Product & Technology

A Solid Bond

Information technology's role in working with private payor insurance.

• By David Kopf
• May 01, 2014

“Diversify or Die.” It sounds a bit harsh, but for many providers frozen out of key Medicare markets and categories by competitive bidding, they have to create news business models. And, as part of those efforts, HME businesses are including moves to ratchet up the revenues they derive from private payor insurance.

While five or six years ago, providers might not have concentrated much attention on private payor insurance carriers, now private payor revenue is a key element in their strategies to save their businesses. And it’s been a tough slog. While they have worked to try and stem the tide competitive bidding or overcome CMS’s audit onslaught, providers have had to simultaneously work to increase the percentage of their revenues that is derived from private payor reimbursement.

“Ten years ago, 14 years ago, when we first started, it was all about making sure that they [providers] were billing Medicare as best as possible,” says Michael Sanderson, president and co-founder of reimbursement software company RemitDATA, which got its start in the DME industry, and now works with some of the largest medical billers on the market. “They were making enough money on Medicare that they weren’t overly worried about the private pays. When competitive bidding came, and then audits, now there has been a general waking up of people toward the question of ‘How do I interact with the commercial payors?’ … In over the past three years we have seen a dramatic increase in what I would call strategic thinking by HME providers and how they’re looking at their business overall.”

Of course private payor insurance is not the end all, be all solution for HME industry woes. In terms of revenue, private payor reimbursement tends to match Medicare reimbursement rates, which means that insurance carriers don’t necessarily represent fatter revenue sources, but simply an antidote to Medicare’s almost surreal reimbursement landscape.

Also, Medicare isn’t the only payor interested in consolidating its suppliers. In another trend that is sure to push down reimbursement rates on the private payor side of the marketplace, some major carriers, such as Humana, have tried entering into single-provider relationships with large national HME providers as they try to drive down their cost structures. Such moves make the landscape that much more difficult.

However, these relationships have not been as successful as the private payors had hoped, and like smart businesses (and unlike CMS), they have realized they might not be able to consolidate as much as they could without upsetting their end customers. Moreover, those larger national providers have also moved subcontract services for certain categories and geographies, as well.

Ultimately, whatever complications might be involved in dealing with private payor carriers, they pale in comparison to Medicare’s obstacle course-comeminefield. This is why providers are developing strategies to tap into the private payor market and truly diversify.

As part of those strategies, providers are engaging in high-level deal-making with insurance carriers; obtaining accreditation for private payors; implementing new billing protocols, simply establishing solid relationships with private payor insurance will require providers to do some very high-level deal-making. The management and ownership level will very likely need to develop highly individualized sales and marketing appeals for each insurance company to ensure they can gain the right traction. Moreover, they will be dealing with higher-level decision makers, which means they will need to enlist the right expertise within their sales organizations.

Software’s Role

While there are similarities between Medicare billing practices and those of private payor insurance carriers, there are far more differences. Each payor has its unique requirements and procedures, which means that providers need to find efficiencies. This is where information technology becomes critical. Just like in the Medicare game, providers much find any efficiency they can to maximize margins in the face of declining reimbursement rates. That efficiency has an additional benefit of creating the sort of fast responsiveness that will reassurance private payor partners and help to contribute to an increased service level that will help cement that relationship.

And of course the ultimate goal of reducing the days between claim and reimbursement is an obvious need, as well. As providers have known for several years now, nothing reduces their DSOs more than billing processes driven by information technology.

This means providers need to ensure that a software system under review supports the private payors with which it works, as well as look at how a software system can help create as fluid a workflow as possible between it and its private payor partners. Key things to look at include reporting tools, documentation tools, and support for payors’ coding schemes. The goal is to have as seamless a system as possible.

In these respects, much of information technology’s role in working with private payor insurance should come as familiar territory to many providers, but there is one element of the process: ensuring fair reimbursement.

Market Intelligence

While working with Medicare can feel like anything but fair, the reimbursement rates that are set are at least uniform. In other words, the reimbursement rate for a wheelchair in a given competitive bidding area is going to be the same for whichever providers hold a contract for that area. And the same holds true for items that are outside the competitive bidding program; the reimbursement rates don’t vary between providers.

But private payor insurance is another game entirely, because it is a free market; providers and carriers are free to come to any agreement they choose. This means a private payor might pay two providers different levels of reimbursement for the same DME and related services. Additionally, providers need to have data so that they can use to determine the best opportunities or the payors that will offer the most hindrances.

Here again, information technology can help. Sanderson says his firm works to collect and provide the kind of market-driven data that providers can use to ensure they build their private payor billing strategies on solid ground.

“I think one of the biggest hang-ups is that [providers] are operating without any real understanding of what’s going on in that market,” Sanderson explains.

“Everybody says, ‘We need to do more of that,’ but where do they start? “… There is leverage, but not unless you know the score,” Sanderson continues. “We see it in our data all the time. There is a large [price] delta across codes, across the U.S., based on geography, based on specialty, based on the referral agreements. But if you don’t walk up to the negotiating table knowing where you have strengths, you might have to take the plan’s payment, and you’re literally leaving large amounts of revenue sitting there.”

The must find a view that shows them everything. Sanderson says providers need to determine factors such as whether or not a private payor is paying more than Medicare in a certain market; is the payor paying faster or slower than Medicare or other payors; or is it denying more often. There have been attempts to consolidate that data in the past, but to do so on a large scale in order to answer questions such as, which codes for which payors are the most profitable, or which markets have been underserved.

This is what Sanderson says his firm is trying to provide to the HME industry: strategic information that leads to confident planning.

“They need to somewhere to start to even have a theory,” he says. “They need a starting point. … We are constantly telling providers, ‘We can give you more information.’ … So it’s understanding the private payor market, understanding how they [providers] fit into that, and it’s about empowering them before they walk into that meeting. That’s the biggest hang-up that they have.”

 

Private Payor Links

Of course, to link with private payors’ billing systems, providers need the right tools to link with them. Here is a rundown of various billing and HME business management software solutions and systems that offer tools for private payor connectivity, with brief descriptions of those features.

AR-Express

Company name: DIABCO – Healthcare Software Solutions, Inc.
Web Address: www.AR-Express.net
Toll-free phone number: 800-864-6210
Years company has been in business: 30
Type of system: A stand-alone system installed on-site
Programming languages and database environments: Microsoft Windows 7, Server 2008, MSQL 2008, .net, VB, VFP
Private payor connectivity: AR-Express features electronic billing for all primary and secondary insurances, including MSP. A table-driven set of business rules lets users define payor-specific validations of claims for the claim scrubbing process. Prior to claim processing, Medicare benefits can be confirmed using ME-First, DIABCO’s web-based eligibility service, which identifies HMOs, deductibles, and addresses. The system’s new ARX E-First tracks real-time eligibility for more than 700 payor insurance reports.

Brightree

Company name: Brightree, LLC.
Web Address: www.brightree.com
Toll-free phone number: 888-598-7797
Years company has been in business: 12
Number of installed systems: 2,700
Type of system: A hosted, web-based/SAAS system
Programming languages and database environments: Brightree’s billing and business management solutions are built using Microsoft’s .NET framework and uses MS SQL Server for its database environment.
Private payor connectivity: Brightree supports more than 3,500 commercial payors through a single interface. Providers don’t have to reach out to payors or multiple clearinghouses to track down payment. It is all handled directly from within the Brightree system.

CPR+, Fastrack, Caretinuum, MestaMed

Company name: Mediware Information Systems
Web Address: www.mediware.com/hme
Toll-free phone number: 866-277-4876
Years company has been in business: 43
Number of installed systems: 1500+
Type of System: A stand-alone system installed on-site; A hosted system, but uses special client software.
Programming languages and database environments: Visual FoxPro and .NET Framework front-end with a Microsoft SQL backend. Microsoft.NET, Microsoft SQL DB, and C#
Private payor connectivity: Mediware provides multiple tools for claims management. Integrated 837 engines, 270/271 benefits verification, interface with Zirmed and Emdeon. Mediware software automatically evaluates all claims for required data and missing documentation such as physician orders to insure a clean claim is generated. The system can hold claims for various reasons and navigate with ease to complete necessary data. Statuses, follow-up dates and notes help to view the claim, complete submit easily with the claims browser. Integration with Zirmed automatically submits the EDI claims returning an immediate response message.

Inscrybe Referral Management

Company name: Authentidate
Web Address: www.authentidate.com/referrals
Toll-free phone number: 877-467-2792
Years company has been in business: 21
Type of system: A hosted, web-based/SAAS system
Programming languages and database environments: .NET
Private payor connectivity: Prior-authorization capability, and complete documentation for reimbursement filings. Electronic interface to practice management/billing systems and EHR systems available.

Medeq Manager

Company name: Bonafide Management Systems
Web Address: www.bonafide.com
Toll-free phone number: 805-908-2333
Type of System: Hosted, web-based only.
Programming languages and database environments: Java for application on redundant unix based web servers. Database is in SQL 2012 active/passive cluster for high availability.
Private payor connectivity: Eligibility and remaining deductible at point of service. Claim scrubbed for payment before order is complete. Completely paperless system for Bonafide’s provider client.

MedFORCE Scan, MedFORCE D&R, MedFORCE WorkFLOW, UPS, USPS and FedEX Shipment Tracker, ZipMit.

Company name: MedFORCE Technologies, Inc.
Web Address: www.medforcetech.com
Toll-free phone number: 866-237-1190
Type of system: A stand-alone system installed on-site; A hosted, web-based/SAAS system
Programming languages and database environments:
Programming languages used are Asp.net, Delphi and C Sharp and uses a SQL database to securely store data.
Private payor connectivity: MedFORCE D&R utilizes generic 835 files from any payor. The system’s ZipMit program will be available for commercial payors as soon as CMS makes this available to commercial payors.

Noble*Direct for Windows

Company name: Noble House
Web Address: www.nobledirect.com
Toll-free phone number: 800-749-6700
Type of system: A stand-alone system installed on-site
Programming languages and database environments: Noble*Direct is a true Windows application utilizing Pervasive SQL
Private payor connectivity: Noble*Direct can submit primary and secondary claims electronically to more than 2,300 payors. In addition, patient eligibility and electronic EOB’s (835s) are also available.

SystemOne

Company name: QS/1
Web Address: www.qs1.com
Toll-free phone number: 800-231-7776
Type of System: A stand-alone system installed on-site; a hosted system, but uses special client software
Programming languages and database environments: Assembler/Visual Basic
Private payor connectivity: Zirmed allows for electronic billing to more than 4,000 private payors.

TIMS Software

Company name: Computers Unlimited
Web Address: www.cu.net
Toll-free phone number: 406-255-9500
Type of system: A stand-alone system installed on-site; A hosted, web-based/SAAS system
Programming languages and database environments: Microsoft .Net and SQL server
Private payor connectivity: TIMS Software offers tools such as claims edits and held A/R reports by error to electronic processing claims directly to payor or through ZirMed for private payors. Automatically upload and apply remittance amounts for rapid reimbursement. Claims transmission technology provides accurate coding of claims in accordance with Medicare and other third-party payor regulations.

TITAN, Reimbursement PRO and WebScan PRO

Company name: RemitDATA
Web Address: www.remitdata.com
Toll-free phone number: 866-885-2974
Type of system: A hosted, web-based/SAAS system
Programming languages and database environments: Applications are built in .NET/C#, Java, and JavaScript. All product database environments are Microsoft SQL Server.
Private payor connectivity: RemitDATA’s SaaS-based offerings are all payor-oriented. The TITAN analytics solution includes real-time alerts and insights around claim processing times, denial rates and causations, and cash flow, so providers can proactively monitor and address inefficient billing practices, as well as payor operational and payment-related issues. The comparative benchmarks within TITAN equip providers with market performance metrics so they can illustrate and communicate payor-specific anomalies that are currently affecting them. Additionally, the Reimbursement Pro denial management workflow tool can work with any practice management or billing system to streamline and reduce claim denials from any payor; thus, significantly improving the provider’s cash flow. Reimbursement Pro allows the provider to quickly identify and fix problematic collection issues while automating their denial management process through the system’s included OnDemand EOB retrieval, OnDemand Query analysis, Denial Q workflow tool and OnDemand (payor-specific) Form generation tools.

This article originally appeared in the May 2014 issue of HME Business.