How a multibillion-dollar global DME powerhouse slashed front-office RCM labor costs by 80% while increasing client engagement, improving patient experience, and doubling shipments.
Medicare Claim History and Billing Medicare
Reduced labor by 80%
Doubled # of Shipments
When a global DME Supplier found themselves with a 500-patient fulfillment backlog in Q4 of 2019, their Senior Director frantically searched for a solution. With a dedicated RCM team of 100-200 manually logging into the CMS MAC Portals to decipher a patient’s Medicare Same or Similar and SNF Claim History, there seemed to be little hope of catching up, let alone establishing a functional long-term fix. pVerify, Inc. stepped in to quickly create and deploy a best-in-class solution via API, transforming workflow and dramatically increasing efficiencies.
Prior to dispensing a medical device or piece of equipment, DME Suppliers must ensure that a patient’s claim history is clear of any items that are within the same category or of similar scope of function as the ordered item. The applicable RUL (Reasonable Useful Lifetime) for each covered item can vary but is most commonly 5 years. If a Same or Similar item is dispensed and billed during the RUL, the supplier’s claim will be denied, unless additional steps are taken to prove a change in medical condition or loss of the originally supplied item.
Once a supplier confirms a clear Same or Similar history, the DME Supplier must confirm there is not an active Inpatient Stay (SNF) or SNF stay, such as an ongoing rehabilitation stay in the hospital, rehab center, or in a skilled nursing facility and, in some cases, a stay has not occurred within the past 90 calendar days. If the patient is currently in the midst of an SNF stay, or a dispensed item is billed with a DOS within the stay period, the DME claim to Medicare Part B will be denied.
With a dedicated RCM team of 100-200 team members reviewing 500-700 patients per day, the existing process to check a patient’s claim history and existing SNF Admissions functioned as follows:
- Each employee required a login to 2 DME MAC Portals (often creating security, compliance, and operational confusion, as well as new employee training difficulties).
- Each employee was required to reference the correct jurisdiction (by state) and self-identify the correct MAC Portal. Once the correct state/jurisdiction was determined, manual transfer of a patient’s demographic and insurance information took place. The claims history of the individual ordered device, as well as the individual devices from a manually assembled “like-items” group was checked.
- Individual interpretation of the Same or Similar history was used to approve or deny shipment of the device, creating inconsistency and erratic claims success.
- For SNF History, the same manual entry and individual interpretation of the data revealed took place. The error rate for such verifications was higher due to the need for an even greater attention to detail required to validate a patient’s history of SNF episodes or current SNF stay.
During the initial assessment, pVerify identified the need for an automated, timely, and operationally consistent process, requiring minimal human input, while maximizing digital transfer and computerized data interpretation. An existing pVerify Medicare Claim History Solution, Same or Similar History, was the perfect fit to process the DME Supplier’s fulfillment back log and prevent a repeat scenario in the future.
pVerify immediately engaged the customer and created an API connection for the Same or Similar Solution, allowing results to display and be saved to their proprietary patient management and distributor inventory management software. During the integration period the customer was able to immediate utilize pVerify’s SaaS Solution – the pVerify Premier Portal (web interface).
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Solution | Key Points
- pVerify provides DME Supplier Administrators with centralized credentials, relieving the need for hundreds of unique sets of credentials while eliminating the complex and difficult manual scenario which often exists, including quarterly reauthorization. Guesswork involving individual data interpretation has been alleviated and a much leaner staff is able to perform all necessary validations via a centralized and consistent verification system. All assigned Same or Similar and SNF Claims History inquiries can be made via a single user login and are tracked for increased accountability and auditing
- pVerify accepts patient verification data via Batch and API interface – dramatically increasing efficiency and reducing errors for high volume processing, a common requirement for large DME Suppliers.
- pVerify’s proprietary human empowered AI offers the highest level of data inspection and quality control available in the industry.
- Multiple ways to review results: Excel Report, Single PDF, PDF Batches, API Get Call, and single patient on the screen.
- Up-to-date Inpatient Skilled Nursing Facility details to crosscheck patient SNF admissions prior to billing Medicare Part A.
- Data is saved for future references and user can search for the Patient records which were verified in the last 60-75 days, prior to the scheduled data purge.
- Complete Same or Similar 5-year history, 100% complete record every time.
- pVerify’s Same or Similar automatically selects the correct jurisdiction, based on the patient’s state selected in Inquiry.
- Business Logic Interpretation Pass/Fail Flag removes the requirement of manual human analysis by an experienced employee, that is still subject to human error.
With pVerify’s existing Same or Similar APIs and knowledgeable developers, the completion of integrating pVerify into the DME’s workflow was a seamless process.
The responsiveness of the entire team from the relationship manager to the developers has been phenomenal.
Four to six hours of work were reduced to 10-15 minutes and her staffing costs were drastically reduced. With the data entry saved and interpretations flags provided, errors were prevented, and the billing cycle’s ROI was the best it had been in years. With the weight lifted, Global DMEs business doubled in 16 months (during a pandemic) and grew from 10,000-13,000 patients to almost 25,000 pieces of equipment issued in a single month.
Medicare Claim History and Billing
Director of Client Experience
The leader in real-time Healthcare APIs for Eligibility, Claim Status, & DME Solutions championing the highest level of benefits parsing with consumable API endpoints, expert developers to stride forward to refine and maximize benefit reporting, and next-level integration with our Business Rules Engine and scalable and seamless infrastructure including Medical, Dental, and Vision APIs. For DMEs pVerify’s specializes in Medicare Claim History and Billing Medicare SNF Influence.
pVerify is a unique service-oriented healthcare company that focuses on value-added solutions for ambitious health and wellness providers. We shine in the industry for unparalleled hands-on support, excellent development tools, and a pre-and post-development foundation unrivaled as a service-oriented partner – NOT just another technology company.