Support for GI/ASC PMS/RCM

Introduction

The clinical workflow, billing requirements, and reimbursements of insurance claims for Gastroenterology are different from other specialties, and many of the clinics/hospitals were using older, legacy Practice Management Systems/Revenue Cycle Management (PMS/RCM) which did not handle GI/ASC specific nuances. To handle such nuances of billing, reimbursements, and the clinical workflow, it was necessary to implement a state-of-the-art, HIPAA-compliant, standards-based, secure cloud-based system that can handle GI workflow in PMS, RCM, Claim Life Cycle Management, and Payment Postings.

expEDIum Medical Billing® (eMB) offers robust PMS features with a proven track record of improving payment reimbursement from various insurance companies (Government and Commercial). The transparency benefits both GI practices and Ambulatory Surgery Centers, leading to increased revenue compared to their earlier legacy and paper-based systems.

Customer Story

eMB is currently being used by a handful of GI Clinics/Hospitals and Ambulatory Surgery Centres (ASCs) across the USA. As mentioned above, GI/ASC clinics had some nuances. The providers and billers were in search of a secure-cloud hosted system that has GI/ASC EHR integrated seamlessly with PMS, that would handle the nuances involved in the claim billing of the different types of patient visits and would speed up the payment cycle by having automated submission, and reimbursement cycles, and eventually increase the revenue generation.

This case study presents an aggregated view across the handful of GI/ASC clinics using the combined system and expEDIum Medical Billing® as the standalone PMS/RCM product.

Our integrated product offered the relevant features with exceptional support, and we were open to making the necessary modifications to meet the requirements of GI/ASC workflow, even if it was not available readymade in the product. The additional features were delivered over a handful of sprints/upgrades. In addition, we were also offered RCM services wherein we combined the EHR + RCM / Medical Billing software + RCM Services as one seamless offering to a handful of clinics.

Challenges Customers Faced

• A Robust Patient Appointments scheduler and a Patient Demographics module – These were used by the GI / ASC clinics as front end, accepting appointments, and doing Patient registration as the patients came in for encounters.
• Bulk Real-time Patient Insurance Eligibility Verifications from the Patient Appointments module for ease of verification.
• Features such as Patient Merge, Patient Payment Agreement (PPA), and Patient Responsibility Agreement (PRA).
• The need for a handful of GI/ASC workflow-specific “edits” were wired in our expEDIum Drools® facility.
• A customized request of having duplicate patient entries for separately handling EHR workflow of handling office and surgery visits for the same patient as two different records in the database
• Configuring and using customized Ledger Transactions, standard transactions, and receipt generation.
• Support for billing and reimbursement of claims for Medicare, Medicaid, Quasi-Government Payers, Private/Commercial Payers, and Contract Payers.
• Real-time Insurance Eligibility Verification (IEV) – The system should be able to verify insurance eligibility in real-time (in addition to batch eligibility) to increase the efficiency of the staff and avoid rejections/denials at a later stage.
• Transparent Error, Rejection, and Denial Management of Claims.
• Apart from office and GI procedure fee schedules, there was a need for supporting anesthesia fee schedules where the units are based on time.
• Handling anesthesia data in outpatient and inpatient claims and EDI (837P and 837I) support of the respective data.
• Invoicing Contract Payers – Feature to generate contracted payer invoices and payment posting and support for Self-Pay claims.
• Support for outsourced Paper claims printing and in-house printing as well.
• Automation of EDI Claim Transactions and Auto-reconciliation of responses – The claims are bundled in HIPAA X12N ready 837P, 837I EDI transactions and transmitted to clearinghouses (even if the payer supports paper claims) in a scheduled automated mechanism, thereby reducing manual efforts and overheads.
• Support for manual and automated remittance advice (ERAs using HIPAA X12N 835 and EOBs) posting.
• Ability to bill secondary claims as institutional claims (hospital) for a primary profession claim and vice versa for maximum insurance reimbursement.
• Better secondary claim visibility and single button secondary billing. The system also supports cross- over payment posting by auto-generating secondary claims and posting adjudication details on secondary claims
• Support for state-specific data reporting formats with information on patient hospital discharges, the diagnoses, the procedures, and the charges of inpatient stay & outpatient services, including ambulatory surgery and emergency department.
• Friendly Patient Data Migration with Balance due and financial data migration.
• Support for transparent aging, cash posting, and other claim and payment reports.
• Transparent Patient Billing/Statements, Collection Reports
• The need for “end-to-end RCM Services” to GI Hospitals and ASCs using MDReports®/Provation® and expEDIum Medical Billing® were met.

Reasons to Choose expEDIum Medical Billing for GI/ASC Billing

The decision made by some of the GI/ASC EHRs to choose our product is based on the feature comparison of our product with other PMS/RCM systems in the market and also us being a single-stop vendor providing a robust EHR, Endo Writer, and Surgical Modules along with RCM software & RCM services available. The comparison included ease of use, integration friendliness, customization and feature enhancement capabilities, great support, other key features related to automation of billing/payment processes, and affordable subscription prices. Only a few products in the market matched these requirements, making the EMR/EHR+ expEDIum Medical Billing® integrated product one of the popular products in the US GI/ASC market.

expEDIum Medical Billing® is a fully integrated system encompassing Electronic Health Records (EHR), Practice Management (PMS), and Billing systems (RCM). This versatile solution caters to various specialties throughout the healthcare industry, including GI/ASC and Anaesthesia. It facilitates easy connections to multiple clearinghouses and MCOs for claims and insurance eligibility inquiries, with Office Ally® as our current preferred Clearinghouse. The system seamlessly integrates with GI/ASC EHRs, providing a comprehensive end-to-end product with built-in access to standards-based clearinghouses.

How do Gastroenterology/ASC practices use the expEDIum® Product?

As a healthcare technology, PMS, RCM, and RCM services company, iTech has a wealth of experience in GI/ASC billing workflows spanning over a decade. This encompasses claim cycles with various payers (government, MCOs, and private payers), enrolment processes for EDI transmission and ERAs, claim payment and denial/rejection patterns, and check/EFT cut-off cycles. Additionally, our exceptional team offers 24/7 support for our product and RCM services for specific clients.

During the initial phase, we faced challenges in customizing our existing EMR+PMS to handle the complex workflow of Visit, ASC, and Anaesthesia billing with multiple payers and support for institutional claims. We also faced the challenge of supporting state-specific data reporting requirements across multiple states, their data format, and getting acceptance of data reporting EDI (837R and proprietary XML, Fixed Record Formats). We supported the following data formats – SPARCS for New York, THCIC for Texas, CHIA for Nevada, and ACHA for Florida. However, we overcame these challenges and delivered a product suitable for all GI practices/hospitals and ambulatory surgery centers.

Results

The product is architected as a general full-fledged, standards-based PMS/RCM product covering several specialties, including Gastroenterology, for serving the US market, allowing specific enhancements on selected modules. It has been instrumental in facilitating the migration of customers from legacy systems that are less user-friendly and requires more manual intervention to a modern, secure, transparent, user- friendly, and feature-rich system that offers faster payment reimbursements and better productivity and revenue management. Additionally, the system offers a lower total cost of ownership (TCO) than other systems.

Due to its consistent success with various GI/ASC clinics, expEDIum Medical Billing®, integrated with GI/ASC EHRs, has been embraced by over 60 clinics spanning 15 states. Over the past several years, our platform has effectively handled over 1.1M claims, 4.6M HIPAA transactions, totaling over $1.2 billion in claim charges, with $270M million reimbursed. Notably, in the previous trailing year alone, these clinics processed more than 150K claims, resulting in around 560k+ HIPAA transactions. Our system historically has had over 2500 users with 400+ providers.

With the success we have achieved in PMS/RCM and RCM Services market, we are stepping into the Office EMR arena, and soon after that, we shall add GI/ASC EHR, Endoscopy, and Surgical Modules to the product suite, which would be seamlessly integrated with expEDIum Medical Billing® to provide along with RCM Services and end-to-end one-stop solution with a robust preferred clearinghouse built-in too.

*We do offer 60-days free trial for users who are new to our product. To learn more, contact us.