In this Business Profile, Tom Myers, chief strategy officer, The SSI Group, discusses the shifting payment environment and how it affects providers’ patient access and claims management processes.

Tom Myers, chief strategy officer, The SSI Group discusses the shifting payment environment and its impacts on providers' payment accessTell us a little about SSI.

SSI’s mission is grounded in providing reliable, easy-to-use software solutions to improve revenue cycle efficiencies while reducing staffing requirements. That’s been our foundation for nearly 30 years now. Over the past 10 years, we’ve also grown our revenue cycle tools and services to become a single-source, end-to-end solution, including front-end patient access workflow to claims management, denial and contract management, and analytics and business intelligence solutions. We currently work with 2,700 client partners and handle $800 billion in claims annually.

Our strength has always been in providing accurate and comprehensive edits, offering richness of focus around documentation requirements, and recognizing what keeps payers from accepting claims. These capabilities are particularly valuable as the industry shifts toward a value-based revenue cycle, where uniting the payer’s rules with workflow is essential.

Can you share a bit about what you are seeing in relation to changing payer dynamics?

The payer side of the market is complex and becoming even more so due to ICD-10, accountable care organizations (ACOs), and population health initiatives. As a result, we’re seeing a fundamental shift where payers own the revenue cycle. In the past, providers typically mastered their own revenue cycle and could pretty much count on getting paid once they sent a claim to the payer. But now, payers dictate highly complex rules that providers must follow in order to get paid.

Providers are challenged with stitching together dozens of these payer-specific revenue cycles into a holistic view with unified definitions and workflow. Supporting revenue integrity processes is challenging when every payer has its own rules and requirements. Working with ACOs and population health-based initiatives can be particularly complex because the rules under these types of arrangements are not specific to any one provider, but are rather a federated arrangement to support the cross-continuum nature of the relationship.

Also, there once was an expectation in the industry that as providers shifted to mega healthcare information system vendors, these suppliers would be perfecting the providers’ billing processes to consolidate separate best-of-breed clinical, financial, and other add-on solutions. In practice, providers are discovering this expectation isn’t feasible due to the complexity of managing thousands of payers nationwide. It’s a real industry problem.

How do you address these types of challenges at SSI?

This is an area we are known for. Because of our long-standing edit capability around electronic billing, including a proven track record with the 5010 conversion and a leading position with ICD-10 testing, we’ve developed a strong relationship and excellent reputation across payers. There are so many emerging trends with respect to meeting payer requirements during patient access—performing eligibility checks, preauthorization, and providing admission notification—as well as back-end processes for claim statusing and remittance processing. We address each requirement very specifically by payer, while still supporting the provider’s quest for a seamless revenue cycle.

Through database workflow, we also support integrated denial management with an automated back-end process, even though payers differ. Product capabilities are available payer by payer to help providers anticipate payments according to the contract and track claims through adjudication to understand any payment variance. As a result, we can isolate denials and underpayments in spite of differences in payer logic. We also put denials and payment variances in normalized queues for staff to work on efficiently, without them having to cobble together separate processes to determine denial category and prioritize efforts.

Are there other revenue cycle trends that should be on providers’ radar these days?

An emerging area that we are addressing on the front end in patient access is high-deductible health plans, including those originating from the Affordable Care Act. Many of these plans have deductibles of several thousand dollars, and thus have created much greater patient liability than we’ve seen historically. It’s now mission-critical for healthcare providers to be able to estimate patient payments and collect up front. Doing so not only improves collection success, but also supports patient satisfaction, as patients are able to make more educated decisions about purchasing healthcare services. By coupling eligibility requests with payer contracts and historical payment amounts, we can provide patient estimates before a service is rendered and then reconcile them on the back end after the payer has adjudicated the claim.

Again, there’s so much complexity around specific payer rules on preauthorizations and admission notification to support a clean claim. Our approach is to treat transactions as payer-specific processes and keep the right provider-centric definitions, as well as workflow, together for consistency. That’s the value we add.

Any important considerations as leaders review key revenue cycle product or service features to support effective claims management?

It’s important to ask about a potential supplier’s relationships with payers. Given the complexity of the payment environment, strong, collaborative relationships are important to ensure the best results.

In terms of product selection, seek connectivity and flexibility. For example, at SSI, our software is all SaaS [software as a service], as we maintain a centralized data warehouse that enables workflow with consistent definitions between payers and across products. This structure allows us to deploy new products or support existing products very quickly. We are also able to capture best practices from clients and incorporate these practices out of the box going forward.

Also, consider whether data will be synchronized if you start with one solution and later add on others. The potential for built-in integration and agility are important in realizing the full value of revenue cycle products, especially as the revenue cycle continues to undergo rapid evolution.

Where can readers learn more about SSI’s capabilities?

Visit our website, where readers will readers will also find ICD-10 testing information, newsletters, case studies, industry news, and our schedule of upcoming events.

HFMA is the nation’s leading membership organization for more than 40,000 healthcare financial management professionals. Business Profiles are funded through advertising with leading solution providers. Learn more. 

SSIContent for this Business Profile is supplied by SSI. This published piece is provided for advertisement purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions of those profiled are those of the individual and not those of HFMA. References to commercial manufacturers, vendors, products, or services that appear do not constitute endorsement by HFMA.

Publication Date: Wednesday, April 01, 2015