Reimbursement Services Workflow
(Typical Scenario from Customer to Healthcare Automation)

Customer Site:

1. Call or fax for a new Referral is received
2. Intake staff takes referral information and verified insurance
1. If there is coverage - all departments are notified to get started on new patient
2. If there is not coverage - Management staff is contacted to determine if patient will be accepted regardless of coverage
3. Pharmacist obtains orders from MD
4. Nurse makes arrangements for in-house nursing staff or agency to meet with patient if applicable
5. Warehouse schedules initial delivery or arranges for other means of delivery via courier or delivery service
6. Intake prepares all patient documentation required for JCAHO, HIPAA, billing, etc. to go with delivery
7. Intake/Nursing/Pharmacy prepares CMN and/or RX for MD's signature
8. Delivery made to patient
9. Delivery confirmed and posted in the software

Reimbursement Center Services Begin:

1. First thing in the a.m. the batch that contains new charges are reviewed for:
   1. Based on insurance - which charges can be billed today and which need to be held until a later date. Examples of why charges cannot be billed right away: payor requires one bill per month.
   1. Based on whether or not they can be billed they are moved in the appropriate batches
   2. Batches are divided by payor or by alpha split depending on the size of the account
2. Patient activity report is generated to determine if there are any new patients. All new patients are QA'd for the following items:
1. Review of insurance information to ensure all required fields are completed
2. All HIPAA related fields are complete
3. A contract is assigned and per diem is set up (if applicable)
4. A valid ICD-9 code is assigned
5. The Physician assigned has a UPIN number
6. Any missing information is reported to the customer via e-mail
3. Patient Records
1. Each new patient has an individual file that is maintained separately by customer
2. All documentation received and claims are maintained in the patient file
3. Healthcare Automation maintains the patient record until the patient is inactive and has a zero balance. Once this is achieved, the patient record is returned to the customer for long-term storage
4. Creating claims/Billing:
1. Billing staff prints an edit report and validates the charges by reviewing the following items:
1. Is there a contract assigned
2. What is the service dates (assigned by the Pharmacy) and are they contiguous to the last packing slip billed for this patient
3. If there are gaps between bills, was the patient hospitalized or temporarily off service OR are the service dates wrong
4. Does the amount of drug shipped match the RX on file
5. Does the net revenue exceed the actual cost
6. What is the history of this patient's accounts receivable and should we continue to bill if there is a potential problem
2. Any billing modifications are made such as:
1. Modifying service dates
2. Changing drug formats to meet payor-specific requirements
3. Including or excluding items in a per diem
3. Claims are batch by payor and sent either:
1. Electronically in a HIPAA-compliant format (preferable)
2. Paper (when home infusion claims are not accepted electronically or when paper attachments are required)
4. Claim notes are logged for future follow up by collection team
5. Collection Activity
1. Each collector is assigned a portion of the aging by either alpha split or payor split - depending upon the size of the account
2. Collectors will follow up on accounts in 30-day intervals until the claim is paid. Follow up is done by either:
1. Checking claim status on-line
2. Checking claim status via telephone
3. Patient copay and deductible bills are sent once per month to eliminate inundating the patient with bills
4. Any claims that are not paid in full are examined in detail to determine how to resolve the balance by one of the following actions:
1. If not paid per the contract - file an appeal
2. If there is no contract in place - review payment determine if drug was paid at a minimum of AWP and supplies at a minimum amount per the account. If this minimum is not reached - file an appeal
3. If the balance is the patient's responsibility - transfer to self pay and bill the patient
4. If the balance needs to be adjusted - a form requiring management approval is completed and turned into the Manager.
1. Adjustments under $500 are approved and processed by the Manager
2. Adjustments over $500 are sent to the customer for approval and then processed by the Manager
5. All documentation and paper claims are maintained in the patient record room for easy access and retrieval
6. Cash Application
1. Cash application team consistently applies and posts cash within 24-48 hours of receipt
2. All denials are also posted for future reference and tracking
3. All claims that are not paid at 100% are copied and distributed to the collection team to be resolved within 7 days
4. All cash receipts are stored by customer by deposit date
5. Copies of EOBs are only filed in the patient's medical record if the claim was not paid in full and additional action was required
7. Additional Services:
1. Healthcare Automation will arrange teleconferences or on-site meetings with any payors that we have continual problems receiving the appropriate payment
2. To ensure the customer and Healthcare Automation are on the same page, monthly conference calls are recommended to review prior month's results and discuss any issues on either side. (Weekly calls are recommended for the first month or two.)
3. We have on-site Medicare experts that can assist you in determining if your patients qualify for Medicare reimbursement
4. Medicare allowables are updated and maintained each year when distributed from Medicare
5. If you are unsure about coverage for a therapy, one of our insurance specialists can re-verify the insurance.
6. We are active members of NHIA and other organizations to ensure that you and us remain current in all reimbursement areas
7. We close each month-end within your specified time-frame but in no event later than the 4th business day unless you request the deadline is extended.

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