HEALTH REVENUE CYCLE MANAGEMENT
THE
HEALTHCARE
REVENUE CHALLENGES
Health Revenue Cycle Management
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Rules Engine
Indexing and Access Management
Payor / Contract Management
Standards & Compliance
Scheduling Providers’ Performance Driven Reimbursements Outpatient/ Inpatient Billing
Workows Congurations
Pharmaceutical Reimbursements Coding & Charges Capture Auditing & Validation
Standards & Compliance
REVENUE CYCLE MANAGEMENT
Eligibility Management
Secondary Claims / Denials/Receivables Management Authorization Management Payor Edit Systems
Claims Scrubbing e-Claims Processing
Business Intelligence, Analytics & Reporting
Integrations to Clinical Systems
Integrations to ERP Systems
Financial stability is always the priority of management in ensuring that organizations remain focused in the pursuit of corporate vision. Sensible implementation of nancial protocols, sustained by sound revenue and receivables management, hold the key to the long-term viability of the institution. myCARE offers a full suite of RCM solutions to help hospitals and practices of all sizes overcome rising costs, shrinking reimbursements and ever-changing regulations and to improve every step of the revenue cycle. Setting pricing mechanisms, managing patient care ows, ensuring comprehensive charge capture, clinical and administrative documentation, coding, provider payables, claims management, denials resolution and nancial integration are some of an endless list of processes that breakdown and derail organizational focus if standards, controls and automation are not properly addressed. myCARE Revenue Cycle solutions and technologies, built within and around a sophisticated in-house Rules Engine and Application Conguration Tools, helps dene build complex rules and conditions and near-impossible business process ows with utmost ease and simplicity.
THE
HEALTH
BUSINESS SUITE
Health Revenue Cycle Management
The Revenue Cycle Suite is broadly modularized as follows: o Patient Billing o Payor Management o Eligibility & Authorization Management o Scrubs and Claims Processing o Cash Management o Receivables Management o Providers’ Payables o Revenue Cycle Daily Business Intelligence
5
PATIENT BILLING
In an increasingly competitive marketplace where healthcare costs are burgeoning and healthcare providers and payors alike are expected to control costs while maintaining business growth without the compromising exemplary patient care and positive health outcomes, the ability to manage data into information for rapid decision making in patient care is becoming imperative myCARE’s Patient Billing System is an integral part of the RCM Suite. The module exibly and comprehensiveness provides a platform for charging, tracking and consolidating billing information across the healthcare facility that enables full command of a business process environment, maintaining cost controls and revenue management. Charges can be entered directly, within other modules of GCI suite and/or via interface with external systems. The module’s core is its rules-building engine which validates the eligibility status of every patient for any single or all services that may be requested. The exibility of the user-denable rules-engine, which requires practically no manual intervention in the determination of eligibilities, differentiates myCARE’s Patient Billing Module from the alternatives.
The Billing Module is seamlessly integrated to all in-house applications and receives data from: -
Master Patient Index; Registration; Pharmacy; CPOE; Laboratory; and Radiology amongst others.
It also acts as the feeder data source for -
Approvals Management; Claims Management (including e-claims); Accounts Receivable; and Provider Payables, among many others.
Health Revenue Cycle Management
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KEY FEATURES Built to accept information and integrate with any feeder system that complies with accepted norms of standard information exchange; Robust rules-building engine that is required by electronically business scenarios of any nature; Infuses into the overall system and helps maintain effective cost controls and revenue management; User friendly, multi lingual interface; Exceptional user-denable reporting and MIS environment are defaults. Flexible Rate Denitions; multiple rates denable Industry Standards Compliance: HL7, ICD, CPT amongst others Workow Based System; easy conguration of work processes, policies, procedures… Package Denitions; easy to dene singleor all Inpatient, outpatient, daycare and any other type of packages Congurable Financial Concepts; Flexibility to support one or more combinations of Financial Concepts eg: - Pay As You Go - After the event Centralized / Decentralized Cashier. Approval Hierarchy for Refunds and Cancellations. Outpatient Deposits and service availed against deposits. Family Tree advance receipts / offsets handling (VIP) Paperless Environment; dealing with payors, administrators, referrals etc
PAYOR MANAGEMENT
Healthcare providers today render services within a complex payor environment. Government, employers, insurance companies, charities typically form part of a major and varied source of healthcare payor groups. Each group, serves as a payor for care seekers, has its own set of policies, procedures, guidelines and limitations that govern payments for patient care. These payors enter into contracts with healthcare providers or patients. The rules, policies and conditions contained in these contracts are the basis on which the payer will make payment. These contract terms and conditions can be as diverse as the care provided. Healthcare providers seeking to manage the eligibility of their patient whilst ensuring optimal care, all within a manual environment will undoubtedly be faced with a monumental task of managing their billing, claims and receivables processes. myCARE’s Payor Management System provides the ideal solution, automating any or all contracts accepted by the practitioner / hospital and enabling real time and automatic processing of eligibility checks during the ordering process itself. With this automatic process in place the practitioner or hospital is able to assure themselves that any or all services provided to their patients are fully covered. This limits the need to manage denials, collections and delays in receipts due to an improper contract management environment.
Health Revenue Cycle Management
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ELIGIBILITY AUTHORIZATION AND
MANAGEMENT Monitoring patient eligibility to healthcare services based on respective coverage is made with absolute ease with the rules and conditions duly and aptly dened within the system with the exibility and functionality provided by the rules engine.
P P A
D E V O R
Alerts are duly triggered when services ordered are not covered. This automatically generates approval requests or redirects the process to a predened workow for further action as appropriate. Preapprovals and related requests are predened and can be executed based on predened workow processes and documentation ows. These can be supported in a fully electronic environment depending on the support and integration enablement of the payor environment.
SCRUBS & CLAIMS PROCESSING The Claims Processing procedure within the system is by all counts an exceptionally simplied process. Prior to nalization, Claim Scrub processes are performed to ensure completeness and comprehensiveness. Editing the claims is permitted with appropriate user authorization There is no need to have a clear denition of claims “period”. Accruals basis of revenue recognition is defaulted Claims can be in traditional manual form or thru paperless electronic environment. Claims submission can be multi-tied to include third party administrators and/or directly through to principal payors
CASH MANAGEMENT
myCARE’s Cash Management module enables effective control of cash that ows into the organization. The control mechanisms built in will enable proper recording of cash receipts, effective reconciliations on a daily basis and management of banking procedures. Non-cash transactions; credit cards, checks and all other recognized forms of payment within the organization are also effectively controlled and managed. This ensures all authorized best practices are fully adopted. Appropriate segregation of duties, approval authorities, and management controls are easily congurable to enable the organization to effectively manage cash ows within the entity. Bank Reconciliations are automated and can be seamlessly linked and downloaded from bankers’ software; reducing the mundane efforts of performing manual reconciliations. Quick and simple views, as required, are easily congurable. Extensions and integrated environments with the other ExChequer modules enable effective management of payable and receivable cash ows thus providing an exemplary environment for effective cash management and controls
PAYOR MANAGEMENT
Accounts Receivable is an integral sub-module of the IQVIA’s ExChequer Financial System. It is seamlessly integrated with Order Management, Billing and Invoicing (e-claims) modules. Detailed analytics within the systems is enabled by strong drill down features, data export features and congurable aging reporting views provides unparalleled management information that helps drive better internal controls, cash ows and customer management. The Receivables module can also easily import order, billing and invoicing data from third party legacy systems. Real time and seamless integrations with Cash Management, Accounts Payable and other ExChequer modules enables state-of-the-art cash management, laudable customer management and excellent management information that can help drive good revenue policies and receivable controls management. Auto or manual /batch or real time postings to Accounts Receivable are optional. Flexible aging analysis provides comprehensive and all-inclusive view of the status of collections.
Health Revenue Cycle Management
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REVENUE CYCLE DAILY BUSINESS
INTELLIGENCE Revenue Cycle traditionally is a domain preordained with immense data, rules, conditions, clinical & administrative information and one that continually grows and pose challenge the ability to assimilate, manage, store and analyze the same. The enriched information gathered within this environment serves to provide various needs; revenue maximization, cash management, cost controls, enhanced care, clinical data assimilation, scrubs & claims, coding, regulatory compliances and reporting requirements. The system has built-in intuitive MIS Engine and Reporting Tools that serve to provide enviable information and intelligence to the users and needs of the organization; when, how and where they require the information. Time-ed report deliveries to the desktop/printer, extraction of information from saved favourites, user-denable parametric reports, export facilitation to Ofce, XML, PDF and other mediums are typical exible features that enable the extensive use of the enriched domain information within a wide continuum of in-house organizational and external demands.
PROVIDER’S
REIMBURSEMENTS
Providers’ Reimbursement module provides a exible and comprehensive means of tracking and consolidating providers’ share of charges for the various services rendered in the healthcare establishment for each patient encounter. The module supports different types of classication of physician like the Physician In-charge, Order Physician, Operating Doctor, Anaesthetist, Assistant Consultant etc. and facilitates systematic calculation of fee due to the care providers. If a valid contractual agreement is available, the care provider’s fee is calculated based on the predened share computation rule.
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Health Revenue Cycle Management
THE
RCM ENABLING TECHNOLOGIES RULES ENGINE IQVIA’s Antara Rules Engine is a built-in component of the myCARE suite that, amongst others, help identify, register, classify, dene, build and manage the application of these healthcare and insurance rules. The engine helps verify consistency in use, manage relationships between multiple rules within complex health care and insurance environments. The engine provides ultimate exibility to dene any and all rules, conditions, processes, alerts and workows that enable awless control of healthcare and health insurance with minimal or no IT or human intervention.
Salient features include: Ability to translate insurance contracts line by line. Diagnosis based exclusion. Handles Exclusions, Deductibles, Coverage etc. Specic Requirements like Deductibles on Gross, Deductibles on Net. Patient Level Policy denition to handle Eligibility and Charity Patients. Multiple payor for single patient Ability to dene Rules Based on any information and combination - Service group , Category , Item Code - Medicine Generic, Medicine Form, Medicine Category, Medicine Code - Patient Sex, Patient Age, Patient Nationality etc. - Diagnosis Code - Doctor Specialty , Doctor Sub Specialty , Doctor Type - Encounter Type (Inpatient, Outpatient, ER) - Bill value and more
INTEGRATIONS
In today’s complex and demanding IT environment, nding a one-stop shop for all your application needs for an organization may not be possible. Likewise, vendors are increasingly becoming niche-focused in their offerings with highly specialized products and solutions. Organizations hoping to adopt best of breed technologies are often burdened with the complex need to ensure that they are able to share and exchange information between disparate systems. This is a major difculty within any healthcare facility. The complex nature of patient care and safety issues demands seamless and accurate information exchange among disparate systems within a multi-system environment. Information may be clinical, nancial or administrative. Their importance is highly signicant to positive health for the organization. Using enviable in-house integration tools, our consultants provide the right advice and guidance to ensure that, irrespective of any complexities that may exist in the providers’ environment, issues relating to seamlessly accessing and exchanging information between different applications will be eliminated. Integrations are typically enabled with Payor Edit Systems, Health Coding Databases, Third Party Patient/Health/Clinical Information Systems and ERP Systems, Clinical Decision Support Systems, Persons Identication Databases, National/Social/Private Health Insurance Programs and Third Party Administrators. Real-time Eligibility Validations, Authorizations, Electronic Claims and Reimbursements platforms completes the tightly integrated loop within which myCARE RCM is offered.
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SECURITY
& PRIVACY
myCARE RCM offerings are seamlessly defaulted with industry standard Information Security & Privacy features. Industry recognizes the following security objectives:
CONFIDENTIALITY: “Preserving authorized restrictions on information access and disclosure, including means for protecting personal privacy and proprietary information…” A loss of condentiality is the unauthorized disclosure of information
INTEGRITY: “Guarding against improper information modication or destruction, and includes ensuring information non-repudiation and authenticity…” A loss of integrity is the unauthorized modication or destruction of information
AVAILABILITY: “Ensuring timely and reliable access to and use of information…” A loss of availability is the disruption of access to or use of information or an information system myCARE embraces these guidelines true to its spirit in all of its solutions and deliverables.