Claims Testing Pre Go-Live
By Becky Clark

I have been asked several times at different facilities, “Can you have the claim testing done in two weeks? That doesn’t seem feasible.” My answer to them is always “Yes,” but will it be right if it’s done in two weeks?

Throughout my experience with claims testing, I’ve realized that there are many factors that must be taken into account when testing. Below are seven thoughts to take into consideration:

• Are you cleaning up edits at a clearing house?
• Who is testing the claims?
• How many claims are tested?
• Do you have a documentation process?
• Is there a controlled testing plan?
• Do you have all payers covered in your testing?
• What is the percentage rate of clean claims for which you are trying to attain?

As we get ready for testing claims, it presents a great opportunity to clean up edits and bridge routines that have been in your clearing house for years—specifically ones that are no longer necessary and are cluttering up the process (which can result in possibly needing to add new ones). Once this is done, you have a clean slate—therefore, number one is all about organization and preparation.

So, “Who is testing the claims?” Over the past few years, it has been relatively new people to the process. After speaking with organizations about claims testing help, the answer often received is “We can give you Sally. She can do the ADT. She just came back from taking her training at Epic. We also have Bill that can help you with the coding. He passed his exams yesterday for HIM.”

Now, I’m very much in favor of helping employees who just went through Epic training. I’m more than willing to have them sit with me, but that would bring us back to number two. In order to have a controlled testing plan, my experience has been to sit down with an employee who is unfamiliar with the system—then that person and I will do the testing of the claims. I’ll show them how to prepare and set-up the claim testing from beginning to end.

For item three, I would like samples of your current claims across all payers for both Hospital Billing (HB) and Professional Billing (PB) Anesthesia. As a safe number with which to work, I’ll need 400 claims for HB and PB, and 200 for Anesthesia.

We are now ready to set-up our documentation process on an excel spreadsheet. The columns at the top should be for all yourdifferent findings on the claim. An example: Patient’s name (please change the name of the patient); Personally, I prefer to use my last name. You can use whatever first name you would like. Occasionally, a middle name will be used. On your spreadsheet, fill in all the information from the claim from which you are working: Payer, physician, dx code, procedure code, etc. Once this is done for all your claims, don’t forget to add a column for reporting, whether or not it passes or fails. Include that with a column for comments.

Now the fun starts. You have your spreadsheet which will become your go-to resource. Register the patient, drop charges, discharge your patient, and/or close the appointment. Coding comes next. Initiate billing, fix any errors and resubmit, and create claim run. By only having one other person work with you on claims, you know for sure that all the information that is on the spreadsheet is being put into Epic (this again brings you back to number two). The purpose for this is so you know what’s the desired outcome for the claim. Now we’ve completed number five!

Once this is done, you check to make sure that you’ve accounted for all your payers (item six).

After processing the claims, it is time to test them with your clearing house. At the end of the day, my goal is to have a 95% clean claims. Having 95% clean claims means that once a they leave Epic and go to your clearing house, 95% of those claims can go out to the payer without being touched again (number seven complete).

As the title of this article notes, this is for pre Go-Live. All said and done, claims testing for pre Go-Live is something I truly enjoy. Now, when it comes to 5010, testing is a whole different game, for a whole ‘nother article...

If you would like more information about claims testing or other Epic solutions provided by VCS, please contact us at 610.444.1233, vcs@getvitalized.com, or www.getvitalized.com.