How to eliminate peer-to-peer calls, generate new revenue, and deliver quality care in the physician practice setting.

1. STREAMLINING
PRE-AUTHORIZATION
WITH
by Apps for Docs
Clinical Decision Support
www.appsdocs.com
TM
IMPROVE PRODUCTIVITY BOOST PATIENT SATISFACTION
INCREASE REVENUE
-1-

2. INEFFICIENCIES IN THE CLAIMS MANAGEMENT PROCESS
THE PROBLEM
BACKGROUND: The healthcare landscape continues to
change at a rapid pace as an estimated 30 million newly
insured people enter the system, alongside ever-rising costs
and a declining number of providers. How will physician
practices effectively treat more and more patients with fewer and fewer clinicians? To
properly manage this state of uncertainty, reform legislation has encouraged providers to
adopt new technologies that improve quality and efficiency while reducing costs. An area
of opportunity for technology solutions can be found within the claims management
process, which is costing physician practices unsustainable amounts of time and money.
PRE-AUTHORIZATION CRIPPLES PRODUCTIVITY
UNCERTAINTY
To receive pre-authorization, the provider must
contact the insurance payer and verify the
procedure is medically necessary
before the procedure is
performed. Only then can the
claim potentially be reimbursed. This is a burdensome, costly effort managed by
clinicians and clerical staff in the physician practice setting. Pre-authorization has
been suggested to consume 20 hours of physician, nurse, and clerk time each
week. While clinicians wait to receive authorization from the insurance payer,
patients wait up to 45 days from the time the procedure is ordered to the time they
receive treatment. This can result in patient anxiety and overall dissatisfaction with
care received. Additionally, the longer it takes to provide treatment, the more
underutilized resources and facilities become.
WAITING FOR RESPONSE
PEER-TO-PEER
CALLS
DENIALS
13.1
1
6.3
"What Does It Cost Physician
Practices To Interact With Health
Insurance Plans," Lawrence P.
Casalino et al, Health Affairs
28.4 (2009): w533-w543 at w537.
Hours devoted to prior authorization each week
Clerk
Physician
Nurse
The claims management process involves
submitting claims and collecting appropriate
payment for services rendered. The American
Medical Association reported that “Cost
estimates of inefficient health care claims
processing, payment and reconciliation are
between $21 and $210 billion. In the physician
practice, the claims management revenue cycle
consumes an unsustainable 10-14 percent of
practice revenue”.
CLAIMS MANAGEMENT PROCESS
REGISTRATION
DOCUMENTATION
PRE-AUTHORIZATION
BILLING
COLLECTIONS
WASTE
$210BB
14%
INEFFICIENCY DISSATISFIED
20hrs/
week
45day
wait
of revenue
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3. EVIDENCE BASED DECISION SUPPORT AND DOCUMENTATION
sidekickCV SOLUTION
Streamlining the pre-authorization process with the intent to improve clinician
productivity, cash flow/revenue, and patient satisfaction is achievable by using clinical
decision support tools at the point of care in the office setting. The American College of
Cardiology Appropriate Use Criteria evidence based guidelines have been adopted as the
benchmark for medical necessity documentation for high
cost imaging procedures by many payers. SidekickCV
delivers these criteria in an accessible form that provides
decision support guidance for appropriate procedure
selection, and medical necessity documentation
for each patient-specific order. This point of care solution
has been shown to produce the following results:
• Increased revenue The inclusion of
evidence-based medical necessity documentation in
the procedure order has significantly reduced the
number of denied claims, resulting in improved cash
flow and overall revenue generation. An analysis on
page 5 details a 2200% ROI and a $1.1 million of
new revenue for an average 300 bed hospital,
by using clinical decision support tools at the
point of care in the physician office setting.
HIPPACOMPLIANT
• Improved clinician productivity The
number of “peer to peer” calls between the clinician and the payer is
drastically reduced, freeing up 2-3 hours per week of clinician time.
• Better patient care The
time period from the procedure being
ordered to the patient being authorized for
the procedure is significantly reduced from
an average of 45 days down to 2 weeks or
less. As a result, patients experience more
satisfaction with the treatment process and
less anxiety while waiting for the
procedure.
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IMPROVE FINANCIAL AND CLINICAL OUTCOMES

4. EXECUTE QUICKLY AND EFFECTIVELY
SidekickCV is a web application that provides access to up to
date Appropriate Use Criteria guidelines and medical necessity
documentation at the point of order. It is accessible from any
internet capable device. A hospital subscription provides
referring physician access to the Clinical Decision Support tool
without complex IT infrastructure redesign. EMR/CPOE system
integration with SidekickCV via API interface or simple
copy/paste of evaluations provides a quick and smooth
workflow for the clinician. The average time to utilize
SidekickCV and generate a patient evaluation report is under a
minute.
Working in a busy Cardiovascular
Electrophysiology Office makes
SidekickCV imperative to
improving our workflow and
productivity". - Dawn Aycock, ARNP
Streamlining the pre-authorization process for imaging
procedures has the potential to show immediate
improvements in productivity, patient satisfaction, and
revenue without extensive and costly redesign of clinical
workflows and processes.
TM
sidekickCV IN WORKFLOW
Diagnostic
Test
Selection
Diagnostic
Test Ordered
in EHR/
CPOE
Test
performed
in hospital
or office
Results
Communication
Better
Patient
Care
Patient
Appropriateness Criteria
Provider Education
Evaluation
report with
evidence
• Signs
• Symptoms
• Special Risk Groups
• Abnormal prior test
Clinician workflow in the office
setting
QA
Reports
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5. A B C D E F G H I
Procedure Type
CPT Code /
DRG
CMS
Reimbursement
per procedure (4)
Avg # of
Procedures /
year
Baseline % of
procedures in Rarely
Appropriate
category (
1,2,3
)
Baseline #of
Proceduresw/ denied
claimsdue to Rarely
Appropriate
classification
Post SideKickCV #
ofProceduresin
Rarely
Appropriate
category (5%)
Adjusted #of
Procedureswith
denied claims
Revenue at risk
due to denied
claims / year
Diagnostic Cardiac Cath 93452 2,727.00$ 800 20% 160 40 120 327,240.00$
Percutaneous Coronary
Intervention (PCI) G0290 7,279.00$ 100 12% 12 5 7 50,953.00$
Cardiac CT 75574 452.00$ 200 10% 20 10 10 4,520.00$
Echo / TEE 93312 236.00$ 3000 10% 300 150 150 35,400.00$
Cardiac Radioclide Imaging 78472 233.00$ 200 10% 20 10 10 2,330.00$
Peripheral Vascular US 93925 153.00$ 2000 10% 200 100 100 15,300.00$
Implantable Cardioverter-
Defibrillator (ICD) 222 - 226 DRG
39,856.00$ 100 22% 22 5 17 677,552.00$
Total 6400 734 320 414 1,113,295.00$
Average procedure rate (Revenue / Total # of Procedures) used in ROI 173.95$
Monthly
subscription # months
Yearly
subscription cost
2,498$ 12 29,976$SidekickCV monthly subscription
Rarely Appropriate procedures - Revenue at risk due to denied claims
SidekickCV evidence based decision support analytics
CMS Part B Cardiovascular Procedure Volumes for 300 Bed Hospital
Listing of the
cardiovascular
imaging proce-
dures that are
covered by the ACC Appropri-
ate Use Criteria
Reduce Denied Claims
A
The following table summarizes the
FINANCIAL IMPACT that a reduction in the
number of Rarely Appropriate procedures
can have for an average
300 bed hospital.
The result of retrospective analysis
of cardiovascular procedure utiliza-
tion in the US shows a certain
percentage of imaging procedures
have fallen into the “Rarely Appropriate“ catego-
ry as per the AUC guidelines. Since January of
this year payers have begun denying claims for
Rarely Appropriate procedures.
E
Procedure volumes
were determined from
an analysis of a
cross-section of Florida
based mid-size hospitals
D
The authors of the referenced articles agreed that
a certain percentage of patients will not fit into the
AUC because their particular clinical scenario are
not detailed in the AUC or there are other extenuat-
ing aspects of their scenario that the clinician thinks warrant
the procedure anyway. The percentage of patients that fall
into this category is 5%. This column includes the volume of
studies in this group.
G
Article References:
1) Chan et al, Appropriateness of Coronary Intervention, JAMA. 2011;306(1):53-61. 2) Ward et al Prospective Evaluation of the Clinical Application of the American College of Cardiology Foundation/American Society
of Echocardiography Appropriateness Criteria for Transthoracic Echocardiography, J A C C : C A R D I O V A S C U L A R I M A G I N G VO L . 1 N O . 5 , 2 0 0 8 3) Sana M. Al-Khatib et al, Non–Evidence-Based ICD
Implantations in the United States, JAMA January 5, 2011, Vol 305, No. 1 4) Procedural Reimbursement Guide Select Percutaneous Coronary and Peripheral Interventions, Boston Scientific 2011
Total revenue at
risk equals
$1.1MM
I
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6. CONTACT:
Aaron Duthie
COO
Apps for Docs
Cell: (352)792-3740
Office: (877) 876-6717
Email: aduthie@appsdocs.com
by Apps for Docs
Clinical Decision Support
www.appsdocs.com
TM
IMPROVE PRODUCTIVITY BOOST PATIENT SATISFACTION
INCREASE REVENUE
-6-