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ABILITY Network Inc. - Company Confidential

ABILITY Network Inc

User Guide

Copyright and Trademark

Copyright

Copyright 2017 ABILITY Network Inc. All Rights Reserved. All text, images, and graphics, and

other materials in this document are subject to copyright and other intellectual property rights of

ABILITY Network Inc. These materials many not be reproduced, distributed, modified, or

republished without the express written permission of ABILITY Network Inc.

Trademark

The marks appearing in this document including, but not limited to ABILITY Network (ABILITY),

ABILITY logo, and all ABILITY services are trademarks and/or registered trademarks of

ABILITY Network Inc. All other brands, product names, or services are trademarks or registered

trademarks of their respective holders.

PROPRIETARY AND CONFIDENTIAL | iii

User Guide

Contents

ABILITY | INSIGHT™ Overview .................................................................................................. 1

Navigation Bar and Folders ......................................................................................................... 2

Configure INSIGHT ........................................................................................................... 3

INSIGHT Configuration ............................................................................................................... 4

Configure Profiles ............................................................................................................. 4

Add Profile .................................................................................................................................. 6

All Reports ................................................................................................................................ 10

Medicare Claim Error Analysis .................................................................................................. 11

Your Medicare Claims ..................................................................................................... 14

INSIGHT (Medicare Claim Error Reasons)...................................................................... 17

Medicare Claim Error Reasons Table ............................................................................. 17

Claim Error Trends .......................................................................................................... 19

Medicare Claim Success Analysis............................................................................................. 20


INSIGHT (Medicare Claim Success Analysis) ................................................................. 26

Medicare Claim Success Analysis Table ......................................................................... 26

Medicare Claim Success Analysis Trend Charts ............................................................. 29

Medicare Revenue Cycle Efficiency Analysis ............................................................................ 30


INSIGHT (Medicare Revenue Cycle Efficiency Analysis) ................................................ 36

Medicare Revenue Cycle Efficiency Analysis Table (HHA) ............................................. 37

Medicare Revenue Cycle Efficiency Analysis Trend Charts (HHA) ................................. 39

Medicare Revenue Cycle Efficiency Analysis Table (SNF) .............................................. 43

Medicare Revenue Cycle Efficiency Analysis Trend Charts (SNF) .................................. 45

Medicare Patient Operational Analysis ...................................................................................... 48

Your Medicare Patients ................................................................................................... 51

INSIGHT (Medicare Patient Operational Analysis) .......................................................... 54

Medicare Patient Operational Analysis Trend table (HHA) .............................................. 54

Medicare Patient Operational Analysis Trend Charts (HHA) ........................................... 56

Medicare Patient Operational Analysis Table (SNF) ....................................................... 57

Medicare Patient Operational Analysis Trend Charts (SNF) ............................................ 59

Medicare Billing and Coding Analysis ....................................................................................... 60

iv | PROPRIETARY AND CONFIDENTIAL

User Guide

Contents (cont.)

Your Medicare Patients ................................................................................................... 63

INSIGHT (Medicare Billing and Coding Analysis) ............................................................ 66

Billing INSIGHT Table ..................................................................................................... 67

HHA Episode Type Analysis ..................................................................................................... 69


INSIGHT (HHA Episode Type Analysis) .......................................................................... 75

Episode Type Analysis Table .......................................................................................... 75

Episodes Trend Charts ................................................................................................... 77

PROPRIETARY AND CONFIDENTIAL | 1

User Guide

ABILITY | INSIGHT™ Overview

At ABILITY®, our mission is to provide innovative products and services that reduce the

administrative complexities of healthcare. We do this through the myABILITY® platform which

provides you with streamlined, easy-to-use access and navigation to all your ABILITY services. As

the name implies, myABILITY gives you the ability to select and configure network services specific

to your business requirements.

ABILITY | INSIGHT is a set of reports intended to give you deeper insight into your organization’s

revenue cycle and financial performance, as well as track that information against your peers. You

can also determine the specific date range for which you want to analyze and filter your reports,

using various dimensions for more in-depth analysis.

ABILITY | INSIGHT can also help you identify cash flow deficiencies and revenue leakage in an

efficient manner, as well as measure the efficacy of corrective actions. Moreover, you can gather

market insights and your relative strengths and weaknesses against your competition. Together,

this information can provide guidance for your business decisions.

ABILITY | INSIGHT Reports

Table 1 provides you with the names and brief descriptions of the six ABILITY | INSIGHT reports.

Table 1: ABILITY | INSIGHT Reports and Descriptions

Report Name Description

Medicare Claim

Error Analysis

See where you need to focus to eliminate claim errors. This report helps

you answer the question, “What causes my claim errors?”

Medicare Claim

Success Analysis

Determine how your RTP and Rejection / Denial rates compare to your

peers. This report answers the question, “Do I encounter claim errors more

than my peers?”

Medicare Revenue

Cycle Efficiency

Analysis

Determine how your organization can maximize revenue and accounts

receivable days compared to your peers. This report answers the question,

“Do I get paid more or less quickly than my peers?”

Medicare Patient

Operational

Analysis

Determine how your organization compares to its peers for operational

metrics such as average patient census and length of stay. This report

helps you answer the question, “How do my patient census and patient mix

compare to my peers?”

Medicare Billing

and Coding

Analysis

Discover how your reimbursement and utilization practices compare to your

peers based on service code (HCPCS / HIPPS / Rate Codes). This report

helps you answer the questions, “Do I get paid less than my peers? Do I

use lower value codes more often?”

HHA Episode

Type Analysis

Compare your percentage of various episode types to regional, state and

national peers. This report helps you determine if you need to take

corrective action if your percentage of PEP and LUPA episodes exceed

industry norms. This analysis only includes paid claims.

2 | PROPRIETARY AND CONFIDENTIAL

User Guide

Navigation Bar and Folders

The navigation bar and folders with tabs appear on the My Workspace page and provide you with

easy access to ABILITY | INSIGHT. The navigation bar appears at the top of all

ABILITY | INSIGHT pages. The folders and tabs only appear on the My Workspace page.

The Analytics selection on the navigation bar (Figure 1) and the Analytics folder (Figure 2) both

provide you with the INSIGHT selection.

Figure 1: Navigation bar with Analytics selected

Figure 2: Analytics folder with INSIGHT selection


User Guide

Configure INSIGHT

Your first step in getting starting with ABILITY | INSIGHT is to configure your profile. You can

configure your profile by clicking Configure INSIGHT in the ANALYTICS folder (Figure 3) or click

All Reports in the ANALYTICS folder (Figure 4) and then Configure Profiles on the All Reports

page (Figure 5).

Figure 3: Analytics folder with Configure INSIGHT indicated

Figure 4: Analytics folder with All Reports indicated

Figure 5: Analytics folder with Configure Profiles indicated


User Guide

INSIGHT Configuration

Use the INSIGHT configuration page to define the data used to calculate your organization’s and

your peers’ benchmarks. You may select the NPIs used to define your organization as well as the

provider type, size and geographic location to define your peer benchmarks. You may toggle

between different profiles for each report in ABILITY | INSIGHT.

Configure Profiles

The Show Entries field and Page Numbering field appear at the top of the Configure Profiles page

(Figure 6).

Show Entries

Use this dropdown box to determine the number of entries that display on each page. Available

choices are 10, 25, 50, and 100. The more entries you have, the greater the number you may want

to display on each page.

Previous / Page Number / Next

Click Previous to display the page immediately before the one that appears, click Next to display

the page immediately after that one that appears, or click a page number to display a particular

page.

Figure 6: Configure Profiles page with Show entries and Page / Page Number / Next indicated

Table 2 provides information on the columns that appear on this page:

Table 2: INSIGHT Configuration Column Descriptions

Column Description

Profile Name The name given to the profile when you or another Administrative User created it.

The profile name must be unique.

Description The description given to the profile when you or another Administrative user

created it.

Options Use this column to either Edit or Delete an existing profile.

Click Edit to open the Add / Edit INSIGHT Profile.

Click Delete to open a dialog box that asks you to confirm the deletion.


User Guide

NOTE: You can toggle the sort on any of the columns where the up and/or down arrows ( )

appear by clicking on the arrows or column name.

The following figures show examples of how you might configure your profiles for a home health

agency (Figure 7) or a skilled nursing facility (Figure 8).

Figure 7: Configure Profile page for Home Health Agency (example)

Figure 8: Configure Profile page for Skilled Nursing Facility (example)


User Guide

Add Profile

Click + Add Profile to open the Add / Edit INSIGHT profile page. Figure 9 (for a home health

agency and Figure 10 (for a skilled nursing facility) provide sample profile examples.

Figure 9: Add / Edit INSIGHT Profile page for Home Health Agency


User Guide

Figure 10: Add / Edit INSIGHT Profile page for Skilled Nursing Facility


User Guide

When you create a profile, select a provider type, a provider size, and ZIP codes similar to those for

your own organization. Also, select multiple NPIs and geographic areas that correspond to all the

providers and areas that apply to your location. By doing so, the results ABILITY | INSIGHT returns

to your users will be most relevant for your location.

NOTE: The ZIP codes you enter on this page determine the regional and state benchmarks.

To take full advantage of ABILITY | INSIGHT, you will probably want to create multiple profiles,

especially if your organization has multiple locations. When ABILITY | INSIGHT reports appear,

your users can toggle between these profiles.

Fields marked with an asterisk are required. Your selections on this page determine how

ABILITY | INSIGHT reports appear to the users that have permissions for this profile.

Complete the fields in Table 3 to add a new profile. Required fields are marked with an asterisk.

Table 3: Active and Archived Records actions

Field Description

Profile Name* The unique name given to the profile.

Profile

Description

Descriptive wording to help you and other administrative users identify the

profile.

Provider Type* Select either of the two provider types:

Home Health Agency – If you select this type, your Provider Size will be

based upon your annual patient census.

Skilled Nursing Facility – If you select this type, your Provider Size will be

based upon your Medicare certified bed count.

NPIs* Use the search field or select at least one NPI (National Provider Identifier).

Provider Size* Select a provider size. The Provider Type you picked determines whether the

selections that appear here apply to your annual census (home health

agencies) or bed count (skilled nursing facilities).

If you define your own custom provider size:

the minimum size must be a multiple of 25 and less than 5,000

the maximum size must be a multiple of 25 and greater than the minimum

Geography Enter one or more ZIP codes to determine the region and state of your peer

providers. ABILITY | INSIGHT uses the ZIP codes you enter when

comparing your data against the data from similar providers. The region is

based upon the first three digits of the ZIP code you enter.


User Guide

Table 3: Active and Archived Records actions

Field Description

User Permissions Only users you select in this field can access this profile. Users with

access to multiple profiles can switch between those profiles on the

ABILITY | INSIGHT report pages.

To provide permissions to a user that does not appear on this list:

1. Go to the Edit User page for that person in myABILITY.

2. Select the Application Specific Settings tab, INSIGHT sub tab.

3. Move one or more profiles from the Available box to the Selected box.

4. Click Save.

If you are creating a new profile, click Save Profile to create it. If you are editing an existing profile,

click Update Profile to save your changes.


User Guide

All Reports

The Analytics selections on the navigation bar and the Analytics folder both provide you with access

to the All Reports page (Figure 11). This page displays further information on all six

ABILITY | INSIGHT analysis reports available to you. Use these analyses to compare your

organization’s financial and revenue cycle performance against your regional, state, and national

peers.

Descriptions for all six ABILITY | INSIGHT reports appear on the following pages:

Medicare Claim Error Analysis (page 11)

Medicare Claim Success Analysis (page 20)

Medicare Revenue Cycle Efficiency Analysis (page 30)

Medicare Patient Operational Analysis (page 48)

Medicare Billing and Coding Analysis (page 60)

HHA Episode Type Analysis (page 69)

Figure 11: All Reports page

Click the arrow ( ) or title to open the corresponding ABILITY | INSIGHT analysis page.

If you have been provided with ABILITY | INSIGHT administrative permissions on the Manage

Users page, then this page also provides you with a link to configure ABILITY | INSIGHT profiles.


User Guide

Medicare Claim Error Analysis

Use the Medicare Claim Error Analysis report (Figure 12) where you need to focus to eliminate

claim errors. This report helps you answer the question, “What causes my claim errors?”

Figure 12: Medicare Claim Error Analysis report


User Guide

Figure 13 shows the fields that appear at the top of the report.

Figure 13: Medicare Claim Error Analysis report (top)

To change any of these values, click Change and use the dropdown box to select another value.

Your changes will be the new default values the next time you select this report.

Profile – The name given to the profile when your administrator created it.

Submission Date Range – The beginning and ending date for the report. The following date

range options are available:

o Most Recent 2 weeks – last two weeks based upon latest data refresh date

o Most Recent Month – last complete month for which results are available

o Previous Months – select any one of the last six previous months

o Most Recent Quarter – last complete quarter for which results are available

o Previous Quarters – select any one of the last four previous quarters

o Custom Range – open a calendar to select a beginning and ending date range

This dropdown box also provides you with the last time this report was refreshed.

NOTE: Since this report focuses on revenue cycle performance, the dates in this dropdown

box refer to the submission date of the claim.

Filters – Click Filters or the right arrow ( ). A panel opens where you can select which

diagnostic and service codes appear on the report.

To search for a particular code, use the Search box to perform a search on all of the

columns. You can also toggle the sort on any of the columns by clicking the column name or

the up / down arrows ( ).

Select a code by checking the checkbox in the left column. Remove the code by clearing the

check or clicking the x on the Filters line. To select/unselect all codes on all pages, select

the checkbox in the header row. To remove all codes, you can also click (Clear All) on the

Filters line.

There are two tabs: Diagnosis (Figure 14) and HCPCS/HPPS/RUG Figure 15).

On either tab, select a diagnosis code by checking the checkbox in the left column. Remove

the code by clearing the check. To select all codes on all pages, select the checkbox in the

header row.


User Guide

Diagnosis tab – Allows you to limit your search by either ICD-9 or ICD-10.

HCPCS / HPPS / RUG tab – Allows you to limit your search by either of the following

criteria:

HCPCS / CPT - Healthcare Common Procedure Coding System (HCPCS)

Terminology / Current Procedural Terminology (CPT

HIPPS / RUG – Health Insurance Prospective Payment System (HIPPS) /

Resource Utilization Group (RUG)

Click Apply to accept your changes and refresh the report with the information you selected.

Figure 14: Filters selection with Diagnosis tab

Figure 15: Filters selection with HCPCS/HIPPS/RUG tab


User Guide

Your Medicare Claims

Use the Medicare Claims panel (Figure 16) to view the following information:

Figure 16: Your Medicare Claims panel

Table 4 describes these fields.

Table 4: Your Medicare Claims field descriptions

Field Description

Total Claims Total number of RTP or rejected / denied claims for the codes and

timeframes you selected.

Your Claim Value Amount Sum of the billed amount for unpaid claims and paid amount for paid claims.

View As Display the trend chart using any of the following selections

ordered from most column to least common:

Number of Rejections / Denials – All reasons.

Billed Amount of Rejections / Denials – Denials as defined

by your outstanding billed amount.

Number of RTPs – RTPs as defined by number of claims.

Billed Amount of RTPs – Reasons for RTPs / denials as

defined by your outstanding billed amount.


User Guide

Export Claim Details

Click this button to export claim details from this analysis to an Excel spreadsheet titled

ExportClaimDetails.csv that you can open or save to your computer. This spreadsheet helps you

identify the exact claims used in the analysis so you can take follow up action.

Table 5 describes the columns that appear.

Table 5: Export Claim Details column descriptions

Field Description

A ClaimId Identification number of the claim.

B ReceiptDate Date you received this claim.

C PayerClaimControlNumber Payer Claim Control Number.

D Tob Type of Bill.

E IsRap 0 is Final Claim. 1 is RAP (Request for Anticipated

Payment)

F Status P-Paid. D - Rejected/Denied. T- Returned to Provider

G IsPaid 1 is Paid. 0 is Unpaid

H IsClean 1 is Clean. Claim was paid without ever being

rejected/denied.

0 claim was Returned to Provider or Rejected/Denied.

I HasResubmission 1 claim was resubmission of a previous claim.

0 claim was not a resubmission of a previous claim.

J HasRtp 1 claim has been Returned to Provider.

0 claim has not been Returned to Provider.

K HasDenied 1 claim has been rejected/denied by Medicare.

0 claim was not denied by Medicare.

L RtpCodes Returned to Provided error code number.

M AdjustmentCodes ANSI Adjustment Code number.

N Npi Ten-digit NPI (National Provider Identifier) Number.

O Capacity For HHA, estimated patient census.

For SNF, estimated bed count.

P Zip3 First three digits of ZIP code. Used to define your regional

peers.

Q State State where ZIP3 is located. Used to define your state

peers.


User Guide


Field Description

R FromDate Original Date of Claim.

S ToDate Ending Date of Claim.

T LengthofStay Number of days patient stayed at your location.

U TotalCharge Total amount you billed Medicare.

V TotalPaid Total amount paid to you by Medicare.

W PaidDate Date in which you received payment from Medicare.

X SubmissionDays Number or days in your report submission.

Y ReimbursementDays Number of days you were reimbursed for the patient stay at

your location.

Z RapSubmissionDays Average number of days from start-of-episode to claim

submission.

AA RapReimbursementDays Average Number of days from claim submission to ERA

received.

AB EpisodeVisits Number of episode visits that occurred for this claim.

AC IsPepEpisode 1 is Pep Episode.0 is not a Pep Episode.

AD IsOutlierEpisode 1 is an Outlier Episode. 0 is not an Outlier Episode

AE IsLupaEpisode 1 is Lupa episode.0 is not a Lupa episode.

AF Diagnosis Codes Diagnosis Codes for this claim.

Each code is separated by a tilde ~ symbol.

AG Service Codes Service Codes for this claim.



User Guide

INSIGHT (Medicare Claim Error Reasons)

This panel (Figure 17) shows you the sample size for the trend charts on this report and your

INSIGHT alert symbol.

Figure 17: Medicare Claim Error Reasons panel

Medicare Claim Error Reasons Table

ABILITY | INSIGHT provides you with this benchmarking information based upon other providers

using ABILITY product offerings. The number in parenthesis indicates the number of providers

ABILITY | INSIGHT used when determining the benchmark. This information is updated on a

regular basis. See the number in parentheses for the sample size.

The following checkboxes are available to you:

Regional Average

State Average

National Average

As you select / unselect each checkbox, the columns in the table appear and disappear.

Figure 18 provides an example of this table.

Figure 18: Medicare Claim Error Reasons Code table

NOTE: An INSIGHT alert symbol ( ) indicates your percentage is 5% or HIGHER than the

regional, state, or national average. If you see this symbol, you may want to conduct further

research into this area to determine the cause and improve on any deficits.


User Guide

By default, ABILITY | INSIGHT sorts the list of error codes by the percentage of errors at your

facility in descending order. Table 6 describes the columns that appear.

Table 6: Your Medicare Claim Error Reason Code column descriptions

Column Description

Code Claim error code.

Type Type of claim error code. The following types can appear:

DDE Reason Code

ANSI Adjustment Code

ANSI Status Code

Description Claim error code description.

NOTE: For ANSI status codes, this description includes the NSI claim status category code description (Figure 19).

Figure 19: ANSI status code in Description column

% of Errors at Your

Facility

Based on all Returned to Provider or Denied Medicare claims at

your facility for the selected time period, the percentage that

makes up this reason code. Hover over the status bar to see the

exact number or dollar amount of claims.

Regional Average, Stage

Average, or National

Average

Based on all Returned to Provider or Denied Medicare claims by

a regional, state, or national average for the selected time period.

This column contains the percentage that make up this reason

code.

If you have more than ten reason codes, use the page numbering at the bottom to see additional

reason code pages.


User Guide

Claim Error Trends

Use the Claim Error Trends chart (Figure 20) to see how your organization trends based upon the

reason codes with the largest percentage of Returned to Provider / Denial Reasons.

To see additional information within the graph, move your cursor along the lines that appear. A

hover box provides the following information:

Date

Reason code and description

Description

Number of Claims or Billed Amount depending upon selection in View As dropdown box

Select Daily, Weekly, or Monthly to determine the trend line increments that appear on the graph.

Horizontal Axis

The time period shown along the horizontal axis matches the reporting time period you selected on

this page.

Vertical Axis

Your selection on the View As dropdown box determines the vertical axis.

Figure 20: Claim Error Trends (daily view)


User Guide

Medicare Claim Success Analysis

Use the Medicare Claim Success Analysis report to monitor the rate at which your claims are

adjudicated successfully as well as the rate at which you experience claim errors (RTPs and

Rejections/Denials). This report answers the question, “Do I encounter claim errors more than my

peers?” (Figure 21).

Figure 21: Medicare Claim Success Analysis report


User Guide

If you find that your RTPs or Rejection / Denial rates are higher than your peers, use the Medicare

Claim Error Analysis report to determine the underlying causes.


Figure 22: Medicare Claim Success Analysis report (top)

To change any of these values, click Change and use the dropdown boxes to select other values.





o Most Recent 2 Weeks – last two weeks based upon latest data refresh date

















Filters line.

There are two tabs: Diagnosis (Figure 23) and HCPCS/HPPS/RUG (Figure 24).



header row.


User Guide



criteria:

o HCPCS / CPT - Healthcare Common Procedure Coding System (HCPCS)

Terminology / Current Procedural Terminology (CPT)

o HIPPS / RUG – Health Insurance Prospective Payment System (HIPPS) /






User Guide


Use the Your Medicare Claims panel (Figure 25) to view the following information:


Table 7 describes the fields in this panel.


Field Description

Total Claims Total number of RTP / Denied claims for the codes and

timeframes you selected.

Your Claim Value Amount Sum of the billed amount for unpaid claims and paid amount for paid claims.

View As Display the trend chart based on either of the following criteria:

Number of Claims - Determine the most common reasons

for RTP / Denied rates as defined by number of claims.

Dollar Value of Claims – Determine the most common

reasons for RTP / Denied rates as defined by the dollar

value of claims.


User Guide







Field Description




D Tob Type of Bill.

E IsRap 0 is Final Claim.

1 is RAP (Request for Anticipated Payment)

F Status P-Paid D - Rejected/Denied T- Returned to Provider

G IsPaid 1 is Paid. 0 is Unpaid.


rejected/denied.














peers.


peers.


User Guide


Field Description








Y ReimbursementDays Number of days you were reimbursed for the patient stay

at your location.


submission.


received.


AC IsPepEpisode 1 is Pep Episode. 0 is not a Pep Episode.


AE IsLupaEpisode 1 is Lupa episode. 0 is not a Lupa episode






User Guide

INSIGHT (Medicare Claim Success Analysis)

This panel shows you the sample size for the trend charts on this report and your INSIGHT alert

symbol (Figure 26).

Figure 26: Medicare Claim Success Analysis panel

Medicare Claim Success Analysis Table

ABILITY | INSIGHT provides you with this benchmarking information (Figure 27) based upon other

providers using ABILITY product offerings. This information is updated on a regular basis See the

number in parentheses for the sample size.


Regional Average

State Average

National Average

As you select / unselect each checkbox, the corresponding columns in the table appear and

disappear.

Figure 27: Medicare Claim Success Analysis table


User Guide

The % of Total Column always appears. Hover over the rows in this column to see the specific

number of claims or dollar amount (as determined by your selection in the View As dropdown box).

Table 9 describes the columns that appear in this table.

Table 9: Medicare Claim Success Analysis column descriptions

Category Status Description

Paid - percentage of claims paid by

Medicare, as calculated by either

number of claims or dollar amount.

NOTE: An INSIGHT alert symbol

( ) indicates your percentage is

5% or LOWER than the regional,

state, or national average. If you

see this symbol, you may want to

conduct further research into this

area to determine the cause and

improve on any deficits.

RTP Percentage of claims that were initially

Returned to Provider by Medicare and then

subsequently paid as calculated by either

number of claims or dollar amount.

NOTE: An INSIGHT alert symbol ( )

indicates your percentage is 5% or HIGHER

than the regional, state, or national average. If

you see this symbol, you may want to conduct

further research into this area to determine the

cause and improve on any deficits.

Rejected /

Denied

Percentage of claims that were initially rejected

or denied by Medicare and then subsequently

paid.







Clean Percentage of claims paid by Medicare upon

your initial submission of the claim.

NOTE: This status is also referred to as First

Pass Acceptance (FPA).


indicates your percentage is 5% or LOWER






User Guide


Category Status Description

Not Paid - percentage of claims

that remain unpaid by Medicare, as

calculated by either number of

claims or dollar amount.

NOTE: An INSIGHT alert symbol

( ) indicates your percentage is

5% OR HIGHER than the regional,

state, or national average. If you

see this symbol, you may want to

conduct further research into this

area to determine the cause and

improve on any deficits.

RTP Percentage of unpaid claims Returned to

Provider by Medicare as calculated by either

number of claims or dollar amount. These

claims remain unpaid.







Rejected /

Denied

Percentage of claims denied by Medicare, as

calculated by either number of claims or dollar

amount. These claims remain unpaid.







Cancelled Percentage of claims cancelled, as calculated

by either number of claims or dollar amount.

These claims remain unpaid.








User Guide

Medicare Claim Success Analysis Trend Charts

Use these color-coded graphics to see the following trends:

Return to Provider – Paid (Figure 28)

Rejected / Denied – Paid

Clean – Paid

Return to Provider – Not Paid

Rejected / Denied – Not Paid

Cancelled – Not Paid



hover box provides the exact regional, state, and/or national averages for the selected date as well

as your own average. A linear trend line, labelled You (trend), lets you see your overall trend.

Horizontal Axis

The time period shown along the horizontal axis matches the reporting time period you selected in

the Date Range dropdown box on this page. The percentage appears from 0% to 100%.

Vertical Axis

The vertical axis display this information as either a percentage of the total number of claims or as a

percentage of the total dollar value of claims, as determined by your selection in the View As

dropdown box.

Return to Provider (Paid)

Figure 28: Return to Provider (Paid) trend chart (daily view)


User Guide

Medicare Revenue Cycle Efficiency Analysis

Use the Medicare Revenue Cycle Efficiency report (Figure 29) to determine how your organization

is maximizing revenue and minimizing accounts receivable days compared to your peers. This

report answers the question, “Do I get paid more or less quickly than my peers?”

Figure 29: Medicare Revenue Cycle Efficiency Analysis report (HHA and SNF versions)


User Guide


Figure 30: Medicare Revenue Cycle Efficiency Analysis (top)

To change any of these values, click Change and use the dropdown boxes to select other values.






















Filters line.




header row.


User Guide



criteria:







Figure 32: Filters selection with HCPCS/HIPPSRUG tab


User Guide


Figure 33 shows the Your Medicare Claims panel.

Figure 33: Your Medicare Claim panel

Table 10 describes the fields that appear in this panel.


Field Description

Total Paid Claims Total number of paid claims for the code(s) and timeframe you

selected.

Your Paid Amount Total paid amount for the code(s) and timeframe you selected.


User Guide







Field Description



C PayerClaimControlN

umber

Payer Claim Control Number.

D Tob Type of Bill.

E IsRap 0 is Final Claim. 1 is RAP (Request for Anticipated Payment)

F Status P-Paid. D - Rejected/Denied.T- Returned to Provider


H IsClean 1 is Clean. Claim was paid without ever being rejected/denied.




J HasRtp 1 claim has been Returned to Provider. 0 claim has not been

Returned to Provider.





N Npi Ten-digit NPI (National Provider Identifier) Number

O Capacity For HHA, estimated patient census. For SNF, estimated bed

count.

P Zip3 First three digits of ZIP code. Used to define your regional peers.

Q State State where ZIP3 is located. Used to define your state peers.




User Guide


Field Description






Y ReimbursementDays Number of days you were reimbursed for the patient stay at your

location.


submission.

AA RapReimbursementD

ays

Average Number of days from claim submission to ERA received.



AD IsOutlierEpisode 1 is an Outlier Episode. 0 is not an Outlier Episode.

AE IsLupaEpisode 1 is Lupa episode. 0 is not a Lupa episode.






User Guide

INSIGHT (Medicare Revenue Cycle Efficiency Analysis)



Figure 34: Medicare Revenue Cycle Efficiency Analysis Table panel

ABILITY | INSIGHT provides you with this benchmarking information based upon other providers

using ABILITY product offerings. This information is updated on a regular basis. See the number in

parentheses for the sample size.


Regional Average

State Average

National Average


disappear.

NOTE: The report you see depends upon whether your profile indicates you are located at a skilled

nursing facility or home health agency.

If you located at a home health agency, continue to the next section.

If you are located at a skilled nursing facility, go to page 43.


User Guide

Medicare Revenue Cycle Efficiency Analysis Table (HHA)

Figure 35 shows the rows that appear if your profile indicates you are located at a home health

agency.

Figure 35: Medicare Revenue Cycle Efficiency Analysis tables (HHA)

Table 12 describes these rows.

Table 12: Medicare Revenue Cycle Efficiency Analysis table (HHA)

Column Description

Average Days to

Submission - Final

Claims

Average number of days from end-of-episode to claim submission.

NOTE: An INSIGHT alert symbol ( ) indicates your percentage is 5% or

HIGHER than the regional, state, or national average. If you see this

symbol, you may want to conduct further research into this area to

determine the cause and improve on any deficits.

Average Days to

Submission - RAPs

Average number of days from start-of-episode to claim submission for

RAPs (Requests for Anticipated Payments).






User Guide

Table 12: Medicare Revenue Cycle Efficiency Analysis table (HHA)

Column Description

Average Days to

Reimbursement -

Final Claims

Average Number of days from claim submission to ERA received for Final

claims.





Average Days to

Reimbursement -

RAPs

Average number of days from claim submission to ERA received for RAP

claims.





Total Resubmissions

The number of claims that required you resubmit them in order for you to

be paid. Use this chart to see how often you had claim errors that required

resubmissions.





Total

Reimbursement

Amount that you billed Medicare compared with the amount that you

received in payment.


LOWER than the regional, state, or national average. If you see this




User Guide

Medicare Revenue Cycle Efficiency Analysis Trend Charts (HHA)

Use these color-coded trend charts to see absolute values and compare them against state,

regional, or national averages.

The following trend charts appear:

Average Days to Submission - Final Claims (Figure 36)

Average Days to Submission - RAPs (Figure 37)

Average Days to Reimbursement - Final Claims (Figure 38)

Average Days to Reimbursement - RAPs (Figure 39)

Percentage Reimbursements Trend Figure 40

Billing vs Reimbursements Trend (Figure 41)



hover box provides the exact average for the selected date.

Horizontal Axis

The time period shown along the horizontal axis matches the Date Range you selected on the top

of this report.

Vertical Axis

Depending upon the trend chart you are viewing, the vertical axis contains either of the following

types of information:

Average Days to Reimbursement Trend- The number of days from 0 to 100

% Reimbursement Trend and Billing vs. Reimbursement Trend - The percentage from 0% to

100% for the Reimbursements of Total Submissions or Reimbursements of Total Billings


User Guide

Average Days to Submission - Final Claims

Figure 36: Average Days to Submission – Final Claims Trend Chart (weekly view)

Average Days to Submission - RAPs

Figure 37: Average Days to Submission – RAPs Trend Chart (weekly view)


User Guide

Average Days to Reimbursement - Final Claims

Figure 38: Average Days to Reimbursement – Final Claims Trend Chart (weekly view)

Average Days to Reimbursement - RAPs

Figure 39: Average Days to Reimbursement - RAPs Trend Chart (weekly view)


User Guide

Percentage Reimbursements Trend

Figure 40: Percentage Resubmissions Trend Chart (weekly view)

Billing vs Reimbursements Trend

Figure 41: Billing vs Reimbursement Trend Chart (weekly view)


User Guide

Medicare Revenue Cycle Efficiency Analysis Table (SNF)

Figure 42 shows the rows that appear if your profile indicates you are located at a skilled nursing

facility.

Figure 42: Medicare Revenue Cycle Efficiency Analysis table (SNF)


Table 13: Medicare Revenue Cycle Efficiency Analysis table (SNF)

Row Description

Average Days to

Submission

Number of days from end-of-episode to claim submission)

NOTE: An INSIGHT alert symbol ( ) indicates your percentage is

5% or HIGHER than the regional, state, or national average. If you

see this symbol, you may want to conduct further research into this

area to determine the cause and improve on any deficits.

Average Days to

Reimbursement

Average number of days from claim submission to ERA received






User Guide

Table 13: Medicare Revenue Cycle Efficiency Analysis table (SNF)

Row Description

Total Resubmissions The number of claims that require you resubmit them in order for

you to be paid. Use this chart to see how often you had claim

errors that required resubmissions.





Total Reimbursement Amount that you billed Medicare compared with the amount that

you received in payment. Use this chart to see the extent to which

discrepancies occur between these two categories when

compared to similar discrepancies that occur among your peers.

NOTE: An INSIGHT alert symbol ( ) indicates your percentage

is 5% or LOWER than the regional, state, or national average. If

you see this symbol, you may want to conduct further research into

this area to determine the cause and improve on any deficits.


User Guide

Medicare Revenue Cycle Efficiency Analysis Trend Charts (SNF)


regional, or national averages.


hover box provides the exact average for the selected date.


Average Days to Submission (Figure 43)

Average Days to Reimbursement (Figure 44)

Percentage Resubmissions (Figure 45)

Billing vs Reimbursements (Figure 46)

To see additional information within the graph, move your cursor along the lines that appear. A hover box provides the exact average for the selected date.


Horizontal Axis


of this report.

Vertical Axis

Depending upon the trend chart you are viewing, the vertical axis contains either of the following

types of information:

Average Days to Reimbursement Trend- The number of days from 0 to 100

% Reimbursement Trend and Billing vs. Reimbursement Trend - The percentage from 0% to 100% for the Reimbursements of Total Submissions or Reimbursements of Total Billings


User Guide

Average Days to Submission Trend

Figure 43: Average Days to Submission Trend Chart (daily view)

Average Days to Reimbursement Trend

Figure 44: Average Days to Reimbursement Trend Chart (weekly view)


User Guide

Percentage Resubmissions Trend

Figure 45: Percentage Resubmissions Trend Chart (weekly view)

Billing vs Reimbursements Trend

Figure 46: Billing vs Reimbursement Trend Chart (weekly view)


User Guide

Medicare Patient Operational Analysis

Use the Medicare Patient Operational Analysis report (Figure 47) to determine how your

organization compares to its peers for operational metrics such as average patient census and

length of stay. This report helps you answer the question, “How do my patient census and patient

mix compare to my peers?”

Figure 47: Medicare Patient Operational Analysis (HHA and SNF versions)


User Guide


Figure 48: Medicare Patient Operational Analysis (top)

To change any of these values, click Change and use the dropdown box to select another value.


Profile – The name given to the profile when your Administrator created it.










NOTE: Since this report focuses on patient care, the dates in this dropdown box refer to the

statement dates of the claim.









Filters line.




header row.


User Guide



criteria:


Terminology





Figure 50: Filters selection with HCPCS/HIPPSRUG tab


User Guide

Your Medicare Patients

Figure 51 shows the Your Medicare Patients panel.

Figure 51: Your Medicare Patient panel


Table 14: Your Medicare Patients field descriptions

Field Description

Total Patients Total number of patients your agency cared for in the timeframe you

selected.

Total Paid Claims Total number of paid claims your agency submitted in the timeframe you selected.


User Guide







Field Description

A ClaimId Identification number of the claim..



D Tob Type of Bill.


Payment).

F Status P-Paid. D - Rejected/Denied. T- Returned to Provider.



rejected/denied.














peers.


peers.


User Guide


Field Description








Y ReimbursementDays Number of days you were reimbursed for the patient stay at

your location.


submission.


received.




AE IsLupaEpisode 1 is Lupa episode 0 is not a Lupa episode.






User Guide

INSIGHT (Medicare Patient Operational Analysis)



Figure 52: Medicare Patient Operational Analysis panel

Medicare Patient Operational Analysis provides you with benchmarking information based upon

other providers using ABILITY product offerings. The number in parenthesis indicates the number

of providers ABILITY | INSIGHT used when determining the benchmark. This information is updated

on a regular basis. See the number in parentheses for the sample size.

The following checkboxes are available to you.

Regional Average

State Average

National Average

NOTE: The report you see depends upon whether your profile indicates you are located at a skilled

nursing facility or home health agency.

If you are located at a home health agency, continue to the next section.

If you are located at a skilled nursing facility, go to page 48.

Medicare Patient Operational Analysis Trend table (HHA)

Figure 53 appears if your profile indicates you are located at a home health agency.

Figure 53: Medicare Patient Operational Analysis Table panel (HHA)


User Guide


Table 16: Medicare Patient Operational Analysis table

Row Description

Average Daily Patient Census Daily average patient census.

Average Length of Stay

(days)

Daily average length of stay. ABILITY | INSIGHT determines this

date by the start and end date on your claims.

Reimbursement Per Claim Average claim dollar amount for your facility.

NOTE: An INSIGHT alert symbol ( ) indicates your

percentage is 5% or LOWER than the regional, state, or national

average. If you see this symbol, you may want to conduct further

research into this area to determine the cause and improve on

any deficits.

Reimbursement Per Patient Average by clinicians to your facility per episode.


percentage is 5% or LOWER than the regional, state, or national



any deficits.

Visits/Episode

(non-normalized)

Average visits by clinicians to your facility per episode.

Normalization treats the generally fewer number of visits in a

shortened non-normalized episode on an equal footing to the

number of visits in a standard length 60-day episode. Because

of this, the non-normalized visits/episode number will probably

be lower than the normalized number below it.


percentage is 5% HIGHER or LOWER than the regional, state,

or national average. If you see this symbol, you may want to

conduct further research into this area to determine the cause

and improve on any deficits.

Visits/Episode

(normalized to 60 day

episode)

Average visits by clinicians to your facility per 60-day episode.


percentage is 5% HIGHER or LOWER than the regional, state,

or national average. If you see this symbol, you may want to

conduct further research into this area to determine the cause

and improve on any deficits.


User Guide

Medicare Patient Operational Analysis Trend Charts (HHA)


regional, and/or national averages:



as your own average and trend.


Horizontal Axis


of this report.

Vertical Axis

Depending upon the trend chart the vertical axis contains the following information:

Number of patients – Patient Census trend (Figure 54)

Average length of stay in days – Length of Stay trend

Medicare Claim Reimbursement Dollar Amount – Reimbursement per Claim trend

Number of Visits per Episode – Visits per Episode (non-normalized) trend

Number of Visits per Episode – Visits per Episode (Normalized to 60-day episode trend

Patient Census Trends

Figure 54: Patient Census Trends chart (daily view)


User Guide

Medicare Patient Operational Analysis Table (SNF)

Figure 55 appears if your profile indicates you are located at a skilled nursing facility.

Figure 55: Medicare Patient Operational Analysis Table panel (SNF)



Row Description

Average Bed Utilization

(# of patients / # of beds)

Number of patients at your organization as a percentage of your

total number of Medicare certified beds.



you see this symbol, you may want to conduct further research

into this area to determine the cause and improve on any

deficits.

Average Daily Patient Census Daily average patient census.

Average Length of Stay

(days)

Daily average length of stay. ABILITY | INSIGHT determines this

date by the start and end date on your claims.


is 5% or HIGHER than the regional, state, or national average. If



deficits.


User Guide


Row Description

Reimbursement Per Claim Reimbursement per claim.





deficits.

Reimbursement Per Patient Reimbursement per patient.





deficits.


User Guide

Medicare Patient Operational Analysis Trend Charts (SNF)


regional, and/or national averages:





Horizontal Axis


of this report.

Vertical Axis

Depending upon the trend chart the vertical axis contains the following information:

Average Bed Utilization (number of patients per number of beds) – Bed Utilization trends

(Figure 56)

Patient Census – Patient Census trends

Average Length of Stay in days – Length of Stay trends

Medicare Reimbursement in dollars – Medicare Claims Reimbursements trend

Bed Utilization Trends

Figure 56: Bed Utilization Trends chart (daily view)


User Guide

Medicare Billing and Coding Analysis

Use the Medicare Billing and Coding Analysis report (Figure 57) to discover how your

reimbursement and utilization practices compare to your peers based on service code

(HCPCS/HIPPS/Rate Codes). This report helps you answer the questions. Do I use service codes

that are reimbursed at a higher or lower dollar value than my peers?

Figure 57: Medicare Billing and Coding Analysis Report


User Guide


Figure 58: Medicare Billing and Coding Analysis (top)

To change any of these values, click Change and use the dropdown box to select other values.















diagnostic and service codes appear on the page.







Filters line.




header row.


User Guide

Diagnosis tab – Allows you to limit your search by either ICD-9 or ICD-10


criteria:





Figure 59: Filters selection with Diagnosis tab selected

Figure 60: Filters selection with HCPCS/HIPPS/RUG tab selected


User Guide

Your Medicare Patients

Figure 61 shows how this panel appears.

Figure 61: Your Medicare Patients panel

Table 18 describes the fields in this panel.

Table 18: Your Medicare Patients field descriptions

Field Description

Total Patients Total number of patients your agency cared for in the timeframe you

selected.

Total Paid Claims Total number of paid claims your agency received.



User Guide







Field Description




D Tob Type of Bill.


Payment)


G IsPaid 1 is Paid. 0 is Unpaid


rejected/denied.











O Capacity For HHA, estimated patient census. For SNF, estimated

bed count.


peers.


peers.


User Guide


Field Description









at your location.


submission.


received.


AC IsPepEpisode 1 is Pep Episode. 0 is not a Pep Episode


AE IsLupaEpisode 1 is Lupa episode.0 is not a Lupa episode






User Guide

INSIGHT (Medicare Billing and Coding Analysis)

Figure 63 shows you the sample size for the trend charts on this report. The sample size provides

you with benchmarking information based upon other providers using ABILITY product offerings.

The number in parenthesis indicates the number of providers ABILITY | INSIGHT used when

determining the benchmark. This information is updated on a regular basis.

Figure 63: Medicare Billing and Coding Analysis panel

The following checkboxes are available to you.

Regional Average

State Average

National Average

NOTE: An ABILITY | INSIGHT alert symbol ( ) indicates your percentage is greater than or less

than 5% of the benchmark. If you see this symbol, you may want to conduct further research into

this area to determine the cause and make improvements.


User Guide

Billing INSIGHT Table

Figure 64 shows the table that appears.

Select either or both of the following checkboxes.

HIPPS/RUG – Select this checkbox to display Payment System (HIPPS) / Resource Utilization Group (RUG)

HCPCS/CPT – Select this checkbox to display Healthcare Common Procedure Coding System (HCPCS) / Terminology / Current Procedural Terminology (CPT)

Figure 64: Billing INSIGHT Table

Table 20 describes the columns in this table.

Table 20: Billing INSIGHT for Service Codes table descriptions

Column Description

Code Type The type of service code. This code is either a Health Insurance

Prospective Payment System (HIPPS) code or Healthcare

Common Procedure Coding System (HCPCS).

Service Code The HCPCS or HIPPS code (UB04 / CMS-1450 Field 44) found

on a service line of a claim.

Description Service code standard description

Total Claim Volume The total number of your claims containing this service code for

the selected time period and filters.

% Service Rendered The percentage of your claims containing this service code for the

selected time period and filters.


User Guide

Table 20: Billing INSIGHT for Service Codes table descriptions

Column Description

National Average % Service

Rendered

The percentage of national peers’ claims containing this service

code for the selected time and filters.


is 5% or HIGHER or LOWER than the regional, state, or national



any deficits.

Your Average Reimbursed

(Billed) Amount

The first value is your average reimbursement for claims

containing the selected HIPPS code This value will always be $0

for HCPCS codes.

The second value (in parentheses) is your average billed amount.

This value is always $0 for HIPPS codes.

Regional, State, and National

Average Reimbursed (Billed)

Amount

For each of these three columns respectively:

The first value is your regional, state, and national peers’ average

reimbursement for claims containing a particular HIPPS code.

This value is always $0 for HCPCS codes.

The second value (in parentheses) is your regional, state, and

national peers’ average billed amount. This value is always $0 for

HIPPS codes.




into this area to determine the cause and improve on any deficits.


User Guide

HHA Episode Type Analysis

NOTE: This analysis is only available if your profile indicates you are located at a home health agency.

This report (Figure 65) lets you compare your percentage of each episode type to regional, state

and national peers. This report helps you determine if you need to take corrective action if your

percentage of PEP and LUPA episodes exceed industry norms. This analysis only includes paid

claims.

Figure 65: HHA Episode Type Analysis Report


User Guide


Figure 66: HHA Episode Type Analysis (top)

To change any of these values, click Change and use the dropdown box to select other values.


Profile – The name given to the profile when your Administrator created it. Click the profile

name to select other profiles available to you.

Statement Date Range – The beginning and ending date for the report. The following date









NOTE: Since this report focuses on patient care, the dates in this dropdown box refer to the

dates of service (or coverage date) of the claim.









Filters line.




header row.


User Guide



criteria:





Figure 67: Filters selection with Diagnosis tab selected

Figure 68: Filters selection with HCPCS/HIPPS/RUG tab selected


User Guide


Figure 69 shows how this panel appears.




Field Description

Total Paid Claims Total number of paid claims for the codes and timeframes you selected.

Your Paid Amount Total paid amount for the codes and timeframes you selected.

View As Display the trend chart based on either of the following criteria:

Number of Claims – Chart percentages based on number of claims

Total Paid – Chart percentages based on paid amounts


User Guide







Field Description




D Tob Type of Bill

E IsRap 0 is Final Claim.1 is RAP (Request for Anticipated

Payment)




rejected/denied.














peers.


peers.


User Guide


Field Description









at your location.


submission.


received.




AE IsLupaEpisode 1 is Lupa episode. 0 is not a Lupa episode.






User Guide

INSIGHT (HHA Episode Type Analysis)

This panel shows you the sample size for the trend charts on this report and your INSIGHT alert

symbol (Figure 70).

Figure 70: INSIGHT (for HHA Episode Type Analysis) panel

Episode Type Analysis Table

ABILITY | INSIGHT provides you with this benchmarking information (Figure 71) based upon other

providers using ABILITY product offerings. This information is updated on a regular basis. See the

number in parentheses for the sample size.


Regional Average

State Average

National Average


disappear. shows the table that appears.

Figure 71: HHA Episode Type Analysis table


User Guide

Table 23 describes these four episode types and the alerts that can appear.

Table 23: HHA Episode Type Analysis table descriptions

Type Description

Standard All types of episodes not fitting one of the other three types in this table.

NOTE: An INSIGHT alert symbol ( ) indicates your percentage is 5% or LOWER

than the regional, state, or national average. If you see this symbol, you may want to

conduct further research into this area to determine the cause and improve on any

deficits.

Outlier CMS paid for excessive costs you incurred. For example, you cared for a diabetes

patient who required many skilled nursing visits for injections. CMS covers your

excessive costs through additional "outlier" payments beyond the standard

payment.

NOTE: An INSIGHT alert symbol ( ) indicates your percentage is 5% or HIGHER



deficits.

LUPA Low Utilization Payment Adjustments. Defined by the following criteria:

Fewer than five visits from any clinical discipline

Payment to you is on a per visit basis, according to discipline specific

allowances set each year by CMS




deficits.

PEP Partial Episode Payments due to a patient transfer to another HHA (usually at the

patient’s request) or the patient was discharged and readmitted to your HHA during

the same 60 day episode. For this type, your standard payment is pro-rated.




deficits.


User Guide

Episodes Trend Charts


regional, and/or national averages. You can also see your own values and trend.






Standard Episodes (Figure 72)

PEP Episodes

Outlier Episodes

LUPA Episodes

Horizontal Axis


of this report.

Vertical Axis

The vertical axis shows the percentage number of claims based upon either your number of claims

or total paid claims selection.

Standard Episodes

Figure 72: Standard Episodes Trend chart (daily view)

Version 1.1 / Document Revision 1.0 / Published 01.09.2017

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