Practice Management Software Moves Beyond Bean Counting

It’s not the data that are necessarily important—it’s what you do with that data, and practices are discovering more ways to use their management resources intelligently.

As cardiology practices look for answers on how to keep pace with internal and external reporting requirements, shifting regulatory requirements and growing financial pressures, they are looking for ways to transform the revenue cycle with improved data management and cash collection, and by maximizing reimbursements—all while trying to keep costs under control. Today’s practice management (PM) software has moved beyond basic revenue cycle management to help practices work smarter, faster and more efficiently.

Practices are looking for software that can provide a full complement of clinical, administrative, business and management functions. Additionally, PM software increases its value when it can be integrated with electronic medical records (EMRs), business intelligence, electronic data services and quality reporting tools. From tools that help organizations find uncollected revenue and days on accounts receivable, and systems that track appointments and patient flow to payor mismatch reports, a variety of software options is available to help administrators tackle the biggest PM challenges.

Collecting for services rendered

Revenue lost through unbilled inventory, unclean claims, denials and rejections threatens a practice’s bottom line. Accurately capturing patient demographics, insurance information, pre-authorization status and existing conditions prior to performing procedures with PM software can only help to minimize lost revenues. If the front office can capture these data correctly, it can eliminate redundant work processes on the back-end and ultimately, drive inefficiency out of the office.

According to Ann Honeycutt, CEO, Virginia Cardiovascular Specialists in Richmond, with nine offices covering ten hospitals, moving things from the back-end to the front desk ensured information was getting collected the first time around, instead of spending more resources reworking claims. The practice implemented athenahealth’s athenaCollector, a web-based PM system, to do a better job at collecting its revenue for its physicians services, as well as transform how they did their work and processes.

Prior to athenaCollector, claims would be denied for eligibility, referral/authorizations, and medical records and the business office would re-work claims to provide the necessary information. A corrected claim or appeal would be sent to the payor, resulting in more claims processing delays.

To accommodate the new system, the practice completely changed its front-end office workflow. The software’s front-end Rules Engine and Auto-Eligibility were key components to pushing work back to the front desk instead of the billing office, since claims are held prior to the billing cycle for such denials, according to Robin Scott, director of the business office, who says the front office staff trained for weeks learning how to work out reasons for denials on the front-end before a claim went out the door.

Initially, athenaCollector costs about $2,000 and once the practice is on athenahealth’s web-based network, the software company takes a percentage of net collections based on type and size of practice. Honeycutt says that they have seen their return on investment. “Our collection percentage is up 1 percent since we started with athena, which is significant money,” she adds, attributing the increase in collections also to staying on top of underpaid claims.

Two sources of claims underpayments come from the payor accessing inappropriate discounts or not following the terms of the contract. Honeycutt says that athenaCollector’s ability to generate a monthly payor mismatch report to make sure new contracts are getting paid according to schedule is a major benefit of the software. The practice was able to completely recoup the software’s cost within the first year of go-live, with the overall collection rate increasing from 44 percent of charges to 45.2 percent. “In a declining fee schedule environment, a net 1 percent gain is extraordinary,” she says.

Honeycutt says they can track practice activity and claims in real time through athenCollector’s Workflow Dashboard, which allows her to see, understand and manage practice operations up to the minute, from anywhere. She monitors clinic productivity to see how well CT is performing, how far out echoes or nuclear slots are, and to gauge the use of the outpatient cath lab—all to make adjustments when and where needed, as opposed to getting lengthy monthly productivity statements.

Additionally, hold and eligibility buckets are all on a dashboard for staff to view workloads for claims holding, no-shows and rescheduled appointments. “Every day I can look at this to see what is waiting in the buckets and catch work that is pending or not done,” she concludes.

Quality reporting to boost reimbursements

Quality reporting is an interesting and complex initiative, says Cathleen Biga, president and CEO of Cardiovascular Management of Illinois, a practice management company. Insurance companies use claims data but quality data has to come from both PM software and the EMR, to know what was billed and what was documented in the EMR.

“This is where a lot of people may not do as well with Physician Quality Reporting Initiative (PQRI), since you have to have billing and the EMR tweaked for the initiative, for things such as outpatient consult codes,” Biga says.

Many practices are participating in quality reporting and pay-for-performance (P4P) initiatives to maximize reimbursements. Honeycutt confirms her practice’s need to document quality metrics. “AthenaCollector helped to ensure that our physician’s work and care were documented and indicators were completed prior to submitting a claim. We received a maximum award for the six months, which is approximately 1.5 percent of our Medicare receipt for six months,” she says.

In 2008, a Centers for Medicare & Medicaid Services (CMS) P4P demonstration project resulted in extra savings of $16.7 million for 10 large group practices across the U.S., for reporting quality measures related to patients with diabetes, coronary artery disease and congestive heart failure. The demonstration was one of the agency’s value-based purchasing (VBP) initiatives designed to tie Medicare payments to performance on healthcare cost and quality measures.

Under another VBP initiative, the PQRI, physicians can receive a 1.5 percent increase in Medicare reimbursement for reporting the same quality measures. As part of athenaNet, athenahealth’s centrally hosted, on-demand PM and EMR service network, all nine offices of Virginia Cardiovascular Specialists were able to leverage the PQRI requirements, since the measures were built directly into the office workflow.

To participate in PQRI, athenaCollector built measures for Virginia Cardiovascular Specialists, which in turn, chose what measures to report, opting for measures five, six and eight. Measures five and eight are concerned with ejection fraction; measure six is antiplatelet therapy.  

Scott says they added a small corner to patient billing slips that physicians, on evaluation and management (E&M) encounters, would complete if the ejection fraction was under 40 percent or over 40 percent, or if they were on antiplatelet therapy based on a diagnosis code. By putting this on the billing slip at charge entry, the PM’s Rules Engine would pop up and prompt, based on the diagnosis and E&M code, the staff to input the additional related CPT codes for the claim to drop.

According to Honeycutt, the challenge continues to be balancing the ROI that the practice has seen, with the financing of the software, to ensure they are getting the value necessary for physicians in an era where reimbursement is targeted to go down, year after year. “We need to make sure our docs are efficient and we need to be efficient in making sure that we get paid appropriately,” she concludes.

Connecting billing & clinical systems

Healthcare consumerism and transparency are bringing about an awareness of the need to adopt next-generation revenue-cycle systems, to have complete integration between revenue-cycle systems and clinical systems.

West Michigan Heart in Grand Rapids, Mich., chose a combined solution of PM and EMR software to provide the infrastructure to solve operations issues, quality maintenance and reporting issues and to assist with capacity management.

PM software impacts the billing and registration and keeps track of who within the practice needs access to that information, according to Suzette Jaskie, CEO of West Michigan. From a capacity management scenario, many cardiology practices have ancillary services, such as stress tests or echoes. PM software allows ancillary services to be monitored and scheduled. By having access to the clinical information within the EMR, however, staff can not only schedule those, but also look at data resulting from those tests and the orders that might result from having the first test. Before deploying platform-independent, client-server PM capabilities integrated with EMR software from NextGen Healthcare Information Systems, West Michigan did not have this capability. Jaskie says they were spending time and money on people and systems to get the two sides of the business properly connected. NextGen’s PM component comes standard with the EMR package.

Take the drug Coumadin for example. To effectively manage the patient taking the medication requires hands on management, from the get-go. Previously, Coumadin information on a patient existed in a separate database from the medical record. Every time staff needed something about that patient’s history or billing information related to Coumadin, they had to do a separate retrieval from the Coumadin database to manage care. They no longer have to do that.

“From a quality perspective, we are managing data so much more appropriately, easily and accurately by using PM software with the EMR that we think we will see a greater impact on our operational effectiveness,” Jaskie says.

There are three immediate ways in which West Michigan has seen an ROI by choosing PM software that is integrated with an EMR. The first is simply by having less foot traffic for coordinating data. The second is in terms of operational efficiencies. “We geared our installation to pre-planning in operational efficiencies to reduce the number of steps to do things,” Jaskie says, adding they have seen a 47 percent increase in productivity. The third is the absence of losing revenue via better management of the order or billing data. An example is the ability to better ensure that patients who are supposed to have an echo actually have that echo ordered. “Being able to manage those data sets and the orders that come out of the encounters is critical to the bottom line,” she says.

Jaskie adds that West Michigan is “just getting its toe wet with PQRI,” however, she acknowledges that NextGen’s integrated PM/EMR solution has an integrated PQRI reporting tool that is embedded into the existing workflow, which pulls data and sends to PQRI.

Big and small

No matter what the practice size, PM software is proving its value in its ability to streamline and automate processes to keep expenses down. Even for a three physician practice like South Beach Preventive Cardiology in Miami Beach, Fla.

By using Intergy PM software from Sage Software, integrated with Sage’s Intergy EMR, the practice goes beyond the basics of scheduling, registration and complete billing. With Intergy PM, they can track the patient arrival time and it is immediately flagged in the EMR as well, tying it to patient flow, according to Marynell Lubinski, practice administrator.  

Prior to the automated features of Intergy PM, the small practice spent hours on the phone or online every day, obtaining insurance eligibility, deductibles and copays. Now, it is an automated function. Two days out, the system connects to the insurance companies and auto verifies eligibility. The only time they have to get on the phone or online now is when the software is unable to verify patient eligibility. “Instead of hours, it now takes minutes,” Lubinski says.

When they brought the system in-house, instead of using a third-party billing company, Lubinski says they decreased the number of accounts receivable days by 15 percent, without adding any staff.

Another important functionality of the PM software for the small practice is the electronic remittance. Until the last few years, she explains, they had to deal with insurance remittances coming back in paper format, which was time-consuming to post in the system while looking for errors. Now, 75 percent of remittances come in electronically and they are automatically processed and posted to all pertinent accounts. “We can have a check for $20,000 for 50 patients and it can post the money to each individual account, automatically,” Lubinski says. If the software is unable to match funds to correct accounts, it holds it aside and flags it for the user.

Costs for Sage Intergy vary based on the number of practitioners and options chosen. It is available both in a client/server model and a subscription-based model. The subscription-based model is available at a lower upfront cost with a predictable monthly fee based on the number of providers licensed on the system.

Looking ahead

Irrespective of size and practice management software vendor, it is evident that PM automation is a key to fiscal success for many cardiology practices. The software is critical to managing the day-to-day operations of the practice that impact the bottom line.

“The only way you can run your business is through analyzing the data. The old software of just patient demographics and scheduling is out—new systems have to be sophisticated and integrated with EMR and must be sophisticated with how they interact with clearinghouse,” Biga comments.

Clearly, challenges still lie ahead for the practice management software market. Practices of all sizes are going to have their hands full with the ICD-10-CM conversion coming and now is the time to figure that out with your software vendor, Biga adds.  

According to a survey of medical practices conducted by the Medical Group Management Association (MGMA), 95 percent of respondents said the transition to the ICD-10 code set would require them to upgrade or replace their practice management software. Nearly two-thirds expected to have to buy code-selection software (see News and Views).