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RCM InterLink
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RCM InterLink Automation & Integration options:
Claim Status Robot fully automates the process of statusing claims and removes the need for manual follow up. No more spending hours of staff time calling Payors or searching Payors Web sites, or trying to decipher why some claims were denied, and making unproductive touches by wasting time chasing claims that have already been approved for payment.
Claim Status Robot replaces endless question marks with answers. Best of all, you can get the answers delivered inside your EMR RCM workflow system, eliminating technology hassles and streamlining your RCM team’s workflow. Claim Status Robot operates as an intelligence feed, delivering detailed and timely answers on claims status including the precise reason for denial and status of each claim service line item.
Progressive Claim Status Robot
Progressive Claim Status Robot performs non-stop daily continuous monitoring of all claims on Payors Web sites for status changes. As soon as a claim status change is detected RCM InterLink feeds claim status change to EMR and drives EMR workflows in real time.
Progressive Claim Status Robot includes an option to enrich each Claim status with eligibility and TAR status information. It eliminates additional manual tasks and drastically improves denial management, since RCM staff does not have to manually check eligibility and TAR status on Payors Web sites for each denied claim to analyze a reason for denial for possible denial errors.
Progressive Claim Status Robot automates revenue collection and denial management to drastically improve collection, cash flow and optimize EMR RCM work flows and eliminates additional manual tasks.
Only RCM InterLink has this Progressive Claim Status with enrichment by eligibility and TAR status.
Progressive Eligibility Robot
Progressive Eligibility Robot performs non-stop daily/hourly continuous monitoring of all/any patient(s) eligibility on Payors Web sites for eligibility and eligibility changes including co-pays, co-insurance, deductible, deductible remaining, benefit limitations, and benefit limitation remaining accumulators.
As soon as an Eligibility change is detected RCM InterLink feeds changed eligibility information EMR and drives EMR workflows in real time.
Progressive Eligibility Robot eliminates collection problems caused by outdated eligibility information.
Progressive Eligibility Robot optimizes revenue collection and minimizes denials to drastically improve collection, cash flow and optimize EMR RCM work flows and eliminates additional manual tasks.
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Self-Pay Eligibility Robot
Self-Pay Eligibility Robot facilitates time critical recovery of millions of dollars for patients with an outstanding Self pay balance.
For example: Self-Pay Eligibility Robot can verify Medi-Cal eligibility for 100,000 patients with an outstanding Self pay balance within 4 hours.
Progressive Denial Management Automation Framework
RCM InterLink denial management framework supports an implementation of auto-appealing.
RCM InterLink document databases stores detail structured documents (claim status, claims individual service lines status, eligibility for claim status enrichment, TAR status for claim status enrichment) and appeal templates. RCM InterLink Robots and data adapters can be customized to generate appeals and submit them.
RCM InterLink uses Spark database to customize Denial Management Analytics based on Deep Machine Learning AI.
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RCM InterLink Benefits Highlights and ROI
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Healthcare providers can get a significant value from utilizing the RCM InterLink Automation technology in many distinct areas:
1) Reduction of labor resulting in a significant reduction of the cost to collect;
2) Reduction and sometimes elimination of outsourcing AR to third party companies;
3) Reduction of denials;
4) Increased collection;
5) Accelerated cash flow;
6) Reduction of write-offs;
7) Optimization of RCM Business Processes and EMR/HIS workflows.
Use of Progressive Claim Status Robot with status enrichment by eligibility can provide more than 50% cost saving from the current A/R follow-up operational expense.
Use of Progressive Eligibility Robot can provide up to 40% decrease in claims denials.
There is roughly 35 times (35x) the cost incurred for a “collector” or A/R follow-up rep when physically “touching” and working the account vs. the transaction cost from RCM InterLink Claim Status Robot. Analysis example: approximately $0.03 per query vs. the approximate cost of $1.10 to perform manually by a collector.
For high volume of claims the cost difference can be 100 times (100x).
RCM InterLink ROI is 6-8 months maximum.
RCM InterLink Self-Pay Eligibility Robot ROI can be 1-3 days.
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RCM InterLink Claim Status Response Workflow Trigger Rules (Actions Rules)
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By default RCM InterLink returns claim status updates for every claim as soon as claim status was updated.
When a customer wishes to get claim status updates only for claims, which require ACTIONS by RCM staff, then the solution is to configure InterLink Claim Status action rules.
Such Claim Status Action rules can exclude from a response all claims without problems/issues and return only claim status of claims with issues which require a follow up by RCM staff.
Once InterLink Action rules are configured, then RCM InterLink will exclude Claim Status Response records, which do not require actions by RCM staff.
Recommended Exclude rules for Progressive Claim Status Robotic Process Automation:
Exclude from Claim Status Response all claims which have each service line category code match one of category these codes: A1, A2, P1, F1.
When Service Lines information is not available for some claims, then for such claims exclude from Claim Status response claims with category code match one of category these codes: A1, A2, P1, F1.
When a single line item of a claim or a claim has claim status category code different than any codes in the exclude rules, then such claim is included in the claim status response.
When all line items in a claim are excluded, then that claim is excluded from claim status response.
When even one line item in a claim is NOT excluded then that claim is NOT excluded from claim status response.
Claim Status responses can be excluded by any sub-string, Category Code and Status code combination.
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Future State of RCM Automation Now
RCM InterLink workflow manager continuously executes RCM transactions (Eligibility Request, Pre-Authorization, Claim Status, etc.) based on Workflow rules defined in JSON documents in MS Cosmos globally distributed HIPAA compliant fault tolerant database.
RCM InterLink keeps all RCM requests/response transactions as HL7 FHIR compliant JSON documents in MS Azure Cosmos database.
RCM continuous workflow is driven by objects change triggers (objects can be Eligibility, Pre-authorization, Claim Status, etc.)
Workflow rules define objects dependencies and triggers which invoke custom plugins to analyze changes of objects made by responses from payors web sites connectors.
If state change requires to create new dependent request(s) then plugin will create them and RCM InterLink will run work processors on new JSON requests to invoke proper connector to get a response from payor web site(s).
Rules can also define under what conditions and in what format return response documents to a customer (EMR / HIS/ staff).
For example: as x12 document and/or as Excel and/or as PDF and/or as FHIR JSON and/or as EHR proprietary file and/or to invoke API.
RCM InterLink does not use standard screen scraping technology – it’s too unreliable.
RCM InterLink connectors use headless WebKit engine to analyze HTTP responses from Web sites and extract data to update FHIR compliant JSON responses.
RCM InterLink provides REST JSON API to its Web Services and to Cosmos Database containing work in progress and all RCM requests/response documents in JSON format.
All RCM InterLink connectors run continuously for every payor (default configuration is to execute daily requests to each payor web site until trigger determine a condition to stop it).
To get extended information eligibility/claim status from payors (not available from x12 transactions) and to get it on demand and monitor daily for changes we run a pool of concurrent Robotic Process Automation (RPA) services, which can login to payors web sites to extract claim status, eligibility, pre-authorization and other information details.
Since HIPAA and payors do not allow account logins sharing, then in typical case when you may have few concurrent requests to same site each concurrent RPA service must use different login.
So when any RPA service selects payor to query an information, it will select one of many accounts registered with that site (it will select an account unused by any RPA service at the moment).
Special resource manager makes sure than same account is not used by more than one RPA service at the same time.
These emails needed to get notifications for registration and account changes, which require support staff action.
Typical workflow trigger dependencies which drive RCM workflows:
Eligibility => Pre-Authorization => Pre-Authorization status => allow medical procedure => Claim proposal => continuous Eligibility until best time to submit claim => submit Claim = continuous (claim status + eligibility) => Claim line denial => notification & output document with all remarks/notes and requirements from adjudicator.