FROM OUR PARTNERS: INTEROPERABILITY BETWEEN PMS AND RCM HELPS PRACTICES BETTER MANAGE CLAIM DENIAL PROCESSES

by Tim Eggena, Vice President, Research & Development,
NextGen Healthcare Information Systems, Inc.

After years of hassles, heartburn and headaches, physician practices are finally reaping the long-promised benefits of HIPAA. Standardization of data sets now allows practices, claims processing vendors and payors to automatically exchange growing volumes of critical coding, billing and reimbursement information.

The most recent advancement has been transparent interoperability between certain practice management systems (PMS) and revenue cycle management (RCM) software to better manage denial processing. Today's best-of-class PMS applications have been developed using an open architecture to allow specific data elements concerning the status of claims to flow seamlessly between the practice and the RCM vendor. These data sets might include:

1) 997 acknowledgements - an initial acknowledgment that the claim was received and, when applicable, alerting the practice about inherent file errors;

2) 277u claim message - an unsolicited message notifying the practice that the claim was received, but contained claim errors;

3) 835 remittance advice - a summary of the paid amount and claim messages, as well as notification of denials;

4) 276 response to claim request - a reply to practice queries about the claim's status, claim errors and claim messages.

This progressive functionality automatically updates the PMS with the most current data about each claim. In addition to granting up-to-the-minute access to this information, the most innovative of these systems also provides workflow tasking features so that any follow-up or corrective activity can be automatically assigned and monitored.

Critical messages about the claim's status are uploaded directly to the PMS. The RCM vendor may identify a problem with the claim, for instance - perhaps payor identification information was inaccurate or a modifier was missing from a procedure code. This red flag is communicated back to the PMS, which links the error message to the original encounter documentation. It then forwards the problem via a workflow task manager to the appropriate staff members to be reworked. Once corrected, the PMS resends the clean claim to the vendor - so all problems are resolved before it is ever submitted to the payor.

Problems that arise during adjudication can be handled just as easily. Once the RCM vendor receives a rejection or denial from the payor, their system can alert the practice's PMS - which again redirects the claim internally so the error can be rectified as efficiently as possible. Gone are the days of having to wait for the EOB to be returned to identify the claim denial reasons. Many days can be trimmed off the A/R cycle with more up-to-the minute claim information.

The benefits of this approach are extensive. Because specific data elements are consolidated within the PMS, practices are able to view important information without having to check with multiple sources - i.e., the claims processor and the payor. Problems are identified and corrected within hours, instead of days, enhancing the revenue cycle.

This emerging level of interoperability, provided through applications like the NextGen® Enterprise Practice Management (EPM) system and the Navicure Revenue Cycle Management system, holds vast potential for physician practices. And its value will only continue to grow, as other transaction data sets can be exchanged and shared among these systems.

For more information on Navicure and the interoperability features it shares with your Practice Management system, please call 877-Navicure.

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