Business Solutions
DIY RCM for HME
Not every provider is at a point where they can outsource their revenue cycle management, but that doesn’t mean they can afford to skip RCM entirely. What tools do providers have on-hand to build their own RCM solutions?
- By Holly J. Wagner
- Mar 01, 2020
There are plenty of companies waiting to take on your revenue cycle management (RCM) for
a fee, and that can let you offload a lot of headaches. But if you think that’s too expensive,
or just prefer to do it in house, many of the tools are already built into the software that
runs your business.
“More than ever, HME providers need software with the right infrastructure and abilities. The
best software enables the user to create billing requirements, design workflows that direct accurate
processing, measure outcomes including human performance, and qualify revenue prior to
billing,” says HME Software Sales Consultant, Gail Turner, of TIMS Software by Computers Unlimited.
“Additionally, providers can leverage the integration capabilities of their systems. Less manual labor
and more automation is key for a reason — it’s effi cient and provides needed insights, lowering costs
and allowing for informed, data-driven business decisions.”
Your files and computers are brimming with information about your patients, referrers, suppliers,
inventory and market. With the right tools and someone focused on using them, your software
should be able to see all of that information and generate a variety of reports that can help you find
and smooth out the bumps that may be slowing your workflow and cash flow.
Effective reporting can’t be done willy-nilly. Someone on staff, most likely in your accounting
department, should be monitoring trends within and outside of your business over the long term. Your accounting folks are already managing
profit and loss reports, sales figures, claims
figures and other basic information. But it’s also
likely that your system can do so much more.
“As we’ve evolved, we see that more clients
want to get into the data themselves,” says Lisa
Anderson, vice president of marketing at Universal
Software Solutions. “Most standard DME systems
are going to offer you standard reports. The ones
that have been around for a long time have more
— hundreds of standard reports — and you don’t
have to pay extra for that.”
If you don’t know how to use the included
features, your software support is just a phone
call away. If the tools you have won’t answer your
questions, most major vendors offer add-on
modules for specific tasks and can customdesign
reports for their clients. Costs will vary
with complexity, but may be lower than you
think. It’s worth asking.
It’s worth noting that pharmacists have
become much more accustomed to fully electronic
systems — and their consequential instant
authorizations — because of CMS pressure for
physicians, facilities and pharmacies to adopt
Electronic Health Records (EHR). The DME world
lags in large part because there’s been no institutional
incentive or penalty — but that doesn’t
mean there’s no benefit.
DME office software is built to let you enter
information manually or receive it digitally, by
fax or electronic ordering. Most software has
built-in cues to make sure required fields are
filled out when you enter an order, so you can
be sure that instructions and authorizations are
filed with the prescription. Those collateral items
can be scanned and uploaded or transmitted
via an e-prescription system. The software’s
billing capability should let you send the claim
and documentation through to payers for prior
authorizations and payment. (NOTE: If you’re a
pharmacy, your software provider probably has
an add-on DME module available.)
Automating your information unlocks a huge
variety of reporting capabilities that can give
you real-time insights into how your business is
running, often in a couple of keystrokes. Most
current software includes dashboards to bring
up information easily on a computer screen, as
well as reporting capabilities to generate reports
by advance scheduling or on-demand. You can
pull reports on just about anything — referrals,
transactions, products, patients, labor, inventory,
orders, claims — you name it.
For example, if you think placing and filling
orders is taking too long, you can look up how
long it’s taking and drill in by product to see
if any particular item or category is lagging,
which might mean a supplier or inventory issue.
You can check by payer, to see if a payer is
rejecting certain orders like a particular item
or code. Or report by referral, to see if orders
from some referrals are taking longer to fill
than others — a sign that a source might not be
sending all the required documentation with
prescriptions.
With DME-specific software, “There is a simple
dashboard, you can look at one screen and it will
show you the top 10 physicians that are sending
you referrals that have incomplete documentation,”
Anderson says. “It’s very clear what they
need to do, and their office managers love that.”
GET IT RIGHT FROM THE START
If you think (RCM) starts with billing, you’re doing
it wrong. Intake is where you take control of your
patient records and documentation. The first
goal is a clean claim, and that means perfect
documentation. Manual, and especially analog,
documentation is sooo last century, not least
because it’s cumbersome and there are so many
opportunities for errors. It’s probably easiest
to have one system that handles all your major
business functions, but it’s essential for whatever
systems you are running to talk to each other —
to be interoperable.
“RCM really starts at intake. The referral sends
you a fax with all the pertinent information, now
you are creating an order within the system, you
are populating the system with the order. You
might have to schedule the delivery, and it shows
you all the necessary information. You have to
get a prior authorization from a payer; you are
getting all that documentation together and all
that pertinent information so now your claim is
ready to send to the payer,” says Sunil Krishnan,
vice president of RCM at Brightree. “Once it
generates invoices, now it is generating revenue
in your system. As an order, it is not revenue yet.
The invoice becomes revenue.”
Intake is the parallel process of gathering
information to get the best product fit for the
patient, records to satisfy payers, and information
that has its own value. Would the patient
rather be contacted by phone, text or email?
Would they prefer pickup or delivery for future
orders? Are they managing conditions other than
what today’s prescription is for? Does the patient
feel lost or unsupported about their condition(s)?
Those bits of information may all be opportunities
for marketing and loyalty — more on that in
a minute. First, a bit on getting paid.
STAKE YOUR CLAIMS
“We all know getting paid is one of the headaches
of the HME industry — reprocessing is
labor-intensive and expensive. The right compliance-centric software helps providers avoid
preventable errors, producing revenue-qualifying
orders the first time,” Turner says.
Pharmacists have become accustomed to
getting instant authorization for medications.
DMEs have been used to a sometimes lengthy
back-and-forth about what’s covered, who’s
paying and how much. Good billing software
gets right in there to speed those authorizations
and your fill times.
“The biggest trend you are reporting is how
many claims are paying at the first pass. You want
to be driving that number as close to 100 percent
as possible,” Anderson says, adding, “The 2
percent that still deny will take a ton of work.“
With electronic submissions, your claim goes
to a clearinghouse “Once it gets to the payer
and they process it, you are able to get approval
electronically. It tells you, you will receive x dollars
of cash and x dollars of adjustment. It tells what
information you might be missing,” Krishnan
says. “The clearinghouse will tell you if it will
reject the claim or send it on to the payer. You are
able to fix it and now it goes to the payer after
the first check.”
The tools allow you to self-audit your business
from beginning to end. Spotting problem trends
and addressing them one at a time is the key to
strengthening and building your business.
“Even if you’re only dealing with a small
percent of claim denials, someone has to be
watching the trends at all times. There is no
profit margin once a claim rejects,” Anderson says. “If you cannot quickly and easily spot
denial trends, your revenue results will never
change. Whether you prefer a dashboard or a
report, it must be robust and frequent.”
PATIENT RELATIONSHIPS
The information you collect at intake isn’t just for
the claim you’re filing today, it‘s an opportunity
to start a dialogue with the patient and learn how
to build that relationship. The email addresses
you collect could be the beginning of an email
marketing campaign. Patient comments about
information they lack can guide your choice of
content for your website or email campaigns.
“With all the data centralized in one place, you
have all this demographic information. You have
the products that are being used. You can now
actually do targeted marketing on that level of
information,” Krishnan says. “I can target certain
areas because they have heavier consumption of
CPAPS and supplies.”
Knowing how patients want to interact should
help you give them reasons to turn to you. You
can send health tips and promote new products
or special offers in email campaigns; post
things like support group links, healthy recipes
and community resources on your website; take
advantage of mobile contact apps that send
medication and refill reminders.
Comprehensive software lets you monitor your
in-stock inventory and distributor orders. If a
patient calls to ask where their order is or when it
will arrive, you have an answer at your fingertips.
There are apps to send a photo of the delivery
driver the customer should expect, for trust and
security reasons.
“It might still be sitting with the primary payer.
You are able to have a more educated conversation
with the patient and provide real-time of
where the order is and the status of the billing,”
Krishnan says. “Once the patient has had a great
experience, hopefully that becomes a lifetime
patient or one who will refer you to others.”
UPPING YOUR REFERRAL GAME
Some vendors have a specific niche, and their
systems should work with whatever you’re already
doing. PlayMaker Health started as a customer
relationship product, but has evolved to be a DME
sales force manager as well. PlayMaker offers a
web- and mobile-based product that combines
comprehensive DME claims data that can tell you
what products are being sold and who the sellers
and referrers are within a given area, right down to
product codes and contact information.
A PlayMaker subscriber can call up a map that
will show every referral for a specific product or
category within an area the user defines — such
as a 20-mile radius around the user’s business —
and it will show what percentage of each referrer’s
business is going to the user and to their individual
competitors. That can help sales reps focus
efforts on opportunities to sway more referrals, or
show you an unfilled need in your area.
Within your business, PlayMaker has fields
for referrer information that includes not just
contacts and appointments, but personal
schmoozing details like their spouses’ and children’s
names. There are fields for notes of interactions.
Since the platform is mobile as well as
online, sales staff can call up details just minutes
before a visit, then update them on the way out.
Managers can then review and analyze that data.
HEADING OFF TROUBLE
A solid DME system keeps track of all your inventory, transactions and documentation,
which helps with ongoing tax accounting.
Tracking transactions from start to finish also
makes it easy to pull up records in the event of
an audit.
“All audits are trying to catch you out for your
documentation. The majority of people that fail
an audit, it’s because they can’t find it. They can’t
get it together in a timely fashion,” Anderson
says. “In terms of what your data can do for you,
[a DME-specific system] really would allow you
to do some pre-auditing yourself before auditors
come in and shut your business down. It
will show where your system and staff are falling
down, where you can make those processes a
little more efficient.”
WHAT DOES IT TAKE?
This shows some of the outreach details that a provider can
drill down to using existing software tools as part of their
homegrown RCM.
Managing your own RCM isn’t free. It takes the
right tools. Most DME software is offered on a
site-license agreement, which allows a specified
number of users to access the programs. That
usually means a monthly fee that depends on the
software capabilities and the number of users.
There will be some staff training time if they are
new to the software.
You also have to consider where your data will
reside. There’s a range of solutions from hard
storage on your premises to the increasingly
popular cloud. Your software provider can help
you decide which option makes the most sense
for your business.
“To add on a report builder or a data warehouse,
there will be an additional cost,”
Anderson says. “If your rep says there’s not, look
over your contract.”
OVERLOAD! LET SOMEONE
ELSE DO IT…
If all of this sounds like more tech anxiety
than your business can handle, outsourcing is
always an option. With that choice, the vendor
essentially takes over your billing system from
orders to collections, and you can monitor how
everything is going. You’re still in control of
your business and day-to-day operations, but
someone else is managing most of your claims
and billing.
Either way, you can’t afford to ignore all that
data buried in your back office. “Providers that
are really winning with customers have smoothed
out that process,” Anderson says. “The key to
that is looking at how it is already going.”
This article originally appeared in the March 2020 issue of HME Business.