Revenue Cycle Management

Claims editing is a step in the claims payment cycle that involves verifying that physician-submitted bills are coded correctly. While claims-transaction systems have some native editing and duplicate checking abilities, these systems are designed to adjudicate claims. As such, even the most robust transaction systems need some help to avoid overpaying claims. Faced with the need for additional editing, payers should decide whether to build an internal editing system or outsource the responsibility to a third-party vendor.

Among the lessons learned in pilot project is the need for comprehensive revenue-cycle management systems and processes.

San Diego County’s Scripps Health (Scripps) was one of many health systems across three states taking part in a three-year recovery audit contractor (RAC) pilot project. "Scripps had a number of challenges at the start of the process," says David Cohn, vice president, revenue cycle, for Scripps.

While the Kentucky Medical Services Foundation was successful in converting users to the new platform, there were surprises along the way.

Two systems, six years and almost 300 users ago, the Kentucky Medical Services Foundation (KMSF) investigated whether or not automated charge-capture technology was a viable solution for its physicians. KMSF, a provider of billing and other administrative services for the more than 700 providers who deliver care across more than 80 sub-specialty areas, had little familiarity with the technology. Interested in its potential, KMSF initiated a pilot study, engaging a small group of physicians to determine if this type of mobile computing would add value to the charge-capture process.

Contract-management system helps centralized billing office recover $2.7 million in contractual underpayments.

When the UCLA Faculty Practice Group (FPG), Los Angeles, began centralizing its billing and collections operations several years ago, it identified a range of measures to pursue in order to take advantage of the restructuring. The physician billing office of UCLA FPG, responsible for billing for 1,300 providers at four hospitals and 65 clinics, first decided to centralize billing for most of its departments.

"We wanted to enhance our efficiency and also improve our financial position," says Anton Loman, director of quality development at UCLA FPG. "One of the initiatives that resulted from the centralization was to transition to a system for validating reimbursement and managing our payers’ performance against contract terms."