Sentinel Outpatient Claim Review Tool

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Sentinel Outpatient Claim Review Tool
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Our Outpatient Solution
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The Vision

• Transfer of knowledge and tools from PCS to the
  Hospital
• Empowering your staff to continually improve
  coding and billing
• Training and support throughout the process

Onsite Claims Review Software
Retrospective Review Rebilling
Education Operational Change
PCS
Hospital
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Managing Your Outpatient Business

• Managing Outpatient billing is not the same as
  Inpatient
• Due to volume, distribution of people and
  services, work flow is a critical component
• of any Outpatient management tool

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Managing Your Outpatient Business
Its a continuum.. And a partnership
Workflow Management
Processing is automated AND Claims are
automatically routed AND Triggering events cause
service alerts, reports are distributed
Processing is automated AND Claims are
automatically routed
Processing is automated
User is responsible for creating the file,
running the process, finding erroneous claims and
performing issue analysis
User is responsible for finding erroneous claims
and performing issue analysis
User performs issue analysis
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Phase I Retrospective Review Billing
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Retrospective Review

• Screen the claims and identify potential impact
• Proprietary edits prioritized by likelihood of
  change
• Plus
• OCE/CCI
• LCD/NCDs
• Full grouper/pricer
• Target 60-70 claims for on-site review
• Claims selected from all major service areas with
  potential issues

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Retrospective Review

• On-site review includes
• Medical record
• Detailed charges (CDM)
• Remittance information
• Denial information
• Orders, nursing notes, radiology reports, etc.
• Frequently performed in conjunction with Hospital
  staff
• Enables the staff to perform reviews on other
  claims

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Retrospective Review

• Summary of Findings
• Issues
• Recommendations and potential operational changes
• Target areas for rebilling
• Claims worksheets
• Claims reviewed on-site with initial and
  recommended coding
• All flagged claims for hospital follow-up
• Excel file listing all flagged claims
• To be used as a management tool

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Retrospective Review

• Options
• Purchase the dataset and implement within the
  hospital
• With support and training as needed
• PCS performs on-site/off-site review of claims
• Phone/onsite support as needed to facilitate the
  efficient rebilling of claims
• Hospital personnel enter changes into the
  hospital system for the actual rebill

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Phase II Onsite Screening
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The Opportunity

• Get the Return on Investment
• you deserve.

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The Problem

• Large re-bill jobs too resource-intensive
• No consistent monitoring of outpatient claims
• Outpatient regulations changing fast
• Specialization is now required for the outpatient
  coder
• Electronic communication on an outpatient claim
  is difficult
• No clean outpatient database internally for
  decision support, education, analysis, claim
  review

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PCS Sentinel

• Review every claim, every day
• Review your CDM
• Represents expertise across the entire outpatient
  arena
• Full APC grouper and Phys/Lab/DME fee schedules
• OCE, CCI, LCD and NCD logic included
• Share information easily among medical records,
  finance, patient accounting
• Comprehensive reporting capability available on
  the hospital intranet

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Different, and Better ..

• Customizable screens make your own, or tinker
  with ours!
• Supports pre-bill, post-bill (or both to track
  changes!)
• Supports all payers
• Linked to your CDM for service code
  identification
• Over 2000 screens covering every outpatient
  department
• Screen impact values go beyond telling you whats
  wrong to how much its worth

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Different, and Better ..

• Screens are categorized by type of change (CDM,
  Coding)
• Screens are prioritized (High, Medium, Low) based
  on historic likelihood of change
• Experienced outpatient coding support offered by
  professionally credentialed PCS staff
• Full ad-hoc capability to generate claim lists,
  reports and charts
• Intranet Web-based tool is accessible, yet secure

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PCS Sentinel
An extension of what you already do.A real-time
expert assistant.
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PCS Sentinel Demonstration

• Review claims for accurate billing
• Coding/Billing Compliance
• CDM Issues
• Education
• Departmental Report Suite
• Decision Support
• Denial/Rejection Analysis

Return on Investment
Managing Outpatient Operations
Manage Risk
Education
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Step 1Process Outpatient Claims

• Flexible input format
• 835,837, electronic UB, customized format
• No user interaction required (scheduled task at
  night)
• Work with hospital IT to make the file available
• Question of process
• Use pre-bill data and correct claims before they
  bill
• Use remit data and rebill
• .. Or use both files to track your changes
• Review daily v. weekly/periodically?

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Step 1Process Outpatient Claims
1.
Pre-bill file
Sentinel
BILL DROPS
OR
Review and change
Sentinel
BILL DROPS
2.
Review and change
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Step 2 Review the Results
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Screening Examples

• Range from run of the mill
• Chemotherapy drug reported without administration
• Medical visit on same day as a type T or S
  procedure without modifier 25 when ED visit
• Physical therapy therapeutic exercises reported
  with units of one
• Pacemaker insertion without pacemaker removal
• Flu vaccine administration without the drug
• Blood product without transfusion code

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Screening Examples

• To More Sophisticated
• Transluminal balloon angioplasty peripheral
  artery SI without procedure
• Bladder cancer with cancer drug and incorrect
  administration
• Aredia reported with lower than expected units
• ED claims with inpatient-only procedure missing
  modifier CA
• Brachytherapy surgical procedure without
  interstitial radiation source application

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Architecture

• Intranet (NOT internet), web-based
• Patient data stays within the confines of the
  hospital network
• Access is controlled at two levels
• Hospital network
• PCS product login
• No proprietary software install for the client
• Microsoft-based solution
• Minimal hospital IT maintenance PCS manages
  remotely
• Dedicated server not required

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Drill-down to Understand the Specific Issues
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Step 3 Work the Claims
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Click on a claim from the targeted list to
review detail information
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Make the Appropriate Changes
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and see the effect of any changes
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Reporting Features

• User-friendly
• Robust ad-hoc functionality
• Real-time response
• Hospital-specific, common query needs can be
  saved
• Ad-hoc supported by a vast library of standard
  reports

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Profile by Service Delivery
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Profile by Service Delivery
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Profile by Service Delivery
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• Use Sentinel to
• manage priorities
• Example Focus on procedures
• driving OCE/CCI denials
• and rejections

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.. But only for those CCIs failing the OCE
hospital edit
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Quantify LCD/NCD Exposure
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Ad-hoc Reporting Features

• Output to graph,report, or drill-down list of
  claims

• Select the information you want to analyze

• Optional filter to focus on a set of procedures,
  LCDs, OCEs, Screens, etc.

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Making Sentinel Work for You

• Low barriers to installation
• Minimal/No custom programming by IT
• Sentinel understands standard 837/835/UBV6
  electronic files
• If 835 file is selected a separate file with
  diagnoses information is necessary
• Minimal capital expense, can share a server if
  the hospital prefers
• Modest hardware and software requirements

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Making Sentinel Work for You

• PCS supports the software remotely
• High level of security
• INTRANET application
• Network level, Server controls
• Sentinel login controls, role-based model of
  security,
• username/password encryption

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Making Sentinel Work for You

• Increases efficiency in what you ALREADY do, not
  another project
• Support - Were committed to your success!
• On-site/Con-calls/Technical and Coding Support
  open line of communication
• Tailoring/adding screens
• Profile reports focus review efforts on the most
  significant opportunity

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Making Sentinel Work for You

• Using it Every Day/Every Week
• Data is automatically accumulating without any
  user intervention
• Intuitive user interface
• Detailed screen descriptions
• Extensive drill-down functionality to get at the
  underlying claims
• Functionality to facilitate sharing across the
  stakeholder community (saving/email reports,
  claim lists, intranet access)

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Making Sentinel Work for You

• Measuring ROI
• Use Sentinel to support claim billing
• Sentinel reports before v. after at a claim
  level
• CDM Maintenance
• Sentinel screens identify coding and CDM
  opportunity
• Coding Education
• Compliance
• Denial Management
• Management reports, Decision Support
• by service area, full ad-hoc capability

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Getting Up and Running with Sentinel
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PCS Sentinel

• Comprehensive outpatient claims review
• Identification of CDM, Coding Revenue Cycle
  Opportunities
• Extensive ad-hoc reporting capabilities
• Experience-based logic
• APC grouper, OCE/CCI/LCD/NCD edits included
• Integration of coding and billing data
• Intuitive, user-friendly format
• Secure, yet accessible

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Discussion Next Steps