Defining Your Needs

A dialysis clinic is an information-intensive enterprise. John Sargent, president of QMS, has written a white paper, as well as several published articles, describing the information needs -- both medical and business -- of clinics, and a strategy for selecting a system to meet those needs. Here is an overview of the white paper:

Information needs of dialysis clinics

Medical

• Patient measurements (e.g., weight, blood pressure)
• Treatments (medications, treatment prescription and delivery)
• Outcomes (laboratory analyses of periodic blood samples and other health results)

Some of this information must be tracked during each dialysis visit; some is tracked less frequently across visits for trend analysis and across the dialysis clinic for enterprise performance. With this level of information use and the bulk of data available, automated systems and analyses targeted on defined problems become essential.

Business

• Billing (capturing charges for complete reimbursement)
• Managing the reimbursement process -- bill production and complete and rapid payment, with optimal staffing requirements

The unique payment structure of dialysis, and the large number of payors and individually negotiated contracts, demand efficient and flexible systems to maximize revenue and reduce costs.

Issues that must be addressed by dialysis clinic solutions

• Managing the large volume of clinical data, and identifying which data are important at a given time
• Assuring that all relevant data are transferred from the clinic to the billing/reimbursement process
• Maximizing revenue per treatment
• Minimizing DSO (days service outstanding, the number of days of service that have not been reimbursed)
• Minimizing abandoned (written-off) charges
• Reducing staff effort required for complete reimbursement and to keep up with reimbursement rules

Special requirements of dialysis reimbursement

To achieve efficient operation, the dialysis reimbursement system must:

• Rapidly generate large volumes of claims
• Generate claims tailored to specific payors
• Accommodate user-defined claim cycles
• Automatically provide for breaks in service
• Check claims for compliance requirements
• Automatically generate re-bills and accounting adjustments for retroactive insurance changes
• Store unlimited insurance plans
• Automatically handle insurance coverage switchover
• Check justifications and facilitate corrections
• Facilitate prevention of lost and abandoned charges
• Process all electronic claims and remittances
• Track accurate Accounts Receivable (AR) -- amounts expected by payor

And, it must be current with all requirements changes and additions.

Why use a system specifically designed for the dialysis industry?

Use of medical billing systems designed predominantly for medical records or for other business applications often does not effectively address dialysis reimbursement issues and commonly creates dramatically greater user workloads and lost revenue for dialysis. For example:

• Artificial admit/discharge cycles
• Manual processing of breaks in service
• Tedious checking and resolution of compliance and justification issues
• Manual generation of re-bills and accounting adjustments for retroactive coverage changes
• Manual switchover of insurance coverage
• Limited insurance plan or payer template storage
• Burdensome access to information to prevent lost and abandoned charges
• System does not support automatic contractual adjustments based on specific payors; doesn't track actual Accounts Receivable (AR)
• There may be little incentive for the supplier to stay current with dialysis requirements changes

Why QMS?

QMS provides guidance, support, and systems designed specifically to the needs of the dialysis field, and has been doing so for more than 29 years. Systems are supplied to our clients and are continually upgraded and maintained. There is only one version of the software, which is supplied to all QMS customers as soon as a new release is available (there are no charges for new and enhanced versions). This results in the most efficient use of our development resources to continually improve and expand our systems to our more than 2,000 providers (approximately 1/2 of the US dialysis field).

QCS -- the QMS clinical application

QCS has been developed to address the issues of tracking clinical information for dialysis providers in order to monitor dialysis, evaluate critical outcomes and support quality improvement initiatives, detect sub-clinical problems, pass on problem issues to future staff, and generate information for all levels of clinical and administrative staff as they need to improve clinical results and respond to ever increasing demands of monitoring and regulatory agencies. Importantly it is designed to address the difficult interface between the busy patient care members, for whom data collection may be perceived as a tedious extra task. More...

QMS Focus

QMS Focus is a highly developed reimbursement system for claim generation, tracking AR, and assisting collections to address the financial challenges of this field. It has been under development for well over two decades and is used by a wide range of providers from small single clinics to some of the most sophisticated multi-provider corporations in the US. More...