RCO Success Story
- 1. Laura L. Vela | Healthcare Consulting Services Director A: 1555 E Orangewood Ave, Phoenix, AZ 85020 O: 602-387-2152 E: lvela@msstech.com Revenue Cycle Optimization Client Profile MSS provided Revenue Cycle Optimization Advisory Services to a behavioral health organization in northern Arizona that services tribal members. The organization specializes in substance abuse and mental health, and receives reimbursements from state Medicaid, Arizona Health Care Cost Containment System (AHCCCS). MSS was engaged by the client to assist with two revenue cycyle projects: ï‚· Remediation of Medicaid reimbursements; and ï‚· Claim submission issues. Project Descriptions Medicaid Reimbursement Remediation The remediation of adjusted Medicaid reimbursements involved retroactively applying monies to posted transactions in the Electonic Health Record (EHR) system. During the project, MSS discovered that the EHR system was not automatically applying any AHCCCS payment or denial transactions. The root cause of the problem is a software bug and MSS advised the client to open a support ticket with the vendor to address the issue. As an interim solution, MSS advised the client to modify the entry process and directed reimbursement staff to manually enter all AHCCCS remittances into the EHR system until the vendor has resolved the issue. In preparation for the change, MSS delivered training to the client for the manual entry process, and developed detailed documentation to capture all steps for the interim solution. As a result, the client was able to capture the adjusted payments and increase overall reimbursements. Claim Submissions The client noticed their EHR system was generating claims for patients with a non-billable primary diagnosis, causing AHCCCS to reject the entire claim file. As a result, the client was required to manually remove all rejected claims from the AHCCCS claim file and create a new one before claims could be resubmitted to AHCCCS. This caused unnecessary delays for submitting valid claims. MSS advised the client to modify their claims submission process and adjust their EHR system. MSS documented the new process and trained client staff on how to review patient services suspended under AHCCCS. The new process detailed when to bill if the patient Diagnosis Review is updated to include a billable primary diagnosis on the date of service. If the client determines a patient does not qualify for a billable primary diagnosis on the date of service, then the balance of the service needs to be adjusted to zero. The EHR adjustment included adjusting settings in the Benefit Plans Table and Diagnosis Codes Table so that AHCCCS claims would no longer be generated for patients with a non-billable primary diagnosis. 602-387-2100 | www.msstech.com