Business Solutions

DIY RCM for HME

Not every provider is at a point where they can outsource their revenue cycle management, but that doesn’t mean they can afford to skip RCM entirely. What tools do providers have on-hand to build their own RCM solutions?

• By Holly J. Wagner
• Mar 01, 2020

There are plenty of companies waiting to take on your revenue cycle management (RCM) for a fee, and that can let you offload a lot of headaches. But if you think that’s too expensive, or just prefer to do it in house, many of the tools are already built into the software that runs your business.

“More than ever, HME providers need software with the right infrastructure and abilities. The best software enables the user to create billing requirements, design workflows that direct accurate processing, measure outcomes including human performance, and qualify revenue prior to billing,” says HME Software Sales Consultant, Gail Turner, of TIMS Software by Computers Unlimited. “Additionally, providers can leverage the integration capabilities of their systems. Less manual labor and more automation is key for a reason — it’s effi cient and provides needed insights, lowering costs and allowing for informed, data-driven business decisions.”

Your files and computers are brimming with information about your patients, referrers, suppliers, inventory and market. With the right tools and someone focused on using them, your software should be able to see all of that information and generate a variety of reports that can help you find and smooth out the bumps that may be slowing your workflow and cash flow.

Effective reporting can’t be done willy-nilly. Someone on staff, most likely in your accounting department, should be monitoring trends within and outside of your business over the long term. Your accounting folks are already managing profit and loss reports, sales figures, claims figures and other basic information. But it’s also likely that your system can do so much more.

“As we’ve evolved, we see that more clients want to get into the data themselves,” says Lisa Anderson, vice president of marketing at Universal Software Solutions. “Most standard DME systems are going to offer you standard reports. The ones that have been around for a long time have more — hundreds of standard reports — and you don’t have to pay extra for that.”

If you don’t know how to use the included features, your software support is just a phone call away. If the tools you have won’t answer your questions, most major vendors offer add-on modules for specific tasks and can customdesign reports for their clients. Costs will vary with complexity, but may be lower than you think. It’s worth asking.

It’s worth noting that pharmacists have become much more accustomed to fully electronic systems — and their consequential instant authorizations — because of CMS pressure for physicians, facilities and pharmacies to adopt Electronic Health Records (EHR). The DME world lags in large part because there’s been no institutional incentive or penalty — but that doesn’t mean there’s no benefit.

DME office software is built to let you enter information manually or receive it digitally, by fax or electronic ordering. Most software has built-in cues to make sure required fields are filled out when you enter an order, so you can be sure that instructions and authorizations are filed with the prescription. Those collateral items can be scanned and uploaded or transmitted via an e-prescription system. The software’s billing capability should let you send the claim and documentation through to payers for prior authorizations and payment. (NOTE: If you’re a pharmacy, your software provider probably has an add-on DME module available.)

Automating your information unlocks a huge variety of reporting capabilities that can give you real-time insights into how your business is running, often in a couple of keystrokes. Most current software includes dashboards to bring up information easily on a computer screen, as well as reporting capabilities to generate reports by advance scheduling or on-demand. You can pull reports on just about anything — referrals, transactions, products, patients, labor, inventory, orders, claims — you name it.

For example, if you think placing and filling orders is taking too long, you can look up how long it’s taking and drill in by product to see if any particular item or category is lagging, which might mean a supplier or inventory issue. You can check by payer, to see if a payer is rejecting certain orders like a particular item or code. Or report by referral, to see if orders from some referrals are taking longer to fill than others — a sign that a source might not be sending all the required documentation with prescriptions.

With DME-specific software, “There is a simple dashboard, you can look at one screen and it will show you the top 10 physicians that are sending you referrals that have incomplete documentation,” Anderson says. “It’s very clear what they need to do, and their office managers love that.”

GET IT RIGHT FROM THE START

If you think (RCM) starts with billing, you’re doing it wrong. Intake is where you take control of your patient records and documentation. The first goal is a clean claim, and that means perfect documentation. Manual, and especially analog, documentation is sooo last century, not least because it’s cumbersome and there are so many opportunities for errors. It’s probably easiest to have one system that handles all your major business functions, but it’s essential for whatever systems you are running to talk to each other — to be interoperable.

“RCM really starts at intake. The referral sends you a fax with all the pertinent information, now you are creating an order within the system, you are populating the system with the order. You might have to schedule the delivery, and it shows you all the necessary information. You have to get a prior authorization from a payer; you are getting all that documentation together and all that pertinent information so now your claim is ready to send to the payer,” says Sunil Krishnan, vice president of RCM at Brightree. “Once it generates invoices, now it is generating revenue in your system. As an order, it is not revenue yet. The invoice becomes revenue.”

Intake is the parallel process of gathering information to get the best product fit for the patient, records to satisfy payers, and information that has its own value. Would the patient rather be contacted by phone, text or email? Would they prefer pickup or delivery for future orders? Are they managing conditions other than what today’s prescription is for? Does the patient feel lost or unsupported about their condition(s)? Those bits of information may all be opportunities for marketing and loyalty — more on that in a minute. First, a bit on getting paid.

STAKE YOUR CLAIMS

“We all know getting paid is one of the headaches of the HME industry — reprocessing is labor-intensive and expensive. The right compliance-centric software helps providers avoid preventable errors, producing revenue-qualifying orders the first time,” Turner says.

Pharmacists have become accustomed to getting instant authorization for medications. DMEs have been used to a sometimes lengthy back-and-forth about what’s covered, who’s paying and how much. Good billing software gets right in there to speed those authorizations and your fill times.

“The biggest trend you are reporting is how many claims are paying at the first pass. You want to be driving that number as close to 100 percent as possible,” Anderson says, adding, “The 2 percent that still deny will take a ton of work.“

With electronic submissions, your claim goes to a clearinghouse “Once it gets to the payer and they process it, you are able to get approval electronically. It tells you, you will receive x dollars of cash and x dollars of adjustment. It tells what information you might be missing,” Krishnan says. “The clearinghouse will tell you if it will reject the claim or send it on to the payer. You are able to fix it and now it goes to the payer after the first check.”

The tools allow you to self-audit your business from beginning to end. Spotting problem trends and addressing them one at a time is the key to strengthening and building your business.

“Even if you’re only dealing with a small percent of claim denials, someone has to be watching the trends at all times. There is no profit margin once a claim rejects,” Anderson says. “If you cannot quickly and easily spot denial trends, your revenue results will never change. Whether you prefer a dashboard or a report, it must be robust and frequent.”

PATIENT RELATIONSHIPS

The information you collect at intake isn’t just for the claim you’re filing today, it‘s an opportunity to start a dialogue with the patient and learn how to build that relationship. The email addresses you collect could be the beginning of an email marketing campaign. Patient comments about information they lack can guide your choice of content for your website or email campaigns.

“With all the data centralized in one place, you have all this demographic information. You have the products that are being used. You can now actually do targeted marketing on that level of information,” Krishnan says. “I can target certain areas because they have heavier consumption of CPAPS and supplies.”

Knowing how patients want to interact should help you give them reasons to turn to you. You can send health tips and promote new products or special offers in email campaigns; post things like support group links, healthy recipes and community resources on your website; take advantage of mobile contact apps that send medication and refill reminders.

Comprehensive software lets you monitor your in-stock inventory and distributor orders. If a patient calls to ask where their order is or when it will arrive, you have an answer at your fingertips. There are apps to send a photo of the delivery driver the customer should expect, for trust and security reasons.

“It might still be sitting with the primary payer. You are able to have a more educated conversation with the patient and provide real-time of where the order is and the status of the billing,” Krishnan says. “Once the patient has had a great experience, hopefully that becomes a lifetime patient or one who will refer you to others.”

UPPING YOUR REFERRAL GAME

Some vendors have a specific niche, and their systems should work with whatever you’re already doing. PlayMaker Health started as a customer relationship product, but has evolved to be a DME sales force manager as well. PlayMaker offers a web- and mobile-based product that combines comprehensive DME claims data that can tell you what products are being sold and who the sellers and referrers are within a given area, right down to product codes and contact information.

A PlayMaker subscriber can call up a map that will show every referral for a specific product or category within an area the user defines — such as a 20-mile radius around the user’s business — and it will show what percentage of each referrer’s business is going to the user and to their individual competitors. That can help sales reps focus efforts on opportunities to sway more referrals, or show you an unfilled need in your area.

Within your business, PlayMaker has fields for referrer information that includes not just contacts and appointments, but personal schmoozing details like their spouses’ and children’s names. There are fields for notes of interactions. Since the platform is mobile as well as online, sales staff can call up details just minutes before a visit, then update them on the way out. Managers can then review and analyze that data.

HEADING OFF TROUBLE

A solid DME system keeps track of all your inventory, transactions and documentation, which helps with ongoing tax accounting. Tracking transactions from start to finish also makes it easy to pull up records in the event of an audit.

“All audits are trying to catch you out for your documentation. The majority of people that fail an audit, it’s because they can’t find it. They can’t get it together in a timely fashion,” Anderson says. “In terms of what your data can do for you, [a DME-specific system] really would allow you to do some pre-auditing yourself before auditors come in and shut your business down. It will show where your system and staff are falling down, where you can make those processes a little more efficient.”

WHAT DOES IT TAKE?

Managing your own RCM isn’t free. It takes the right tools. Most DME software is offered on a site-license agreement, which allows a specified number of users to access the programs. That usually means a monthly fee that depends on the software capabilities and the number of users. There will be some staff training time if they are new to the software.

You also have to consider where your data will reside. There’s a range of solutions from hard storage on your premises to the increasingly popular cloud. Your software provider can help you decide which option makes the most sense for your business.

“To add on a report builder or a data warehouse, there will be an additional cost,” Anderson says. “If your rep says there’s not, look over your contract.”

OVERLOAD! LET SOMEONE ELSE DO IT…

If all of this sounds like more tech anxiety than your business can handle, outsourcing is always an option. With that choice, the vendor essentially takes over your billing system from orders to collections, and you can monitor how everything is going. You’re still in control of your business and day-to-day operations, but someone else is managing most of your claims and billing.

Either way, you can’t afford to ignore all that data buried in your back office. “Providers that are really winning with customers have smoothed out that process,” Anderson says. “The key to that is looking at how it is already going.”

This article originally appeared in the March 2020 issue of HME Business.