expEDIum PMS / RCM Product with Enhancements & Customizations

Introduction

Many billing companies across the USA have been relying on older systems with less automation and more moving parts to perform RCM / Medical Billing activities for the roster of clients they have. One such biller from California wanted to implement a secure, state-of-the-art, HIPAA-compliant cloud- based system that can handle a handful of their clients effectively performing RCM workflow and Payment Postings efficiently to handle their increasing customer base and claims volume. To meet their requirements, expEDIum Medical Billing® (eMB) was chosen by this biller as a viable and cost- effective solution. In addition, iTech was willing to make some customizations adding specific edits and features that would reduce their billing pain points.

expEDIum Medical Billing® has exhaustive PMS / RCM features with a proven track record in improving the payment reimbursement cycle from thousands of insurance companies (both Government and Commercial) with transparency wherein users can track the claim history to determine where a given claim is at a given point of time. eMB, as it is a standards-based product, supports many specialties, including GI/ASC, Cardiology, Behavioural, Ambulance/EMS, Family/Internal Medicine, and public health clinics, etc., and connects to multiple clearinghouses and MCOs for claims and insurance eligibility inquiries. eMB currently uses Office Ally® and PhiCure® as the preferred Clearinghouses to offer a complete end-to-end, seamless product with standards-based access to the clearinghouse.

Customer Story

expEDIum is currently being used by clinics and hospitals across various states in the United States of America as most PMS/RCM systems were offering only the standard features with less agility towards customizations, product enhancements, and extendable validation edits. This biller was searching for a secure, cloud-based system that could accommodate their billing needs better than their older legacy system, together with additional enhancements and billing requirements, and at an optimal total cost of ownership. They required a system that could scale up and handle more patients and process claims more efficiently, ultimately speeding up their revenue generation for their clients.

Our product offered the relevant features with exceptional customer support, open to making the necessary custom modifications to meet their requirements. After more than a dozen conference calls along with demos, cross walking of their legacy workflow to expEDIum workflow, and identifying any immediate custom requirements, this customer signed up to subscribe to expEDIum. Please note that this customer had only evaluated our expEDIum® product and went ahead with us after the 60-day free trial.

Challenges Customers Faced

As mentioned above, this biller was able to choose expEDIum as their preferred RCM / Medical billing software based on a handful of parameters, including our ability to do customizations fairly quickly and as the product covered many of the features they were looking for.

The following lists the various customizations and configurations iTech did for this biller:

• Ability to configure the client practice and other practices for which they handle billing/RCM in a single expEDIum account and manage multiple billing provider/tax ID combinations from a single login.
• Support of fee schedules with the Place of service (POS) (for office visit/professional claims) and Facility Type (for hospital/institutional claims) dimension. This was implemented to ease handling fee schedules that were wired differently based on the Place of service codes.
• Additional custom claim validation edits based on the billing provider, rendering provider & service facility combinations. This includes payer-specific edits too.
• Customization of ESB Templates to have more fields for the specialties supported – This included supporting all the dates available in the CMS-1500 claim form, Prior Authorization fields, etc. This is to simplify their billing workflow and reduce data entry, thus providing efficiency.
• Enhancement of Patient List to show more configurable fields.
• Enhancement to configure default Practice and Facility information in patient demographics. With this, the ESB template itself would drive the facility and billing provider to which a given patient is associated, thus providing billing efficiencies.
• Support for primary and secondary claim billing and reimbursement of claims for Medicaid, Private/Commercial Payers, and Contract Payers.
• Support for Self-pay claims for patients not having insurance or inactive/expired/non-covered insurance.
• 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.
• 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.
• 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 outsourced Paper claims printing and in-house printing as well.
• Support for manual and automated remittance advice (ERAs using HIPAA X12N 835 and EOBs) posting.
• Invoicing Contract Payers – Feature to generate contracted payer invoices and payment posting. This feature was enhanced for this customer to make the Address Type and Address of the sender configurable.
• Configuring and using customized Ledger Transactions, standard transactions, and receipt generation.
• Transparent Patient Billing/Statements and collection reports.

Reasons to Choose expEDIum Medical Billing for GI/ASC Billing

The customer made the decision to go ahead with expEDIum Medical Billing® after a series of demos & discussions and after that, satisfactorily answering the questions and objections posed by the customer, cost-effective claims-based pricing including a free tier wherein providers submitting less than ten claims a month coming on board free of cost. The customer also used a 60-day free trial of eMB to evaluate before coming on board in production mode so they could make an educated decision.

How does the customer use the expEDIum Medical Billing® Product?

This customer has ramped up the volume of claims since inception several months back, and they have completely moved out of their legacy system. This customer has 22 billing providers configured in the system, with 53 rendering providers, 503 facilities, 641 referring providers, and 14 ambulance facilities configured. They have 20 active billers/users using the system currently from different geographies. iTech continues to interact with this customer to understand and address any further pain points with periodic account management conference calls.

Here is the list of top 80% of the payers used by this biller, an exhaustive list almost had 500 payers.

Here is the payment delay summary with 90 percentiles of claims getting paid within 22 days of submission

Here are a few testimonials from this customer:

Results

Remarkably, this biller has ramped up and efficiently processed over 62k claims and 280k+ HIPAA transactions through eMB in just a handful of months. During this period, the total value of the claim amount was around $12 million, and they successfully received reimbursements amounting to more than $3.1 million.

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