To: Honorable Board of Supervisors
From: Louise F. Rogers, Chief, San Mateo County Health
Chester J. Kunnappilly, MD, Chief Executive Officer, San Mateo Medical Center
Subject: Agreement with Experian Health for the Implementation of Revenue Cycle Software Solutions Fully Compatible with the Integration with Epic
RECOMMENDATION:
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Adopt a resolution authorizing an agreement with Experian Health to transition the Experian Health suite of real-time eligibility software solutions from the agreement with Cerner Health Services, Inc. and to additionally implement the Experian Health ClaimSource claims editing software and management system while combining both services in a single contract, for the term of October 1, 2023, through September 30, 2028 in an amount not to exceed $3,200,000.
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BACKGROUND:
On November 6, 2018, the Board of Supervisors approved an amendment to the agreement with Cerner Health Services Inc. (Cerner) to add the Experian Health suite of real-time eligibility software solutions. The Experian Health suite provided adequate software tools to support efficient and accurate patient registrations while work continued for a new electronic health record (EHR 2.0). At the time of EHR 2.0 planning, it was determined that Experian was fully compatible with all systems being contemplated by the EHR 2.0 initiative.
Additionally, in April 2023, the Board of Supervisors approved an extension of the agreement with TruBridge, LLC, to continue the provision of a claims editing software and management system while San Mateo Medical Center (SMMC) assessed the need for a Request for Proposals (RFP) to evaluate enhanced features and functionality to optimize the integration with the EHR 2.0 vendor Epic.
DISCUSSION:
With the selection of Epic as San Mateo County Health’s (SMCH) new integrated electronic health record system, it is still necessary to utilize Experian Health’s real-time eligibility software to optimize the enhanced functionality offered by Epic. SMMC’s contract with Cerner ends in December 2024, requiring a new contract directly with Experian Health to continue using Experian Health software in the Epic environment.
The Experian Health real-time eligibility software adds essential functionality to patient registration through an automated work queue management system, with performance measurement and reporting. The software supports real-time insurance eligibility and verification, identity verification, validation of patient address, payor notification of inpatient admissions, and preparation of patient estimates. Additionally, Experian Health’s integration with Epic will be seamless, resulting in workflows that feel entirely contained within the Epic system and allowing users to operate more efficiently and optimize patient registration functionality.
The continued use of Experian Health’s real-time eligibility software is essential for meeting the Epic project implementation timeline. The future use of third-party eligibility and registration software will be evaluated during the Epic optimization period in 2025 and sourced in accordance with County procurement rules.
Although no RFP was issued for Experian Health’s real-time eligibility software, it is in the best interests of the County to continue to use Experian Health’s real-time eligibility software with Epic, combining the scope of Epic’s system and service with Experian Health’s claims editing software and management system, as described immediately below.
SMMC completed an RFP in July 2023 for a claims editing software and management system that both offered enhanced features and functionality and was fully integrated with Epic. Experian Health was selected due to demonstrated integration experience with Epic, substantial references from similar public safety-net hospitals, independent evaluation firm KLAS Research’s feedback and scoring, and content expertise, which exceeded competing vendors. Experian Health’s ClaimSource system provides seamless integration with Epic to streamline claims processing workflows, resulting in improved efficiency and increased revenues for both Hospital Facility and Professional claims. Additionally, ClaimSource's capabilities include processing the unique claims editing and submission requirements for Federally Qualified Health Center claims, the dental ADA 837D claim form, and long-term care billing.
The County Attorney has reviewed and approved the resolution and agreement as to form.
The resolution contains the County’s standard provisions allowing amendment of the County’s fiscal obligations by a maximum of $25,000 (in aggregate).
The Information Services Department has reviewed and approved the IT component of this amendment.
It is anticipated that with the implementation of these Experian Health solutions, the accuracy and completeness of patient registrations will increase to the industry standard of 95%, and the percentage of clean claim processing without the need to obtain additional information will increase to 95%.
PERFORMANCE MEASURE:
|
Measure |
FY 2022-23 Actual |
FY 2023-24 Estimated |
|
Real-Time Eligibility: Percentage of accuracy and completeness of patient registrations |
93% |
95% |
|
ClaimSource: Percentage of clean claim processing without the need to obtain additional information |
70% |
93% |
FISCAL IMPACT:
The term of the agreement is October 1, 2023, through September 30, 2028. The amount of the agreement is not to exceed $3,200,000 for the five-year term. Funds in the amount of $708,000 are included in the SMMC FY 2023-24 Recommended Budget. Similar arrangements will be made in future years.
Expenses at SMMC are covered by fees for services or third-party payors whenever possible. The portion of expenses for services provided to the medically indigent or to those covered by programs that do not meet the full costs of care are covered by the County’s General Fund contribution to SMMC and are within the existing annual appropriation.
ATTACHMENT:
RFP Matrix