In this Business Profile, Greg Burgess, Founder and Chief Product Officer at Burgess shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.

Greg BurgessTell me a little about your organization.

Burgess provides medical claims reimbursement and payment integrity solutions for healthcare payers, providers, third party administrators, suppliers, Accountable Care Organizations (ACOs), and other consumers of healthcare reimbursement data.

Our original mission—one that still holds true today—is to facilitate the use and comprehension of government program-based data for various stakeholders, which can improve the overall performance of the healthcare system. Our company’s proprietary software applications and consulting services help organizations save millions through improved accuracy, efficiency and performance, while offering powerful analytics and automation. We have a loyal, long-standing client base due to our broad and deep expertise in Medicare and Medicaid reimbursement. Our clients’ business needs are the focus of our innovation and growth. Burgess Reimbursement System® (BRS) solutions are designed with our clients in mind; we specifically tailor new functionality to individual client needs.  In fact, many well-recognized national and regional organizations have partnered with us for more than a decade.

In 2009, we made a commitment to transition to a Software as a Service (SaaS) platform to improve the quality of our offerings. This occurred well before we knew that protected health information in claims-level transactions would be a viable data source for large health plans or ACOs. Even large commercial payers turn to us for data hosting because it eliminates IT overhead. Today, virtually all of our clients have moved or are moving to the SaaS platform.

We continue to strive as the market leader in payment integrity solutions, offering unparalleled functionality, business value and quality. Our vision is to bring payment integrity and transparency towards the point of service.

When you think about the tectonic shifts occurring in healthcare information technology, what types of challenges and opportunities do you see in the marketplace today?

All healthcare organizations are reinventing themselves as the industry consolidates and transforms. The constant changes in new contracting models and payment methodologies underscore the need for a consistent, reliable anchor on which to model and predict financial outcomes. Medicare and Medicaid data serve in this role. We’re seeing large growth in out-of-network commercial business that uses Medicare data as a baseline to pay for services and support negotiations.

There’s also a real need for companies to think differently about their payment integrity technology. Unfortunately, systems at most organizations are outdated in the face of an industry reinventing itself at lightning speed. “Old school” legacy systems are becoming a significant challenge because they’ve been around for twenty to thirty years but aren’t made to support comprehensive reimbursement that includes clinical editing, pricing and network contracting. As a result, organizations have to install bolt-on solutions to manage these tasks. This is problematic because a health plan typically will have multiple software solutions without a consistent interface that ensures smooth information sharing.

Not only are organizations realizing the need for modern solutions, they are looking to onboard the technology rapidly. Just two years ago, some of the largest companies we work with said they could not employ SaaS because they required internal controls to sufficiently protect data. Today, many of those companies are moving to a SaaS product, seeing it as a top competitive priority.

Another challenge is the time requirement for claims processing and adjudication. While other industries have mastered how to receive and pay bills quickly, accurately and efficiently, healthcare lags behind. Roadblocks, such as frequent technology updates that take time to operationalize, are part of the problem. For instance, reimbursement based on Medicare or Medicaid requires constant updates to be in compliance. By the time IT tests and validates these changes, the updates go live weeks or months after the effective dates, so thousands of claims are still paid incorrectly.

How does Burgess address these issues?

Our solutions combine payment data, rates, policy expertise and high levels of automation to yield an efficient software application. In fact, we are building a true one-stop shop for claims data and network contracting. It will be the first of its kind to bring the disparate parts—editing, pricing, network contracting and analytics—together. Offering these solutions in a SaaS model is essential to this technology shift.

We aim to keep our solutions as nimble as possible. To do this, we took a close look at our internal workflow to assess if we could manage technology updates more efficiently. We now release changes every two weeks with 100 percent compliance so clients pay claims right the first time. This saves substantial rework because they don’t have to re-adjudicate and reconcile wrongly denied claims. Not only does this help with efficiency, it also boosts provider satisfaction.

When organizations merge and consolidate, they don’t have to change their core systems to work with our solutions. All of the organization’s mission-critical reimbursement—network contracts, edits, payment policies, provider dispute resolution—happen outside the core claims system safely and securely in a highly scalable environment. With our system, you can plug 837 connections into any different number of claims systems and have a single source of truth for how to manage payments. It’s game-changing.

While enabling easy edits and streamlined payments is important to us, we spend the most time designing the user experience. You can have great processes, but if they don’t interact well or meet the user’s needs, ultimately they are useless. We focus on examining how people use the solution and ensure our design reflects their workflow. In fact, we recently reengineered our software to meet a new generation of demand. Our solution was successful before, but we knew it could be even better.  We see the value in making time and resource investments that elevate our solutions to the next level.

What are your recommendations to leaders considering vendors for these types of services?

First and foremost, you should think outside the box. Understand how you can be part of and capitalize on the changing landscape rather than fighting it. If you work for a health plan, for example, instead of thinking “How can I hold claims longer?” think: “How can I move to fast, high accuracy payments to negotiate lower rates with providers who’d love to get paid more quickly?” Today, it’s all about effective collaboration, and organizations should look for a company that believes in that approach.

Also, organizations should consider total cost of ownership before committing to a solution. I find that executives often zero in on software licensing costs but neglect to consider larger costs, such as a lengthy, expensive implementation; delayed update efficiency; slow process improvements; or costs associated with suppliers who haven’t fully thought through the workflow. Sometimes leaders are so focused on ensuring there is an army of vendor staff to fix problems, they neglect to perform due diligence on the front end with respect to workflow needs. If it’s well-designed technology, it can be built and delivered in a way where it’s 80 percent ready without frequent and complex integration and implementation challenges.

You additionally want to make sure you and your potential partner share the same vision. What is their long-term road map? What are they trying to accomplish and does it fit with your needs and vision? It’s easy to focus on today’s hot problem rather than whether a partner is a fit with the overall strategic plan. Organizations should define real business requirements and stick to them—don’t be an impulse buyer. You want to feel confident that product features solve not just your internal needs, but also the requirements of the people you serve. This is what makes for strong relationships.

Products should be user friendly because complex features and functionality just result in confusion. The most valuable solutions are the ones users employ on a daily basis to actually improve workflow. So, when choosing a solution you should ask: “How is your product going to affect my workflow? How do I know my staff is going to use your system effectively?”

What kinds of best practices do you see your business partners using?

First, they truly see our company as a long-term partner, fully engaging with us and leveraging the most out of the technology. Often, a significant percentage of an IT system’s capabilities aren’t used. We tend to solve the most urgent problems while additional system capabilities are never fully tapped. However, organizations that ask for solutions and seek methods to optimize them realize the value we bring as we continue to build interfaces and applications.

Another practice is time spent bringing stakeholders from across the organization together. This is important in facilitating engagement because our company works across various departments, from medical and claims departments to compliance, actuarial, and provider relations. We touch the work of many people through our holistic solution; therefore bringing together all stakeholders to discuss problems, solutions, and strategies is valuable.

Where can readers learn more about Burgess’ payment integrity solutions?

Visit us on our website for more information on BRS payment integrity solutions and latest news. Download our September 9th webinar featured on Health Payer News.

The webinar titled ‘How to Improve the Predictability of Healthcare Payments Using CMS Standards,’ proposes the use of Medicare as a baseline to enable accurate cost predictions for healthcare payers and at-risk providers.

For ideas on how to simplify the business of healthcare, visit the Insights section on the Burgess website for relevant case studies and white papers on cost containment, prediction, and modeling. Read our latest whitepaper featured in Modern Healthcare titled ‘Claims Wasteland: Reducing Incorrect Payments between Providers and Payers.’ For more information, contact us at or call us at 800.637.2004.

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.

BurgessContent for this Business Profile is supplied by Burgess. 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: Thursday, October 01, 2015