Anesthesia Key Edits - Ambulatory
Helps ensure accurate billing through defined edits. Instead of relying on reports, the user has an organized View integrated with the system along with detailed workflow reporting. Available in GECB version 6.1+.
TES Edits
The old issues of redundant edits and staff seeing edits they have no control over is history with this workflow. Flexibility in the Preview and Instruction panes and the use of agents will improve the current workflow in TES. ETM’s detailed reporting capabilities allow volume, inventory, and productivity to be tracked. Available in GECB version 4.3+.
Claim Edits
Do away with stacks of paper lists sorted by claim. Transitioning to ETM organizes the work and eliminates the ‘black holes’ of more manual processes. When users believe they resolved an edit, but it does not allow the claim to produce, ETM returns the edit for rework. ETM’s detailed reporting capabilities allow volume, inventory, and productivity to be tracked. Available in GECB version 4.0+.
Claim Ack Rejection
Both EDI Services and EDI toolkit customers can utilize this workflow to work 277CA Rejections via ETM. When the EDI file is loaded into GECB the 277CA results become available within the invoice and the Rejections immediately trigger a Task for end-user follow up. The integration of the outside data creates a more complete picture of the history of the invoice. ETM’s detailed reporting capabilities allow volume, inventory, and productivity to be tracked. Available in GECB version 5.0+.
Rejections
Setting up the Rejection Subsystem to appropriately allocate the work is the first step in a successful ETM implementation for this workflow. Using ETM, you can transfer the responsibility of rejections (e.g. business office transfers to the charge correction team) and still have the controls in place to ensure all the work is being resolved. ETM’s detailed reporting capabilities allow volume, inventory, and productivity to be tracked. Available in GECB version 4.0+.
No Activity/Insurance Follow-up
Once you integrate the status of invoices based on other workflows, the follow up on insurance claims can be more efficient and exception-based. Redundancies from other flows are removed. Your staff will be following up on accounts that truly require follow up at this time. Following up on a payment posted with no claim prepared at 2 days vs an invoice that a claim was submitted 30 days ago is the flexibility that this workflow allows. The 276/277 transaction set is also incorporated allowing you to report on claim statuses and dictate follow up based upon those events. ETM’s detailed reporting capabilities allow volume, inventory, and productivity to be tracked. Available in GECB version 4.0+.
Note: This workflow is referred to as Insurance Follow-up in other implementations.
Self Pay Follow-up (includes Statement Edits)
Integrating dunning table value with ETM efficiencies, this workflow can be implemented to allow the flexibility to pursue collections on accounts that have the best chance of collections. ETM’s ability to categorize accounts by analyzing past BAR activity enhances follow up by breaking out patients that have been previously sent to collections as well as accounts where recent payments were made. The workflow includes the ability to assign Tasks that are currently editing as well as follow up on Budgets. ETM Agents can be utilized to perform the transfer to the external collection agencies. Available in GECB version 4.3+.
Credit Balance/Refunds
Identifying credit balance opportunities, increasing the efficiency of the staff, delineating reasons for refunds, and enhanced reporting of credit balance aging are all benefits of this workflow. The actual cause of the credit balance is reported, whether it is a patient payment with no charges or a redundant insurance payment, we categorize the method of creation for task allocation and resolution. ETM’s detailed reporting capabilities allow volume, inventory, and productivity to be tracked. Available in GECB version 4.0+.
Payer Contract Module (PCM)
ETM can generate tasks for underpayments and overpayments based on flexible rules and not impact subsequent A/R follow up. ETM records payment variances so that they can be pursued individually or in bulk. If contract updates are made that impact existing Tasks those Tasks are updated and removed, if needed, helping to keep an accurate follow-up list. Tasks can be assigned Categories and Phases in bulk making it easier to perform bulk follow up with payors. ETM’s detailed reporting capabilities allow volume, inventory, and productivity to be tracked. Available in GECB version 4.3+.
Sequence & Dependencies
Many clients want to start the ETM implementation with their most significant pain points, which is oftentimes the insurance follow-up process. If workflows were implemented with minimal integration, the sequencing would not matter as significantly as it does in an integrated workflow. Because of integration points, you may not be able to start with your first choice of workflow. But there is a benefit is starting at less critical workflows because it allows the opportunity for client understanding and acceptance of the tool as well as allowing for an integrated product as a whole.
In BAR, to allow for proper workflow integration before implementing the No Activity workflow the Claim Edits, Claim Ack Rejections, and Rejections workflows should be implemented. This ensures that invoices held up in these preliminary workflows are not worked redundantly in the No Activity process. If a rejection is in progress, why have an insurance clerk even touch the invoice until the issue has been addressed? An additional workflow of correspondence follow-up is also recommended before insurance follow-up so that items that are received as individual pieces of correspondence can also suspend unnecessary calls to insurance companies until the items are addressed.
| Workflow | Dependency |
|---|---|
| Claim Edits | none |
| Claim Ack Rejections (formerly Payer Edits) | BAR EDI 277CA |
| Rejections | BAR EDI 835 |
| Correspondence | EDM Application |
| No Activity/Insurance Follow-up | Most effective following CE, CAR, REJ; BAR EDI 276/277 |
| Credit Balance/Refunds | No Activity/Insurance Follow-up |
| Self Pay Follow-up (includes Statement Edits) | none |
| Payer Contract Module | PCM Application |
| TES Edits | none |
| Anesthesia Key Edits | Anesthesia Module |
| SIU Interface Edits | SIU Interfaces |
| Hold Bills/Alerts | VM Application |
| Referrals | Open Referrals |
| Pre-Visit (non VM) | EWS Application |