The Revenue Cycle Management Rules engine is integrated throughout the application and surrounds all processes required to bill and manage AR. Rules can be defined to ensure accuracy of patient data, ensure transactions are complete and correct prior to billing, ensure payer claims and client invoices contain information as required by the recipient, ensure remittances process automatically, provide notification that you are getting paid according to contract, assist with efficiently managing any bad debt and much more. Rules can be modified and added as needed, and many are driven by effective date range for easy change management. Additionally, selected rules can be imported from Excel® data files to make compliance updates simple.
Patient Accuracy Rules
Patient accuracy starts with using multi-tier matching rules and interface processing rules to ensure patient updates from a host system can occur with minimal intervention, which is augmented with other rules that ensure all patient data required to bill a payer or patient are completed. Additionally, payer-specific rules can be applied to ensure completed data meets formatting requirements (e.g., policy number), as well as payer-specific data defaults can be defined (e.g., identification qualifiers) to streamline data entry and accuracy. The application is patient-centric, allowing an unlimited number of insurance plans to be assigned to the account but also ensuring that any patient definitions are maintained and can be applied to all transactions without touching each transaction. Patients for whom accuracy rules have not been met are automatically put on Claim Hold and are worked via the Held Account Workqueue, which provides extensive tools for easy client contact, note documentation and update of required patient account data.
Transaction Rules
Charges and credits are received from your LIS or pathology system via an HL7 Charge Interface. An unlimited number of charge interfaces can be supported by the application, and interface rules are applied upon initial processing for translations, for field mapping and to ensure transaction integrity. Subsequently, transaction rules are virtually unlimited and validate incoming charges and credits. For example, you can apply rules for exploding, imploding, verifying medical necessity, assigning CPTs and applying payer specific edits (e.g., which jurisdictional payer to assign, which distinct service modifier to use, if the CPT is covered and many, many more). All transactions that pass the transactions rules process can automatically proceed to billing without any user intervention. Errors that have one or more failures are worked via the Error Workqueue, which provides extensive tools for easy client contact, PDF views of requisitions and error management.
Payer Rules
Payer rules ensure transactions are appropriately packaged and presented as the payer requires on 837 electronic claim submissions or printed as required on CMS-1500 or UB-04 forms. Payer-specific rules include account-required field checking, imploding, distinct service modifier assignment, CPT grouping instructions for service line presentation, non-covered CPT disposition, Medically Unlikely Edits, automatic attention level assignment and the field-by-field instructions to complete the claim forms or the segment instructions for the 837 files. Payer rules specific to professional versus institutional claim submission can be defined. Payer rules give users complete control of their claims ensuring submissions are not denied due to inappropriate filings.
Client Rules
The organization can utilize client-based rules to meet each client’s requirements for invoicing formats, content and distribution, as well as processing requirements (e.g., are selected procedures ordered from a client eligible to be billed to the associated financial class or should they be billed back to the client, should some procedures be excluded from client billing or are some clients not even eligible for client billing). Client rules are all designed to ensure that the billing processes performed by the organization adhere to the service requirements of your clients, giving your laboratory a competitive advantage.
Reimbursement Rules
Reimbursement and remittance rules are designed to optimize the processing of payer remittance. Remittance rules include definitions on how 835 files are processed (e.g., automatic crossovers, adjustment save rules), expected reimbursement and variances required for management notification, remittance instructions on the next automatic action for the system to apply to a claim based upon adjustment group and reason codes, automatic adjustment rules, appeal rules and more. Remittance rules are designed to improve the workflow while providing management with process control and notification when payers are not remitting according to contract.
Bad Debt and Write-off Rules
Rules can be defined for amounts required for small balance write off, precedence and conditions to automatically transfer amounts to bad debt, fields for collection agency notification and the rules required to automatically write off bad debt. These rules allow the organization complete control of the schedules and automation of the bad debt and write offs process, while minimizing manual intervention and surrounding this process with additional security.
In Summary
Rules provide you with the power to customize and update the application to each of your client and payer requirements, as well as to meet your efficiency and compliance goals without requiring custom changes as you grow. The copy feature makes it easy to implement rules that may apply to multiple payers or clients, while the effective date range for each rule allows the organization to control when each rule is implemented and maintains a history for reference.