Sentinel Outpatient Claim Review Tool - PowerPoint PPT Presentation

1 / 45
About This Presentation
Title:

Sentinel Outpatient Claim Review Tool

Description:

Empowering your staff to continually improve coding and billing ... Brachytherapy surgical procedure without interstitial radiation source application ... – PowerPoint PPT presentation

Number of Views:45
Avg rating:3.0/5.0
Slides: 46
Provided by: provi6
Category:

less

Transcript and Presenter's Notes

Title: Sentinel Outpatient Claim Review Tool


1
Sentinel Outpatient Claim Review Tool
2
Our Outpatient Solution
3
The Vision
  • Transfer of knowledge and tools from PCS to the
    Hospital
  • Empowering your staff to continually improve
    coding and billing
  • Training and support throughout the process

Onsite Claims Review Software
Retrospective Review Rebilling
Education Operational Change
PCS
Hospital
4
Managing Your Outpatient Business
  • Managing Outpatient billing is not the same as
    Inpatient
  • Due to volume, distribution of people and
    services, work flow is a critical component
  • of any Outpatient management tool

5
Managing Your Outpatient Business
Its a continuum.. And a partnership
Workflow Management
Processing is automated AND Claims are
automatically routed AND Triggering events cause
service alerts, reports are distributed
Processing is automated AND Claims are
automatically routed
Processing is automated
User is responsible for creating the file,
running the process, finding erroneous claims and
performing issue analysis
User is responsible for finding erroneous claims
and performing issue analysis
User performs issue analysis
6
Phase I Retrospective Review Billing
7
Retrospective Review
  • Screen the claims and identify potential impact
  • Proprietary edits prioritized by likelihood of
    change
  • Plus
  • OCE/CCI
  • LCD/NCDs
  • Full grouper/pricer
  • Target 60-70 claims for on-site review
  • Claims selected from all major service areas with
    potential issues

8
Retrospective Review
  • On-site review includes
  • Medical record
  • Detailed charges (CDM)
  • Remittance information
  • Denial information
  • Orders, nursing notes, radiology reports, etc.
  • Frequently performed in conjunction with Hospital
    staff
  • Enables the staff to perform reviews on other
    claims

9
Retrospective Review
  • Summary of Findings
  • Issues
  • Recommendations and potential operational changes
  • Target areas for rebilling
  • Claims worksheets
  • Claims reviewed on-site with initial and
    recommended coding
  • All flagged claims for hospital follow-up
  • Excel file listing all flagged claims
  • To be used as a management tool

10
Retrospective Review
  • Options
  • Purchase the dataset and implement within the
    hospital
  • With support and training as needed
  • PCS performs on-site/off-site review of claims
  • Phone/onsite support as needed to facilitate the
    efficient rebilling of claims
  • Hospital personnel enter changes into the
    hospital system for the actual rebill

11
Phase II Onsite Screening
12
The Opportunity
  • Get the Return on Investment
  • you deserve.

13
The Problem
  • Large re-bill jobs too resource-intensive
  • No consistent monitoring of outpatient claims
  • Outpatient regulations changing fast
  • Specialization is now required for the outpatient
    coder
  • Electronic communication on an outpatient claim
    is difficult
  • No clean outpatient database internally for
    decision support, education, analysis, claim
    review

14
PCS Sentinel
  • Review every claim, every day
  • Review your CDM
  • Represents expertise across the entire outpatient
    arena
  • Full APC grouper and Phys/Lab/DME fee schedules
  • OCE, CCI, LCD and NCD logic included
  • Share information easily among medical records,
    finance, patient accounting
  • Comprehensive reporting capability available on
    the hospital intranet

15
Different, and Better ..
  • Customizable screens make your own, or tinker
    with ours!
  • Supports pre-bill, post-bill (or both to track
    changes!)
  • Supports all payers
  • Linked to your CDM for service code
    identification
  • Over 2000 screens covering every outpatient
    department
  • Screen impact values go beyond telling you whats
    wrong to how much its worth

16
Different, and Better ..
  • Screens are categorized by type of change (CDM,
    Coding)
  • Screens are prioritized (High, Medium, Low) based
    on historic likelihood of change
  • Experienced outpatient coding support offered by
    professionally credentialed PCS staff
  • Full ad-hoc capability to generate claim lists,
    reports and charts
  • Intranet Web-based tool is accessible, yet secure

17
PCS Sentinel
An extension of what you already do.A real-time
expert assistant.
18
PCS Sentinel Demonstration
  • Review claims for accurate billing
  • Coding/Billing Compliance
  • CDM Issues
  • Education
  • Departmental Report Suite
  • Decision Support
  • Denial/Rejection Analysis

Return on Investment
Managing Outpatient Operations
Manage Risk
Education
19
Step 1Process Outpatient Claims
  • Flexible input format
  • 835,837, electronic UB, customized format
  • No user interaction required (scheduled task at
    night)
  • Work with hospital IT to make the file available
  • Question of process
  • Use pre-bill data and correct claims before they
    bill
  • Use remit data and rebill
  • .. Or use both files to track your changes
  • Review daily v. weekly/periodically?

20
Step 1Process Outpatient Claims
1.
Pre-bill file
Sentinel
BILL DROPS
OR
Review and change
Sentinel
BILL DROPS
2.
Review and change
21
Step 2 Review the Results
22
Screening Examples
  • Range from run of the mill
  • Chemotherapy drug reported without administration
  • Medical visit on same day as a type T or S
    procedure without modifier 25 when ED visit
  • Physical therapy therapeutic exercises reported
    with units of one
  • Pacemaker insertion without pacemaker removal
  • Flu vaccine administration without the drug
  • Blood product without transfusion code

23
Screening Examples
  • To More Sophisticated
  • Transluminal balloon angioplasty peripheral
    artery SI without procedure
  • Bladder cancer with cancer drug and incorrect
    administration
  • Aredia reported with lower than expected units
  • ED claims with inpatient-only procedure missing
    modifier CA
  • Brachytherapy surgical procedure without
    interstitial radiation source application

24
Architecture
  • Intranet (NOT internet), web-based
  • Patient data stays within the confines of the
    hospital network
  • Access is controlled at two levels
  • Hospital network
  • PCS product login
  • No proprietary software install for the client
  • Microsoft-based solution
  • Minimal hospital IT maintenance PCS manages
    remotely
  • Dedicated server not required

25
Drill-down to Understand the Specific Issues
26
Step 3 Work the Claims
27
Click on a claim from the targeted list to
review detail information
28
Make the Appropriate Changes
29
and see the effect of any changes
30
Reporting Features
  • User-friendly
  • Robust ad-hoc functionality
  • Real-time response
  • Hospital-specific, common query needs can be
    saved
  • Ad-hoc supported by a vast library of standard
    reports

31
Profile by Service Delivery
32
Profile by Service Delivery
33
Profile by Service Delivery
34
  • Use Sentinel to
  • manage priorities
  • Example Focus on procedures
  • driving OCE/CCI denials
  • and rejections

35
.. But only for those CCIs failing the OCE
hospital edit
36
Quantify LCD/NCD Exposure
37
Ad-hoc Reporting Features
  • Output to graph,report, or drill-down list of
    claims
  • Select the information you want to analyze
  • Optional filter to focus on a set of procedures,
    LCDs, OCEs, Screens, etc.

38
Making Sentinel Work for You
  • Low barriers to installation
  • Minimal/No custom programming by IT
  • Sentinel understands standard 837/835/UBV6
    electronic files
  • If 835 file is selected a separate file with
    diagnoses information is necessary
  • Minimal capital expense, can share a server if
    the hospital prefers
  • Modest hardware and software requirements

39
Making Sentinel Work for You
  • PCS supports the software remotely
  • High level of security
  • INTRANET application
  • Network level, Server controls
  • Sentinel login controls, role-based model of
    security,
  • username/password encryption

40
Making Sentinel Work for You
  • Increases efficiency in what you ALREADY do, not
    another project
  • Support - Were committed to your success!
  • On-site/Con-calls/Technical and Coding Support
    open line of communication
  • Tailoring/adding screens
  • Profile reports focus review efforts on the most
    significant opportunity

41
Making Sentinel Work for You
  • Using it Every Day/Every Week
  • Data is automatically accumulating without any
    user intervention
  • Intuitive user interface
  • Detailed screen descriptions
  • Extensive drill-down functionality to get at the
    underlying claims
  • Functionality to facilitate sharing across the
    stakeholder community (saving/email reports,
    claim lists, intranet access)

42
Making Sentinel Work for You
  • Measuring ROI
  • Use Sentinel to support claim billing
  • Sentinel reports before v. after at a claim
    level
  • CDM Maintenance
  • Sentinel screens identify coding and CDM
    opportunity
  • Coding Education
  • Compliance
  • Denial Management
  • Management reports, Decision Support
  • by service area, full ad-hoc capability

43
Getting Up and Running with Sentinel
44
PCS Sentinel
  • Comprehensive outpatient claims review
  • Identification of CDM, Coding Revenue Cycle
    Opportunities
  • Extensive ad-hoc reporting capabilities
  • Experience-based logic
  • APC grouper, OCE/CCI/LCD/NCD edits included
  • Integration of coding and billing data
  • Intuitive, user-friendly format
  • Secure, yet accessible

45
Discussion Next Steps
Write a Comment
User Comments (0)
About PowerShow.com