Case Study

Adventist Health Streamlines Claims Management

“SSI has provided superior support, and they have helped us make all of the major transitions in healthcare and claims”

07.01.15 • Case Study

Healthcare billing and claims handing has become increasingly complex. With the transition to Version 5010 of the HIPAA electronic transaction standards, the expansion of billing codes under ICD-10, and the ever changing requirements of insurance companies and the Centers for Medicare and Medicaid Services (CMS), it can be nearly impossible for providers to keep up.

For Adventist Health System (AHS), an Altamonte Springs, Fla.-based system that operates 45 hospitals, accurate and efficient claims handling is a critical part of both ensuring patients receive the best care possible, and maintaining the financial health of the organization. AHS has deployed a full suite of revenue cycle management solutions, including EDI, billing, and claims management from The SSI Group, LLC (SSI). Using these tools, AHS has accelerated accounts receivable (A/R) processes and decreased the number of claim denials system wide.

Over the past several years, AHS has converted 29 of its hospitals and home health agencies to the SSI product suite. In addition to improving claims accuracy and billing processes, SSI has also provided assistance in meeting new payer and CMS requirements.

“SSI has provided superior support, and they have helped us make all of the major transitions in healthcare and claims,” says Debbie Lare, Patient Financial Services Assistant Director at AHS. “SSI is a comprehensive product with strong edits throughout the claims process. The solutions take us from claim filing all the way to the payment file, with processes in between to support those activities.”

Claims Edits Are Critical

When AHS generates claims in its internal systems, the claims are interfaced with SSl’s billing solution for electronic editing, validation and transmission of claims. “The heart of the system is really the editing, and SSI does a great job with those edits,” Lare says. “They stay on top of all of the updates from CMS and commercial payers so they can implement those changes. If anything is found that could cause a problem or might indicate a difference in interpretation, SSI quickly resolves those within days or even hours.”
Once the edits are complete, SSI transmits the claims to the payers. AHS can then use SSI to post who was billed, and how much was billed. AHS uses the SSl’s Confirmation Note Posting module for reports that come back from the payer directly upon claims submission, and for ANSI 276/277 health care claim status requests and response transactions. The Claims Status Module (CCSM) manages Medicare claims and tracks claims to commercial payers using the 276 and 277 claims status transactions.

“Posting the 277 responses from the payers keeps us up-to-date with the current status of our claims,” Lare says.

“They stay on top of all of the updates from CMS and commercial payers so they can implement those changes. If anything is found that could cause a problem or might indicate a difference in interpretation, SSI quickly resolves those within days or even hours.”

Once the claim has been adjudicated, the 835 Electronic Remittance Advice transactions can be posted into SSI and the AHS host system. “That same 835 is posted into the SSI Billing product to begin the advanced secondary billing processes,” Lare says.

SSl’s EDI Tracker module is used by staff to confirm claims, review rejection reports, and for daily accounts receivable balancing.

Thanks to the SSI solution, AHS is able to closely monitor claims status and ensure that claims are not denied. “With the edits in place, SSI provides us with a very high claim rate,” Lare says. “We have a very high validation rate. When you have solid edits, then your days in accounts receivable are lower. The process is much faster if you send out clean claims in the first place.”

Not only does the system provide strong edits, but AHS is able to run reports on those edits to root out the underlying causes of any claims problems. “The reports are easy to read, and they help you drill down and determine what documentation or coding issues might need to be corrected,” Lare says. ‘You can sort them so you can see what fixes will have the biggest impact.”

That allows AHS to go back to the source of the errors. “You can go back to those departments and work with staff, because you have very specific examples of what needs to be updated or reviewed,” Lare says. “Or we can work with those teams to determine if something needs to be adjusted on the SSI side.”

SSI has done more for AHS than provide software; the company has also helped manage the transition to Version 5010 and the upcoming ICD-10 coding. SSI provides front-end testing for ICD-10, and has helped AHS ensure that the payers it works with are able to take those codes and move them through to acknowledgement.

“SSI has done more for AHS than provide software; the company has also helped manage the transition to Version 5010 and the upcoming ICD-10 coding. SSI provides front-end testing for ICD-10”, and has helped AHS ensure that the payers it works with are able to take those codes and move them through to acknowledgement.

“SSI has done more for AHS than provide software; the company has also helped manage the transition to Version 5010 and the upcoming ICD-10 coding. SSI provides front-end testing for ICD-10”

SSI is also assisting AHS with its latest transition: converting its billing offices to the Cerner Patient Accounting product. With SSl’s help, AHS has been able to quickly test changes associated with the new system to ensure billing remains accurate. SSI was also able to adapt to new file formats required by Cerner.

“SSI helped us through the conversion of our accounts receivable system at three business offices so far, and there are six more to go,” Lare says. “SSl’s support and flexibility has been phenomenal.” With SSl’s support, Lare is confident that AHS can handle any new changes or requirements. “They provide us with a true revenue cycle management solution,” Lare says. “We have a true partnership with them, and their support has been a key part of our success with the solution since day one.”

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