There are 4 Steps to correctly and completely process claims electronically for Adult Day Care and Elder Care Service providers. This process should be relatively the same in most elder care management software applications available. If it's not the same, it should be very similar and if it's not, then it is very likely their process is flawed. The only noticeable differences should be the names or terminology used to describe steps, entities or attributes.
This document summarizes the 4 Steps in ElderSuite when processing electronic claims for Adult Day Care and Elder Care Service providers. You can view a detailed document for each step with additional information including instructions for completing each step within ElderSuite.
ElderSuite's 4 Steps to Process claims for Adult Day Care and other Elder Care Service providers are:
Each step is a crucial part any Adult Day Care or Elder Care Service provider billing process and skipping any of the steps can result in loss of revenue by the Adult Day Care or Elder Care Service provider.
The diagram below shows the flow of ElderSuite's Electronic Billing Claims Process for Adult Day Care Providers:
This step is exactly what it sounds like. Scrubbing Claims is the process of "cleaning" your Adult Day Care claims to ensure the claims do not contain errors.
It's a silly analogy, but after eating dinner if you didn't scrub and clean your dinner plate before putting it away in the cabinet, the next person to grab that dirty plate wouldn't be so happy and would probably just pick another.
The electronic claims process for Adult Day Care claims is just the same. Claims need to be scrubbed to ensure they are free from any errors before sending them through to the next step. In this step, ElderSuite implements automation services to scrub the Adult Day Care claims and ensure they are do not contain any errors. It's a quick process, but when complete, ElderSuite will display all the Adult Day Care claims it has scrubbed. Each scrubbed Adult Day Care claim will show the status with a visual indicator. The visual Scrubbed Status of a claim is noted as shown below:
Any claims which contain errors after scrubbing are claims which ElderSuite could not fix automatically and requires user interaction.
Important Note: Any claims "Not Scrubbed" or which Contain Error(s) will be NOT move to the next step and will NOT be processed further by ElderSuite until they have been scrubbed and deemed to contain No Errors. Medicaid, Medicare, private insurance, and most other payers have a deadline for claims to be successfully submitted after Adult Day Care services are rendered. If your Adult Day Care claims are not submitted successfully by the payer's deadline then that will be lost revenue. We call these Rotten Claims because they have been left to spoil.
If you are unfamiliar with the automation services ElderSuite provides, I recommend that you review this document: Getting Started with ElderSuite - Your First Steps. This document is recommended reading for all ElderSuite users and explains in detail how ElderSuite's automation services works. It points out what areas of data within ElderSuite need to be paid special attention. It explains how ElderSuite implements automation services and uses the data provided by users to complete tasks automatically. The focus is to ensure that data input into ElderSuite is complete and accurate which will save time.
Important Note: ElderSuite's automation services completes work automatically and is a wonderful time saver. However, ElderSuite's accuracy of completed automation are based on the accuracy of the data it provided by users. For, example if a users inputs a Medicaid number into incorrectly, ElderSuite will be using an incorrect Medicaid number when it automatically generates claims and processes any claims related to that Medicaid number. So, it is very important to provide accurate information.
In this step, ElderSuite generates HIPAA compliant transactions and submits those transactions electronically to a clearinghouse. Your organization will need to have an account with any clearinghouse(s) through which you wish to submit claims electronically. ElderSuite will only submit claims electronically through a clearinghouse and will not submit claims directly to payers. You can view the Manage Clearinghouses document to learn more about clearinghouses. As noted above in the Scrub Claims step, ElderSuite will only submit claims that do not contain errors.
This is vital step which is often omitted by users. Many users mistakenly assume their claims have been processed successfully once they have been submitted electronically. As explained previously, the Adult Day Care claims automatically generated by ElderSuite are only as accurate as the data provided the user(s) which is used to create those claims. Although ElderSuite's Scrub Claims automation service catches and fixes many issues, there are some things ElderSuite can not see as an error or fix. This is why downloading, viewing and monitoring billing reports is so vital.
Users should always download and review reports after each batch of claims is submitted to a clearing house for processing. These reports will explain the if the submitted batch was rejected in whole or if any particular claims were denied or rejected. Additionally, these reports also provide the assigned Batch ID numbers to each back submitted and explain why any claims were denied or rejected. If you need to contact the clearinghouse or payer for further detailed information about denied or rejected claims, you will need the Batch ID number of the batch before contacting the clearinghouse.
Important Note: When this step of the process is omitted, users are unaware if there are any issues with the submitted claims. When there are issues and this step is skipped, at best it will delay the reimbursement of funds; however, at worst you will have lost revenue.
The last step in the process. Reconciling Claims is very similar to reconciling a checking account. Each claim in ElderSuite has a Claim Status applied to it from the moment it is created within ElderSuite. Once a claim has been submitted to a clearinghouse, the status will change, an so on. Basically, this Claim Status will change after each step either automatically or by the user if the user fully completes the recommended steps.
Just like the View Reports Step, this too is a step often omitted by users. At best, omitting this step can cause hours of unnecessary paper work. For example, when required information is needed to generate yearly cost reports. Instead of spending a few minutes running reports in ElderSuite, employees will spend hours performing unnecessary manual counting and calculating of attendance, claims, amounts etc. In addition, this introduces human error. At worst, omitting this step prevents the ability to determine which claims have been submitted, rejected, denied, or paid and which haven't and ultimately can result in lost revenue.
I hope I've made it clear how vital it is complete each step in ElderSuite's electronic claims process for Adult Day Care and Elder Care Service providers. The claims process is exactly that, a process which has more than one step and can cause major issues or headaches when a step is skipped. For detailed information about each of these steps including instructions, see the linked documents below: