"Monarch is helping us win the battle in getting paid every penny RIA is entitled to. That makes Monarch an indispensable tool for every healthcare organization."

 

No one in healthcare needs to be reminded of the urgent need to contain costs and collect every possible penny for healthcare services provided. This fact, combined with the paper-intensive nature of the healthcare industry, makes Monarch's Report Mining capabilities a powerful data access and analysis solution for healthcare organizations, large and small. Radiology Imaging Associates (RIA) of Denver, CO has been utilizing Monarch with exceptional success for years.

"We use the VitalWorks system for our healthcare transaction processing," explains Linda Philipp, Programmer/ Analyst for RIA, "but the system does not furnish us with the comprehensive reporting that we need. We use Monarch to help us fulfill our need. We extract information from a wide variety of VitalWorks reports, as well as reports and data we receive from external sources. The end result is data we can easily work with." RIA then uses the data from Monarch to effectively manage a wide variety of key healthcare business functions, from effective recovery of underpaid collections, claims management, and even effective negotiations with insurers.

Getting Every Penny from Insurers with Monarch

One key way RIA uses Monarch is to ensure the company is paid the contracted amount from insurers. "Sometimes an insurer does not pay the right contracted fee for services," says Linda. "It is up to us to find and request a correction. Monarch makes this process easy."

"Using information from several system reports, we create a report with Monarch to give to the various insurance companies, to show them where they have not paid the contracted fee for services," Linda says. "Using Monarch, we are able to give each insurer only the claims that are over-or underpaid, including the patient name, policy number, date of service, exam code, expected amount, what they paid, and how much they are over or under."

"Monarch makes this data access and presentation easy. I export the data to Excel and most insurance companies work right from this report to pay us the owed amount. This capability has collected hundreds of thousands of dollars for our company."

Another collection issue unique to health-care is the fact that some patient exams will consist of several procedures. The insurers will pay a contracted price for the entire exam, not each individual procedure. "This often results in underpaid claims," explains Linda. "But, using Monarch's filter, export and join abilities," says Linda, "I can combine the procedures that were performed as a single exam, and compare to the contracted price. This ability has also allowed us to collect hundreds of thousands of dollars in underpaid claims."

"Sometimes an insurer does not pay the right contracted fee for services. It is up to us to find and request a correction. Monarch makes this process easy."

Monarch Turns Thick A/R Reports into Actionable Data

Monarch has also proven an effective solution to manage RIA's accounts receivable. "Our VitalWorks 'AGE' accounts receivable aging report is broken out by insurance company, but includes all insurance companies (about 360) in one report. We have a team of 6-8 people working our receivables; each person works with specific insurance companies. Using Monarch, I can filter in just the accounts worked by each individual and give them their customized data set."

"I can also help them to spot problems accounts quickly by using filters to find accounts that have been filed more that 60 days ago, accounts where the secondary insurance has not been filed, etc. We can even use this data to track the collection performance of each member of our receivables team. Using Monarch Pro has greatly reduced our Accounts Receivable."

Monarch Helps Effectively Manage Medicaid, Other Insurers

"Another problem for us has been dealing with Out of State Medicaid claims," says Linda. "All these claims are lumped into one generic financial class in our VitalWorks system, but each state requires the doctors to be credentialed by their state."

"Using Monarch Pro's ability to join, I can pull the state from the free form insurance company address in our database, into our 'AGE' report, then sort by state and doctor, to see which doctors need to be credentialed in which states. This has saved us much time and has allowed us to collect the money owed more quickly."

Of course, in addition to Medicaid, RIA contracts with insurers to pay preset amounts for services. "We establish preset reimbursement amounts with insurers as a result of contract negotiations," explains Linda. "Monarch lets me provide managers with the data they need make informed decisions when negotiating contracts."

"In our VitalWorks system, one insurance company line of business may have many Insurance Company (C) codes, because there are different products and "submit to" addresses within that insurance company. Using Monarch's calculated field capabilities, I can lump all the IC codes for each line of business together. Then I can give management reports comparing the business for each consolidated insurance company. This data is critical for our managers to negotiate the best contract possible with our insurers. This is a key example of how Monarch helps us not only collect payments due to us after services are provided, but also proactively manage what our reimbursements for future services should be."

New Monarch Skills, New Claims Management Benefits

RIA is expanding its use of Monarch even further, after gaining advanced Monarch skills from Datawatch's 2003 User Conference, along with the new power of Monarch Pro. "We are using Monarch to extract data from reports we receive from our claim processing clearinghouse," says Linda. "Our different insurers send 'edit reports' back to the clearinghouse, which then sends them all to us as a single text file. These edit reports are in different formats by insurer, showing all claims received by each insurer."

"Using advanced Monarch techniques, we are extracting all of the claims data with Monarch, and then using Monarch Pro's unique ability to join this data with our internal insurance log. We can now identify any claims that, for whatever reason, failed to reach the insurer. If we do not identify such missing claims in a timely fashion, we risk losing the opportunity to file the claim at all. Monarch will help us avoid such preventable loss."

"Monarch helps us in even more ways: denial management, patient demographics, general error corrections and more," adds Linda. "We use Monarch in so many different areas here at RIA. And best of all, Monarch is helping us win the battle in getting paid every penny RIA is entitled to. That makes Monarch an indispensable tool for every healthcare organization."

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