insurance team review. The more eyes, the better the results, so they thought—until they explored the idea for a rules engine. A new chapter in raising efficiency and implementing cost savings had begun.
Upon the implementation of the RCxRules Revenue Cycle Engine, staff efficiency rose significantly.
The RCxRules team worked closely with Crystal Run's charge entry team to understand their various billing and coding requirements, and then transferred that knowledge into custom rules. Due to the comprehensive knowledge transfer, RCxRules went live without missing a beat. This helped ensure the cash flow never took a hit during the 90-day implementation period.
“Now the charge is submitted from the physician, goes on to the rules engine, the modifier goes on, it flows into the PM system, and nobody has to touch it,” said Stohner. “The rules engine ended the need to attach codes manually before going out the door, which saves time.”
The outside vendor which was crucial in the earlier review process was no longer needed because the rules engine handled all of the work. Manual charge correction tasks for the billing team became unnecessary. By accomplishing more with fewer sets of eyes, Crystal Run was able to expand and take on the revenue cycle management business for practices outside of Crystal Run. They added a 60-provider group without hiring additional staff.
Before implementation, the charge entry team focused primarily on coding and coding guidelines. With RCxRules, errors related to coding or payers are detected and automatically tasked in the RCxRules dashboard.
The mundane, tedious work of reviewing each charge was eliminated. Crystal Run became more goal-driven as the staff was able to focus their attention on charges that needed extra help.
“Having the rules engine stop codes that would cause a rejection or denial before claims went out saves time in all the work of fixing errors. Another benefit is that if the rules engine sees a surgical post-op code come through and looks back 90 days instead, and doesn’t see a surgery, it’s going to stop that for us. This helps capture lost revenues that we may not have otherwise realized because the surgery code never went out.”
The team’s roles evolved since they could incorporate coding and payer guidelines within RCxRules. As a result, Crystal Run no longer needed to hire the five additional FTEs to support the charge and insurance review work. They were able to redeploy ten existing billing staff members to assist in insurance follow-up.
“The ability to transfer ten staff members to specifically work on appeals from insurance companies was a true win-win for us,” said Gillies. “The move definitely benefited our A/R and outstanding A/R functions.”
Staff work in RCxRules until the end of business hours. From there, everything is automated. After hours, new charges are moved into RCxRules. Clean claims are moved into the PM system. Another benefit is that when insurance companies make changes that affect billing, RCxRules provides alerts.
“We perform mass billing after hours, so everything is much smoother than before,” said Gillies. Stohner added, “The processing time is not delayed, and the IT department stopped complaining about too many staff using the PM system during the day.”
Moving transactions out of the PM system and into RCxRules, significantly cuts down on the time for 35 staff members who previously reviewed transactions in the PM system during the day. No uploads and interfaces are tying down the PM system during regular working hours. This step enabled providers to use the PM system without risks of slowdowns resulting from heavy use by the charge review and billing staff.
“Another ROI for the rules engine was enabling the system’s increase in performance for providers,” said Gillies. “And our IT department once again loves the revenue cycle department because we successfully stopped clogging up the system.”