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TRAINING YOUR BILLING OFFICE FOR REVENUE SUCCESS Sarah J Holt, PhD, FACMPE Holt Medical Practice Solutions MGMA 2013 AC San Diego, CA October 7, 2013,

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Presentation on theme: "TRAINING YOUR BILLING OFFICE FOR REVENUE SUCCESS Sarah J Holt, PhD, FACMPE Holt Medical Practice Solutions MGMA 2013 AC San Diego, CA October 7, 2013,"— Presentation transcript:

1 TRAINING YOUR BILLING OFFICE FOR REVENUE SUCCESS Sarah J Holt, PhD, FACMPE Holt Medical Practice Solutions MGMA 2013 AC San Diego, CA October 7, 2013, 9:45 AM-11:30 AM

2 Objectives: Examine the characteristics and knowledge of effective medical billing staff Optimize collections with standardized training for billing staff Review the system processes that effectively support maximizing collections 2

3 Utilize Assessment Tools: Hire the Right People - Behavioral Characteristic Assessment Insurance Staff Front Desk Staff Train Every New Employee - Knowledge Assessment Insurance Staff Front Desk Staff Implement the Right Processes Organizational Impact Assessment Pre-Visit Time-of-Service Post-Visit 3

4 Effective Medical Billing Staff: Characteristics ResponsibilitySelf-Reliance Value of Experience Effective Communication Persistence 4

5 Need for Standardized Training: Medical office insurance staff are liaison among clinical and non-clinical staff, patients, and patients insurance carriers. Credibility of the medical practice requires that staff speaks with a consistent, confident voice. All staff members need the same opportunity for success. 5

6 Training Knowledge: Fundamentals of Insurance Work Encounter Filing a claim Elements of payments Types of insurance 6

7 Training Knowledge: Filing the Claim to Getting Paid for Services Provided Service; typically a face-to-face encounter Documentation & coding - CPT & ICD Create claim - electronic filing/paper filing Claim sent to carrier or TPA Adjudicate claim - clean or unprocessable Edits - participating/non-participating, assignment 7

8 Training Knowledge: Adjudication Considerations Impacting Claim Payment Eligibility Primary or secondary payer Covered or excluded service In-network or out-of-network Precertification Deductible Out-of-pocket maximum Modifiers 8

9 Elements of Health Insurance Premium Co- Payment Deductible Insurance Pays Co- insurance 9

10 Elements of Health Insurance Premium Typically, determined by employer. Price paid monthly is based on contracted benefits package. Portion of monthly premium paid by employee vs. employer is determined by employer. Paid by insured before insurance pays. Copayment Amount stipulated by benefits package to pay when accessing health care services. Paid by insured before insurance pays. 10

11 Elements of Health Insurance Deductible The self-insured portion of health insurance. Re- sets with each plan year and must be met before insurance benefits kick- in. Insurance Payment The portion paid by the insurance carrier for covered health care services received. Payment is dictated by the benefits package purchased and will vary depending if services were in-network or out-of-network. 11

12 Elements of Health Insurance Coinsurance This is the remaining balance of the contracted amount on a covered charge after insurance pays. The patient is responsible for paying this amount on the services they received. The co-insurance percentage varies based on the benefits package purchased. FACTS ABOUT ELEMENTS Patient and/or employer are responsible for all but one of the 5 elements. Health insurance carrier designs benefit plan that is selected by employer. Employees are not guaranteed opportunity to select benefits. 12

13 Framework of Health Insurance: Types GovernmentCommercial For Profit Non-Governmental Not-for-Profit 13

14 Source: Medical Office Billing: A Self-Study Training Manual. Used with permission from the Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado Copyright 14

15 Managed Care Spectrum (least restrictive to most restrictive) Fee-for-service Called indemnity insurance, 80/20 Discounted Fee-for-service Provider gives carrier discount on standard fee. Example, carrier pays 15 % reduction from billed charges. Discount is passed on to insured. 15

16 Managed Care Spectrum (least restrictive to most restrictive) Health Maintenance Organizations (HMOs) Designed to cut cost by controlling accessreferrals & pre-certification Preferred Provider Organizations (PPOs) Usually no gatekeeper but in-network care Combines features of FFS & HMO Point-of-Service Plans (POSs) Require gatekeeper & in-network care 16

17 Consumer-Directed Health Pans FSAset up by employers to allow employees to use pre- tax dollars, set aside through payroll deductions, to pay for qualified unreimbursed medical expenses. No insurance requirement for participation. No rollover allowed from year to year. HRAInsurance plan partially self-funded by employer, who pays a premium up to a cap. Designed at discretion of employer, only employers make contribution. Usually pays copays, drug card copays, deductibles, coinsurance. HSAIntended to provide account funded with before tax dollars used for both current and future qualified medical expenses. Rollover allowed from year to year. 17

18 Government Insurances Medicare Medicaid TRICARE Childrens Health Insurance Program (CHIP) Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal Employee Health Benefits (FEHB) Indian Health Services (IHS) Veterans Benefits (VA) Workers Compensation 18

19 Government Insurance Medicare Instituted in 1965 as safety net for elderly, established by Congress, regulated at the federal level By Social Security Act Title XVIII - Complement to Social Security signed into law in 1935 Funding Streams - employers, employee, general revenues, beneficiaries Federal crime to commit fraud against Medicare Violations of regulations subject to Civil Monetary Penalties to $10,000 19

20 Major Players in Medicare The federal government - governs funding and appropriates money Medicares administrative agencies - CMS: 10 Regional Offices (ROs) and 4 consortia Non-governmental agencies- private contracting agencies called Medicare Administrative Contractors (MACs) 20

21 Medicare Eligibility Age 65 or older Eligible to receive SS or RRB benefits If younger, eligible for disability benefits for at least 24 months Receiving dialysis or renal transplantation for ESRD 21

22 Part D Part C Part B Part A HospitalPhysician Drug Managed care 22

23 Medicare Insurance Card 23

24 Training Knowledge: Medicare Overview Suffixes: A Beneficiary is wage earner B Wife of wage earner B1 Husband of wage earner C Children, C1 - youngest child, etc. D Deceased spouse status F Parent with aged dependents J&K Entitled based on SS quarters M Part B coverage, but not Part A T Chronic renal disease W Disabled & deceased spouse 24

25 Medicare Part A Satisfy eligibility criteria FFS insurance pays for hospital inpatient services, blood, SNF, home health, and hospice Benefit periodPatients have 90-day stay in hospital in benefit period (period renewed when patient has not been in hospital or SNF for 60 days) Patients have 60-day lifetime reserve after 90-day stay is exhausted 25

26 Medicare Part A Coverage Approved Inpatient Stays:Includes: Acute care hospital Critical access hospital Inpatient rehabilitation facility Long-term care hospital Qualifying clinical research study Mental healthcare Semi-private room Meals General nursing services Drugsrelated to inpatient treatment Complete coverage first 60 days, next 30 days require co-insurance, days charged in full days 26

27 Training Knowledge: Medicare Part A Inpatient vs. Outpatient Inpatient Requires physicians order Order date is 1 st day, last inpatient day is day before discharge Outpatientall observations services including overnights with no order Payment differences X-rays, drugs, lab tests SNF (covered if 3 days in a row as inpatient) 27

28 Medicare Part B Must satisfy Part A criteria and select enrollment - typically requires monthly premium FFS insurance pays for physician services outpatient hospital services to include ASC services some home health medical equipment and supplies diagnostic tests ambulance transportation & more… 28

29 More Part B Covered Services Clinical lab services Emergency department Surgical 2 nd opinion Surgical dressing Diagnostic tests EKG – initial screening Hearing & balance exam Kidney dialysis serv/sup Kidney disease education Occupational therapy Cardiac rehab Implantable defibrillator Diabetes supplies Foot exam and treatment Prosthetics/orthotics Cataract surgery glasses Physical therapy Pulmonary rehab Speech pathology services Rural health clinic services Chiropractic services Transplants & drugs 29

30 Training Knowledge: Medicare Part BCovered Services Bloodno charge from blood bank If purchased, pay or replace first 3 units Beneficiary pays 20% Ambulance services, x-ray, MRI, CT, EKG, hearing & balance exam, kidney dialysis services and supplies & 6 sessions of education, cardiac rehab, automatic defibrillator implant, prosthetic/orthotic, oral cancer drugs - nebulizers & infusion pumps 30

31 Medigap Policies: Supplemental Insurance Purchased by Beneficiaries 3 categories: Pre-standard plans, OBRA 1990 standard plans, and Waiver state standard plans (3 states MA, MN, WI) Standardized plans - protect beneficiaries from out-of- pocket expenses: copayment, deductible, coinsurance Standardized plans identified by lettersA,B,C,D,E, F etc. (M&N new) (E,H,I,&J no longer offered) Illegal to sell to persons with Medicare Advantage Medicare SELECT, sold in some states, requires usage of certain hospitals & physicians 31

32 Part B Authorized Providers Physician Physician assistant (PA) Nurse practitioner (NP) Audiologist Certified registered nurse anesthetist (CRNA) Clinical nurse specialist (CNS) Clinical psychologist (PhD-level) Clinical social worker (MSW) Occupational therapist Physical therapist 32

33 Part B - Authorized Settings Physician office Hospital ASC Skilled nursing facility Post-acute care setting Hospice Outpatient dialysis facility Clinical lab & home care 33

34 Covered Part B Services Must Meet: Medical Necessity Criteria Be reasonably beneficial for patient Be proven to be effective Be appropriate for specific diagnosis 34

35 Medicare Non-covered Services Not medically necessaryinappropriate location, exceed LOS, exceed E&M level required, excess usage, diagnosis not warranted Bundled Servicesfragmented services already covered, indirect prolonged care, physician standby, case manage services/phone calls, supplies included in allowable/surgical tray Other excluded servicesacupuncture, cosmetic surgery, custodial care home or nursing home, most dental, routine eye, most care provided outside the US 35

36 Medicare Part B Requirements ABN Signed only when provider believes payment will be denied because service considered medically unnecessary Written notice in advance of care making patient aware of financial responsibility ABN related modifiers on claim forms GA - not likely covered GY - service is not covered GZ - beneficiary did not sign, likely denied Mandatory Filing Covered services must be filed within 12 months from DOS or denied Beneficiaries not responsible for payment if timely filing requirement not met 36

37 Special Circumstances New Patient New to practice or not received face-to-face services from physician or physician group in the three years prior to the visit Mid-level providers / physician extenders Bill under own NPI85% of physicians fee schedule-may reassign payment to employer (PAs no Medicare direct billing) Incident-to services100% of physicians fee schedule 37

38 Special Circumstances Incident-to services Physician provides initial service & active in subsequent services Billing sent under physicians name and NPI Services must be integral part of professional service Appropriately provided for setting and scope of licensure Treatment plan & diagnosis already established by physician Established patients with new problems, must be seen by physician or billed under mid-levels NPI Under direct supervision of physician in same office suite May have collaborative agreement with more than one physician & Medicare considers physicians within group interchangeablecan treat patient of physician not in suite if another physician is in suite 38

39 Training Knowledge: Medicare Part B Benefit Enrollment Period Initial Coverage Election Period - 7 months, 3 months before, month of, and 3 months after 65 th birthday Annual Coordination Election Period - Nov 15-Dec 31 Special - certain life events occur, lose coverage, financial status changes, Medicare takes action to terminate a plan Transfer - Beneficiary enrolled in Part C may enroll in premium Part A 39

40 Training Knowledge: Medicare Part B NPI application process - NPPES, website, , telephone, or letter Medicare Provider Enrollment Participation vs. non-participation Opt-outcontracting privately with patients, 2 yr. commitment, cannot file Medicare claims on any covered item except for emergency/urgent situations Mandatory filing12 mos. DOS 40

41 Training Knowledge Medicare Part C Must be eligible for Parts A & B Medicare Advantage /Medicare Managed Care Medicare Part C eliminates the need for Parts A & B Offered by private healthcare carriers Medicare Part D Voluntary drug program Separate sign up from Part A and Part B Plan designs differ coverage benefits differ such as deductibles, premiums, and co-pays 41

42 Preventive Services Expanded January 1, through Affordable Care Act Not subject to co-pay, deductible, or co-insurance Fate uncertain Learn more at 42

43 Medicare Beneficiaries: Medicare as Primary or Secondary Payer Primary Patient covered GHP, employees under 20 Patient on retirement plan or disabled Patient disabled, covered LGHP <100 Patient ESRD, GHP, on benefits > 30 months Patient ESRD, COBRA, benefits > 30 months Secondary Patient covered GHP, employees 20 plus Patient disabled, covered LGHP >100 Patient ESRD, GHP, on benefits < 30 months Patient ESRD, COBRA, benefits < 30 months Patient on work comp Patient injured, covered by no-fault liability 43

44 CPT Modifiers: 22substantially more work billed with procedure of post op period of 0, 10, 90 days; not E/M code 25used with E/M code, occurring same day as procedure; substantiate with documentation 57used with E/M on same day as initial decision for major surgery was made 59independent, separate or different procedure. Not with E/M code 54transfer of operative care, used by surgeon to note transfer of care 55used by physician who assumes transfer of care post operatively 44

45 Medicaid Provides benefits to certain low income groups without health care insurance Federal government establishes guidelines and requires certain mandatory services Each state is free to establish eligibility and benefits structure 45

46 Funding Medicare vs. Medicaid Mandatory contributions General tax revenue Beneficiaries Federal government State governments Beneficiaries (some states) 46

47 Medicaid Eligibility Groups Defined by federal and state law Categorically needy Medically needy Special groups 47

48 Categorically Needy Families who meet state eligibility requirements for Aid to Families with Dependent Children Low-income pregnant women and children under age six Children ages 6-19 with family income below the federal poverty level Legal caretakers of low-income children Supplemental Security Income (SSI) recipients Individuals living in medical institutions 48

49 Medically Needy Those with too much money, income or savings to be classified as categorically needy, Pregnant women through a 60-day postpartum period, Certain newborns and children under 18, Persons who are aged, blind or disabled (SSI may serve as determining factor), Some groups of children under 21 who meet requirements and are full time students, or Individuals who would be eligible if they were not enrolled in an HMO. 49

50 Special Groups Women who have breast or cervical cancer, People with tuberculosis (TB), Medicare beneficiaries, or Individuals who may have lost their Medicare coverage though they are employed but are still below the federal poverty level. 50

51 Mandatory Services Inpatient hospital treatment, Outpatient hospital, X-ray and lab, State licensed pediatric and family nurse practitioner, Nursing facility if 21 and older, All medically necessary screening, diagnosis, and treatment if under 21, Family planning, and 51

52 Mandatory Services Physician, Medical and surgical dentistry, Home health if entitled to nursing facility, Nurse mid-wife, Pregnancy and complicating conditions, and Postpartum - 60 days. 52

53 Pre-visit: Revenue Cycle 53 Educate self & staff re: federal & state regulations & agencies Understand role of: Health Level Seven (HL7) Health Insurance Portability and Accountability Act (HIPAA) HIPAA Title II: Administration Simplification

54 54 Health Level Seven (HL7) - allows data exchange between systems, focuses on format standardization Health Insurance Portability and Accountability Act (HIPAA) - provides continuous insurance coverage limiting pre-existing exclusion HIPAA Title II: Administration Simplification - standardizes electronic transactions (code sets) & protects privacy by securing information

55 Regulations: 55

56 Regulations: CPT ICD-9 and ICD-10 Fraud and abuse Compliance Incentives / penalties HITECH ACT Meaningful UseStage 1 and 2 Electronic prescribing PQRS 56

57 Pre-visit: Revenue Cycle - General 57 Billing process starts before the patient comes in Establish consistent message about payment expectations Develop system to get only preliminary information from referring physicians office Make conscious decision about full or abbreviated registration at appointment scheduling If full registration, follow-up with patient

58 Pre-visit: Revenue Cycle - People 58 Foundation of success starts with the people Hire the right people Be clear of expectations through job descriptions, meetings, communication scripts, employee touch points Devote time to train & educate adequately Reinforce education & trainingchange environment Get comfortable with the idea of high turnover until the right people are in place Cross train so they know how their performance impacts the whole

59 Pre-visit: Revenue Cycle - Processes 59 Evaluate & modify processes regularly Formalize processes Hold targeted meetings to reinforce process Require consistency in gathering information Be sensitive to community dynamics Leverage relationship opportunities from information sources

60 Pre-visit: Revenue Cycle - Technology 60 Know your needs via needs assessment Great technology will not fix problems perpetuated by the wrong people or broken processes Carefully review and purchase the best practice management system you can find Utilize it to fullest to get value for revenue cycle improvement Automate as many processes as possible - especially high volume Insist on great reporting system for tracking key benchmarking elements Keep up with and utilize, when appropriate, new technology opportunities

61 Pre-visit: Revenue Cycle 61 Overview for scheduling an appointment Create scripts for schedulers - no medical jargon Follow prescribed steps to ensure collecting consistent information and conveying a consistent message to patients Train schedulers to address patients prior behavior: no show appointments, unpaid balances, etc. Direct schedulers to instruct patients about where to look on their card to provide information Be capable of answering questions about health plans Clarify participation issues & misunderstanding

62 Pre-visit: Record information based on insurance filing fields 62 Box 1Type of insurance Box 1aInsureds ID number (or subscriber) Box 2Patients name (as on card) Box 3Patient DOB & Sex Box 4Insureds name (same or differ box 2) Box 5Patients address Box 6Patient relationship to insured (patient, spouse, parent, other)

63 Pre-visit: Record information based on insurance filing fields 63 Box 7Insureds address (patient or differ) Box 8Patient status (single, married, other) Box 9Other insureds name (secondary ins) Box 9aOther insureds policy / group # Box 9bOther insureds DOB & sex Box 9cEmployer or school name Box 9dInsurance plan name …through 11d

64 Pre-visit: Revenue Cycle - Scheduling 64 Script schedulers conversation with patients Scheduler establish insurance status Review organization requirements for insurance status Dont be shy about organizations financial requirements Disclose financial policy relating to collecting at time of service: co-pays, deductible payment, etc. Offer payment options based on particular circumstances of patient and organization - credit cards accepted, charity care, financial counseling, etc.

65 Pre-visit: Revenue Cycle - Scheduling 65 Ask patient to have insurance card in hand to provide accurate information Scheduler directs patient where to locate information on card Educate scheduler to understand various insurance plan types - government (Medicare, Medicaid, TRICARE, etc); commercial (FFS, DFFS, HMO, PPO, POS, etc.); self-insured benefits (FSA, HRA, HSA, etc.)

66 66 Scheduler directs patient where to locate information on card

67 Pre-visit: Revenue Cycle- Scheduling 67 Verify Insurance Eligibility Organizational decision based on circumstances of practice Online verification preferred - avoid telephone eligibility verification when possible - too time consuming When online verification used, ensure that staff knows how to interpret information on screen Always verify Medicaid eligibility - changes often, some services covered while others are not, spend down may apply and may not be met, etc.

68 Pre-visit: Revenue Cycle Provider Enrollment 68 Ensure that providers are credentialed with plans Schedulers know difference between participating and non-participating providers Schedulers able to explain ramifications of status Utilize CAQH Use Physician Credentialing Checklist tool (Ex 4.1, Get the Money in the Door - Physician Billing Basics, page 71) Medicare and Medicaid Provider Enrollment found at: lmentApplications.asp#TopOfPage

69 Pre-visit: Revenue Cycle Organizational Structure 69 Creates policies that positively impact the revenue- cycle and requires them to be followed Supports policies by committing resources to training and broad education relevant to revenue-cycle efficiencies Establish amicable relationships and contacts with payers, work collaboratively when possible, demonstrate open-mindedness Develop excellent patient relationships, be fair, friendly, communicate well and appropriately

70 Visit: Revenue-Cycle Processes and Collections 70 Start with accurate & complete information recorded in PMS Financial Policy: written, developed in advance, communicated to all staff and patients Signage in practice supports financial policy expectations Perform essential tasks - dont try to do everything at the front desk - inform patients about additional fees and have them sign other forms at the appropriate time (ABNs, record copying fee, etc.) Create organizational processes following good business principles to support time-of-service collections - daily posting, computer balancing, daily deposits, etc.

71 Visit: Revenue-Cycle Processes and Collections 71 Check inInitial face-to-face touch point Greet patient: immediately look up to acknowledge patient, verify appointment in friendly manner Ask to see at every visit: Patients Insurance card and drivers license Look at the patient: Verify that the photo on the drivers license is that of the patient Scan insurance card, front and back, each visit. Store in PMS. Scan drivers license & keep on file. Store in PMS.

72 Visit: Revenue-Cycle Processes and Collections 72 Check-in paperwork to include: A time to set the tone for a positive impression Face Sheetpersonal & demographic information If pre-visit functions were not carried out, perform now Verify insurance coverage Verify benefits eligibility Receive financial policy (give opportunity to discuss with collector to understand or clarify) Obtain referral or authorizations, if required

73 Visit: Revenue-Cycle Processes and Collections 73 Check-in paperwork for patient to sign: Authorization for release of information - permission to release information for insurance purposes, Signature on File on insurance claim Assignment of Benefits - allows carrier to send payment directly to medical practice Insurance Coverage Waiver - patient agrees to be responsible for payment for services if insurance carrier determines patient is not eligible for coverage Scan and retain all paperwork for insurance and collection purposes

74 Visit: Revenue-Cycle Processes and Collections 74 New Patient Present to patient - Notice of Privacy Rights and Organizations Privacy Policy Have patient sign form acknowledging receipt of HIPAA information Record - create standardize recording mechanism in PMS that patient has been informed of rights under HIPAA - Notice of Privacy Rights and Organizations Privacy Policy Record - patients consent of individuals to whom information can be released

75 Visit: Revenue-Cycle Processes and Collections 75 General Issues Use automated processes whenever possible If patient information was gathered prior to visit, verify correct content with patient Ensure that front-desk personnel have the skills, ability and personal characteristics to effectively perform the duties required Establish follow-up processes that monitor the intended behavior from front desk personnel is being carried out Provide continuing education and training to staff

76 Visit: Revenue-Cycle Processes and Collections 76 Check-out process A time to set the tone for another positive impression at parting Schedule the next appointment Schedule any follow-up procedures or testing from the appointment based on circumstances within the organization Inform patients about follow-up intentions - future actions of provider organization and needed actions from patient

77 Visit: Revenue-Cycle Processes and Collections 77 Check-out processes Collect all time-of-service payment due by the patient Have processes in place to establish all legitimate payments that are due or past due Use this face-to-face time to reiterate financial expectations from the patient Any unresolved payments due by the patient should be settled in a private setting by the organizations collections department

78 Visit: Revenue-Cycle Tools and Technology 78 PMS automated tools to monitor internal control processes Run encounter ticket resolution report Manage co-pays, track collections Track insurance claims denied based on registration process Registration data Eligibility data Deductible data

79 Visit: Revenue-Cycle Tools and Technology 79 PMS automated tools to monitor internal control processes (continued) Reports to track appointment type / compare per physician to historical data / compare to other physicians in the practice Reports to track patient demographics Reports to track charges Reports to track office visits with procedure charges at same visit

80 Visit: Revenue-Cycle Script Time-of-Service Collections 80 Examples: Straightforward expectation Your fee for seeing Dr. Jones today is… How would you like to pay for services today - cash, check, or card? Before I schedule your follow-up appointment, lets go ahead and settle the fee for today You may pay for todays charges with cash, check, debit or credit card

81 Visit: Revenue-Cycle Processes and Collections 81 General Prepare written organization wide financial policy Followed by all staff – such as no agreements to accept insurance only Followed for all patients - such as discounts for self-pay patients follow established criteria Take all controversy away from the front desk as quickly as possible Meet with organizations financial counselors/ collectors in private area

82 Post-Visit: Revenue-Cycle Optimization 82 Concentrate on processes in the entire organization - looks for gaps Is charting in medical record immediate after service is provided? Are charges entered timely? Are all payments posted timely? Are all appeals worked? Are members of the organization held accountable when they fail to carry out their responsibility?

83 Post-Visit: Revenue Cycle Know Where to Focus 83 Common billing mistakes Wrong ID number Incorrect CPT code Claim sent to incorrect insurance Incorrect date of service Timely filing not met Eligibility requirements not met Charge applied to deductible Non-covered service

84 Post-Visit: Revenue-Cycle Optimization 84 Are the right people in the right place? Behavioral characteristics of insurance staff are persistent, responsible, self-reliant, good communicators, and emphasis on experience Is behavioral interviewing used in hiring? Are staff members exposed to regular training and education? Are regular meetings held with insurance staff to focus on goal setting and achievement?

85 Post-Visit: Revenue-Cycle Optimization 85 Daily processes: bulk claims management Claims generated Claims scrubbed Claims corrected before submission Claims submitted Confirm electronic claims submission

86 Post-Visit: Revenue-Cycle Optimization 86 Daily processes: bulk claims management Generate / mail paper claims Electronic payment posting Manual payment posting insurance Manual payment posting personal Verify payment amounts for accuracy

87 Post-Visit: Revenue-Cycle Optimization 87 Manage secondary claims Batch Send Follow-up on Medicare cross-over claims Send letter If two carriers paid as primary Ask for carrier resolution

88 Post-Visit: Revenue-Cycle Optimization 88 Payment: daily bulk management Balance individual batches Balance collective batches Create daily deposit Deposit daily income

89 Post-Visit: Revenue-Cycle Optimization 89 Individual account follow-up Have clear assignments of responsibility Work A/R buckets weekly Management meet weekly with staff for accountability

90 Post-Visit: Revenue-Cycle Optimization 90 Immediate follow-up on incorrect payment amount Call carrier for direction if unclear, Fix claim and resubmit, or Appeal claim immediately

91 Post-Visit: Revenue-Cycle Optimization 91 Begin account follow-up with 15 day bucket Was the claim received? Was it a clean claim? When will it be paid? Create note in PMS (acct & tickler) Follow-up if not received

92 Post-Visit: Revenue-Cycle Optimization day follow-up Worked by payer (not by provider) Research and resolve insurance issues Review & make requests additional information Review & respond to request additional information Resolve payment issues, make notes in system based on organizationally agreed to style

93 Post-Visit: Revenue-Cycle Optimization 93 Continue individual account follow-up 60 day 90 day 120 day 150 day 180 day +

94 Post-Visit: Revenue-Cycle Optimization 94 Denial management By practice Categorize reasons Practice driven? Payer driven? By payer Categorize Practice driven? Payer driven?

95 Post-Visit: Revenue-Cycle Optimization 95 Denial management of no-pays Post all no-pays, without delay Transfer balance to patient responsibility as appropriate Research reason for no-pay Correct Resend corrected claim

96 Revenue-Cycle Track: Post-Visit Optimization 96 Denial management: appeal claims individually Follow payers process for appeal Create standardized letters used by everyone in insurance department Use appropriate standardized letter Create teaser file to follow-up on appeals

97 Revenue-Cycle Track: Post-Visit Optimization 97 Insurance resolution: individual accounts Transfer balance to patient after insurance pays Send statement to patient immediately Follow-up in short time frame based on expectation already established with patient Collect based on organizational timeframe as established in financial policyalready communicated to patient Follow established policy, turn accounts over to collection Process credit balance refunds promptly

98 Carriers Claim Appeal Process Tool 98 Anthem 2 Levels of Appeals60 days from claim remittance to file Instructions: Medicare 5 Levels of Appeals120 days from claim remittance to file Instructions: United Healthcare 2 Levels of Appeals12 months from date of EOB Instructions:

99 Timely Filing Tool 99 Carriers Name: Plan Type Timely Filing Time Frame Notes: Medicare12 monthsBeginning January 1, from DOS BCBS180 daysFrom DOS UHC120 daysFrom DOS (claims & appeals ) Medicaid120 days HealthLinkVariesPolicy dependent

100 Track Financial Key Indicators Share Information with Insurance Staff 100 Charges Adjustments Receipts Collection rate Accounts Receivable balance Days in A/R A/R > 90 days A/R > 120 days

101 You cant pick cherries with your back to the tree. JP Morgan Sarah J Holt, PhD, FACMPE

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