Problem for CMS
The Centers for Medicare & Medicaid Services (CMS) is working hard to reduce improper payments by developing a new method of detecting inappropriate billing and payment before claims are paid alongside the current method of post-payment audits of providers.
Why is this important to providers? Legislation requires that most Medicare claims be paid within 30 days which traditionally has meant that CMS paid out claims before investigating them – what officials call the "pay and chase" model. CMS is under increasing pressure to move away from this model to a more proactive and preventative approach that scrutinizes providers claims before they are paid. Providers’ claims will now be analyzed and audited before a payment is made for services, therefore affecting revenue flow on a daily basis. 1
Several features that are included in this pre-payment review methodology are: rigorous review of medical necessity and documentation, prior authorization certifications and physician reimbursement. CMS will incorporate a Predictive Analysis Model to prevent fraud and abuse which will utilize a claim pre-payment edit method. The predictive analysis may use a methodology that would include alerts for physician practices that routinely charge the highest amount for a procedure in a given zip code. High risk claims are flagged by the editing algorithms for providers who routinely over utilize certain services or items based on claim histories. As claims move through the CMS predictive analysis system, it will build profiles of providers, billing patterns, and utilization assigning risk scores to each provider. Providers with high risk scores will be flagged and their claims will undergo greater scrutiny. 2
Predictive analysis has been used in other business segments for a long time such as by lenders and credit card companies. Ever wonder how Amazon recommends items to purchase? Amazon uses predictive analysis data mining based on what you have bought before. Ever wonder why you were denied purchasing gas at a gas station three states away from home? Predictive analysis flagging potential fraud based on where you reside. One busy afternoon of shopping at the mall – or a whole day of shopping at the mall – warrants a call from your credit card company to check if the one doing all the spending is you. Predictive analysis is predicting you have had enough of treating yourself, with spending limits flagged and challenged at the point of purchase. This same method of predictive analysis has been applied to medical claims as of July 1, 2011 in 10 states that have the highest risk of waste fraud and abuse and will be rolled out to an additional 10 states by October 1, 2012.3
Problem for Providers
These types of payment pattern models cause a profound impact on physician practices as they struggle to keep up and adapt to reflect compliance with CMS guidelines, the looming ICD-10 changes and the ever more demanding meaningful use criteria of Electronic Health Records (EHRs) already burdening physicians.
How does a busy practice prevent improper payment and interruptions to revenue flow? As CMS moves to pre-payment claims review, physician practices are best served with utilizing a claims editing solution that also incorporates medical necessity checking with documentation alerts. The solution should also have the charges validated as being covered, non-covered and at Medicare Par and Non-Par rates.
While CMS has indicated that certain patterns determined through predictive modeling will be flagged and investigated, very little information is available regarding what those patterns or targets may be, therefore it is also a priority to be able to change and create edits quickly in a claims editing software as CMS alters any of its analytics metrics.
One suggestion is that providers should monitor their own claims for patterns and outliers that may raise a red-flag for CMS. Providers should be prepared to explain and demonstrate why such patterns and outliers exist. By applying pre-payment edits to the front of the practice workflow using a claims editing solution much can be accomplished before the claim is transmitted to CMS. Pre-payment denials can be avoided and the likelihood of additional audits can be decreased.
Solution
A solution that fits the prepayment schema is ClaimsEditor®. Edits are displayed with messages and alerts and reports are provided that parallel CMS, RAC, OIG and the Fraud and Abuse predictive modeling. High cost services, or equipment by provider can be identified through your claims information. See what you‘ve been missing and how we can help you stay on your game at http://www.context4healthcare.com.
1. CMS Manual Pub 100-20 One Time Notification , dated February 24, 2012, Transmittal 1049 CR 7669
2. US Department of Health and Human Services Strategic Plan Fiscal years 2010-2015
3. CMS Small Business Jobs Act of 2010
Friday, March 9, 2012
Friday, February 24, 2012
Health Trends in 2012 – What’s in a Number
Medical cost trends are expected to rise from 8.1% to 8.5% in 2012.
As cited in the article titled “Behind the Numbers Medical Cost Trends for 2012-Health” Health Research Institute 2011, medical cost trends are expected to rise from 8.1 % to 8.5 % in 2012.
Medical cost trend is the projected increase in the cost of medical services and is used for setting premiums for health insurance plans. About 33 percent of all benefit cost is attributed to physician services, while inpatient hospital costs are second at around 31 percent and outpatient hospital services are 17 percent. Prescriptions are at 15 percent of medical cost and the remaining 4 percent are costs associated to services such as Home Health, Skilled Nursing Facilities and medical equipment.
This increase is influenced by the unit cost inflation, changes in unit prices of medical products and services that may be affected by the economy, inflation and new technology. Changes in the volume of services or utilizations are another driver that may increase medical costs and may be affected by demographics, advertising and the use of technology.
For consumers, providers and payers, it is important to know what the cost of a service, equipment and new technology will be for each year, as health plans prepare to set their yearly insurance offerings to employers.
Finding out what other providers of medical services and equipment are charging can be a daunting task. Each year new services and their related procedure codes and fees need to be established from a variety of data points.
One way to access this cumulative data is to obtain the fee of the service or medical equipment from Context 4 Healthcare. Based on Geozip - Usual, Customary and Reasonable Fees (UCR), Physician Fee Reports, as well as Medicare Par and Non Par fee for service are available in a single data source. Armed with knowledge that represents cumulative data, correct decisions can be made to price medical services and equipment.
As cited in the article titled “Behind the Numbers Medical Cost Trends for 2012-Health” Health Research Institute 2011, medical cost trends are expected to rise from 8.1 % to 8.5 % in 2012.
Medical cost trend is the projected increase in the cost of medical services and is used for setting premiums for health insurance plans. About 33 percent of all benefit cost is attributed to physician services, while inpatient hospital costs are second at around 31 percent and outpatient hospital services are 17 percent. Prescriptions are at 15 percent of medical cost and the remaining 4 percent are costs associated to services such as Home Health, Skilled Nursing Facilities and medical equipment.
This increase is influenced by the unit cost inflation, changes in unit prices of medical products and services that may be affected by the economy, inflation and new technology. Changes in the volume of services or utilizations are another driver that may increase medical costs and may be affected by demographics, advertising and the use of technology.
For consumers, providers and payers, it is important to know what the cost of a service, equipment and new technology will be for each year, as health plans prepare to set their yearly insurance offerings to employers.
Finding out what other providers of medical services and equipment are charging can be a daunting task. Each year new services and their related procedure codes and fees need to be established from a variety of data points.
One way to access this cumulative data is to obtain the fee of the service or medical equipment from Context 4 Healthcare. Based on Geozip - Usual, Customary and Reasonable Fees (UCR), Physician Fee Reports, as well as Medicare Par and Non Par fee for service are available in a single data source. Armed with knowledge that represents cumulative data, correct decisions can be made to price medical services and equipment.
Wednesday, January 18, 2012
400th Usual, Customary, & Reasonable Client, Lone Star TPA Calls Upon Context 4 Healthcare
Context 4 Healthcare, Inc. announced today that they have added Lone Star TPA of Tyler, TX as their 400th client utilizing its Usual, Customary & Reasonable health payment benchmarking databases.
“We are pleased to have added Lone Star TPA as number 400.” said Mark Earles, President and CEO of Context 4 Healthcare. “Lone Star TPA provides benefit design and administration services to employee sponsored health plans in a very complex and challenging market. Our health payment benchmarking solutions will empower Lone Star’s mission of providing value added partnerships to its clients.”
“Attaining our 400th UCR client is an important milestone for Context, but it is our ability to create and maintain successful client partnerships that is crucial to our success”, added Earles. “We look forward to serving Lone Star TPA for years to come.
About Context 4 Healthcare Inc.
Headquartered in Naperville, IL, Context 4 Healthcare, Inc develops software solutions to solve complex medical claim coding, claim editing and reimbursement challenges. Context’s software and data products enable healthcare providers and payors to reduce claim errors, denials and claim-handling costs. Privately held, Context 4 Healthcare is not affiliated with any payor or provider organization. More than 3,500 physician practices, hospitals, insurance carriers, third party administrators and managed care organizations currently use Context 4 Healthcare products. Learn more at www.context4healthcare.com .
About Lone Star TPA
Lone Star TPA distinguishes itself through experience in the self-funded industry, integrity, responsive service, integrated technological solutions and commitment to client satisfaction. Learn more at www.lonestartpa.com .
Thursday, December 1, 2011
Context 4 Healthcare, Inc. fills Vice President of Sales role with Healthcare Software Sales Leader
Naperville, IL, December 1, 2011 -- Context4 Healthcare, Inc., a leading provider of database and software solutions for reimbursement challenges in the healthcare industry, today announced that it has hired Mark J. Oman to the position of Vice President of Sales. Mr. Oman most recently led the national sales team at KnowledgeLake, Inc. of St. Louis, MO.
"Mark’s passion, dedication, leadership skills and work ethic along with his wide breadth of executive level sales experience, make him a well-qualified addition to our executive team," noted Mark Earles, Chief Executive Officer of Context 4 Healthcare. “We feel very fortunate to have him on board with us during this exciting time in the healthcare industry and during this period of growth in our business,” Earles added.
“I’m very pleased to join the Context4 Healthcare Family, stated Oman. “I look forward to reaching out to Context’s existing clients and other longtime contacts whom I’ve done business with in the past. It is an honor to be part of an organization that places such importance on serving its clients through innovation, devotion, and successful partnerships,” Oman added.
In addition to his service with KnowledgeLake, Mr. Oman served in a senior sales capacity with EMC Corporations’ (NYSE:EMC) Documentum Software Group and as a management team member of the Captiva Software (NASDAQ:CPTV), Healthcare Solutions Group. While at EMC|Captiva Healthcare Solutions Group, Mr. Oman’s focus was on helping healthcare organizations become more efficient within their claims processing operations.
About Context 4 Healthcare, Inc.
Headquartered in Naperville, IL, Context4 Healthcare, Inc develops software solutions to solve complex medical claim coding, claim editing and reimbursement challenges. Context’s software and data products enable healthcare providers and payors to reduce claim errors, denials and claim-handling costs. Privately held, Context4 Healthcare is not affiliated with any payor or provider organization. More than 3,500 physician practices, hospitals, insurance carriers, third party administrators and managed care organizations currently use Context4 Healthcare products. Learn more at www.context4healthcare.com.
Wednesday, October 5, 2011
Context 4 Healthcare Expands Relationship with Molina Medicaid Solutions
Context’s medical crosswalk databases to support Molina’s Medicaid processing services.
Naperville, IL & Reston, VA – October 4th, 2011 – Context 4 Healthcare, Inc., a leading provider of database and software solutions for reimbursement challenges in the healthcare industry, today announced an expanded partnership with Molina Medicaid Solutions, a subsidiary of Molina Healthcare, Inc., for use of Context’s data products.
“Context has an excellent track record for data accuracy and seamless integration. Our extensive validation analysis of Context products resulted in Context being the vendor of choice for our Medicaid data needs,” notes Warren Leber from Molina’s technology development team.
“Context’s ability to meet our unique product requirements reinforced our confidence in expanding the relationship.”
“We are pleased to announce our expanded partnership with Molina in support of their business process outsourcing (BPO) needs. Our collaborative efforts on these products have culminated in the development of a robust suite of healthcare database products. We look forward to continuing our relationship with Molina and supporting the complex challenges they face,” states Mark Earles, President and CEO of Context.
“Our relationship combines Molina Medicaid Solutions’ excellence in government-sponsored health care programs together with Context’s highly reliable healthcare data solutions. We look forward to continuing our relationship with Molina and our shared commitment to accuracy in Medicaid processing services,”added Earles.
About Context 4 Healthcare Inc.
Headquartered in Naperville, Ill., Context 4 Healthcare, Inc develops software solutions to solve complex medical claims coding, claim editing and reimbursement challenges. Context’s software and data products enable healthcare providers and payors to reduce claim errors, denials and claim-handling costs. Privately held, Context 4 Healthcare is not affiliated with any payor or provider organization. More than 3,500 physician practices, hospitals, insurance carriers, third party administrators and managed care organizations currently use Context 4 Healthcare products.
About Molina Medicaid Solutions
Molina Medicaid Solutions (MMS), a subsidiary of Molina Healthcare, Inc., provides business processing and information technology administrative services to state agencies administering Medicaid and entitlement programs. MMS is uniquely positioned to help state agencies meet their health care administration and Medicaid Management Information Systems (MMIS) goals. MMS currently holds contracts with the states of Idaho, Louisiana, Maine, New Jersey and West Virginia as well as a contract to provide drug rebate administration services for the Florida Medicaid Pharmacy program. For more information about MMS, go to http://www.molinahealthcare.com/abtmolina/plans/Pages/mms.aspx.
Thursday, September 1, 2011
Context4 Healthcare Professionals Participate in ONC HIT Program
Context4 Healthcare’s Medical Director Dr. Margaret Klasa and Business Analyst Emilia Burlasz have recently been accepted into the Office of the National Coordinator‘s Health Information Technology (HIT) Program. Respectively, the completion of their six month program at Moraine Valley and NOVA , will occur early 2012 and will then be eligible for the HHS’ HIT-Pro certification.
The goal of the program is to train skilled health IT professionals who will be able to help providers implement electronic health records and achieve meaningful use.
Context4 Healthcare is proud to be part of this initiative and support our channel partners in EHR adoption and implementation.
Tuesday, February 15, 2011
Context4 Healthcare, Inc. Launches CodeLink Pro® 2011
Context4 Healthcare, Inc. Launches CodeLink Pro® 2011
Medical claims coding software solution drives accurate reimbursement as healthcare providers navigate the transition to the new International Classification of Diseases coding system.
Naperville, IL – February 15th, 2011 – Context4 Healthcare, Inc., a leading provider of software solutions for reimbursement challenges in the healthcare industry, today announced the release of CodeLink® Pro 2011. This advanced software will play a critical role as the healthcare industry transitions to the new International Classification of Disease medical claims coding system. The new release includes a cross reference from ICD-9 to ICD-10 based on the Center for Medicare and Medicaid General Equivalency Mapping.
“During the transition from ICD-9 to ICD-10 the healthcare industry is confronting significant reimbursement, compliance and staff training issues”. “Almost every facet of the care management process will be affected by this change” notes Mark Earles, President and CEO of Context. “We are committed to providing tools that give healthcare organizations the ability to successfully navigate this transition and this is the driving force behind our new release”.
“In this new version, we leveraged our 20 years of development experience and relied heavily on customer collaboration and industry expertise in refining CodeLink® Pro”, comments Earles. Highlights of the new release include an enhanced user interface, Medicare fees and more robust CCI information. More information about the benefits of CodeLink® Pro 2011 can be seen at http://www.context4healthcare.com/index.php/products/code-link/.
Remaining true to its reputation as a fast and accurate coding tool built for coders; CodeLink® Pro 2011 contains the entire listing of CPT®, HCPCS, ICD-9-CM and ICD-10-CM codes, notes, include and exclude notes, linkage libraries and cross-reference relationships between CPT® and ICD-9-CM / ICD-10-CM codes on a specialty-by-specialty basis.
“CodeLink is an invaluable tool that assists our office in finding CPT and ICD codes that accurately reflect procedures performed”, comments Barbara Byrne, CPC of Upstate Orthopedics located in Syracuse, NY.
“The new version of CodeLink has a great feature which allows ICD-9-CM codes to map to the new ICD-10-CM codes helping us get acclimated to the forthcoming change”.
“We look forward to continued success in developing industry leading software and database products during the coming year and remain optimistic about our ability to drive innovation in the reimbursement marketplace” commented Earles.
About Context4 Healthcare
Headquartered in Naperville, Ill., Context4 Healthcare, Inc develops software solutions to solve complex medical claims coding, claim editing and reimbursement challenges. Context’s software and data products enable healthcare providers and payors to reduce claim errors, denials and claim-handling costs. Privately held, Context4 Healthcare is not affiliated with any provider or payor organization. More than 3,500 physician practices, hospitals, insurance carriers, third party administrators and managed care organizations currently use Context4 Healthcare products. Learn more at www.context4healthcare.com.
CPT is a registered trademark of the American Medical Association.
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