Presentation on theme: "Training Your Billing Office for Revenue Success"— Presentation transcript:
1 Training Your Billing Office for Revenue Success Sarah J Holt, PhD, FACMPETraining Your Billing Office for Revenue SuccessSarah J Holt, PhD, FACMPEHolt Medical Practice SolutionsMGMA 2013 ACSan Diego, CAOctober 7, 2013, 9:45 AM-11:30 AM
2 Sarah J Holt, PhD, FACMPEObjectives:Examine the characteristics and knowledge of effective medical billing staffOptimize collections with standardized training for billing staffReview the system processes that effectively support maximizing collections
3 Utilize Assessment Tools: Hire the Right People - Behavioral Characteristic AssessmentInsurance StaffFront Desk StaffTrain Every New Employee - Knowledge AssessmentImplement the Right ProcessesOrganizational Impact AssessmentPre-VisitTime-of-ServicePost-Visit
4 Effective Medical Billing Staff: Characteristics ResponsibilitySelf-RelianceValue of ExperienceEffective CommunicationPersistence
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.
6 Training Knowledge: Fundamentals of Insurance Work EncounterFiling a claimElements of paymentsTypes of insurance
7 Training Knowledge: Filing the Claim to Getting Paid for Services Provided Service; typically a face-to-face encounterDocumentation & coding - CPT & ICDCreate claim - electronic filing/paper filingClaim sent to carrier or TPAAdjudicate claim - clean or unprocessableEdits - participating/non-participating, assignment
8 Training Knowledge: Adjudication Considerations Impacting Claim Payment EligibilityPrimary or secondary payerCovered or excluded serviceIn-network or out-of-networkPrecertificationDeductibleOut-of-pocket maximumModifiers
9 Elements of Health Insurance PremiumCo-PaymentDeductibleInsurance PaysCo-insuranceElements of Health Insurance
10 Elements of Health Insurance PremiumCopaymentTypically, 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.Amount stipulated by benefits package to pay when accessing health care services.Paid by insured before insurance pays.
11 Elements of Health Insurance DeductibleInsurance PaymentThe self-insured portion of health insurance. Re-sets with each plan year and must be met before insurance benefits kick-in.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 orout-of-network.
12 Elements of Health Insurance CoinsuranceFACTS ABOUT ELEMENTSThis 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.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.
13 Framework of Health Insurance: Types Sarah J Holt, PhD, FACMPEFramework of Health Insurance: TypesGovernmentCommercial For ProfitNon-GovernmentalNot-for-Profit
14 Source: “Medical Office Billing: A Self-Study Training Manual 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 2012
15 Managed Care Spectrum (least restrictive to most restrictive) Fee-for-serviceCalled indemnity insurance, 80/20Discounted Fee-for-serviceProvider gives carrier discount on standard fee. Example, carrier pays15 % reduction from billed charges. Discount is passed on to insured.
16 Managed Care Spectrum (least restrictive to most restrictive) Health Maintenance Organizations (HMOs)Designed to cut cost by controlling access—referrals & pre-certificationPreferred Provider Organizations (PPOs)Usually no gatekeeper but in-network care Combines features of FFS & HMOPoint-of-Service Plans (POSs)Require gatekeeper & in-network care
17 Consumer-Directed Health Pans FSA—set 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.HRA—Insurance 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.HSA—Intended to provide account funded with before tax dollars used for both current and future qualified medical expenses. Rollover allowed from year to year.
18 Government Insurances MedicareMedicaidTRICAREChildren’s Health Insurance Program (CHIP)Consolidated Omnibus Budget Reconciliation Act (COBRA)Federal Employee Health Benefits (FEHB)Indian Health Services (IHS)Veterans’ Benefits (VA)Workers’ Compensation
19 Government Insurance Medicare Instituted in 1965 as safety net for elderly, established by Congress, regulated at the federal levelBy Social Security Act Title XVIII - Complement to Social Security signed into law in 1935Funding Streams - employers, employee, general revenues, beneficiariesFederal crime to commit fraud against MedicareViolations of regulations subject to Civil Monetary Penalties to $10,000
20 Major Players in Medicare The federal government - governs funding and appropriates moneyMedicare’s administrative agencies - CMS:10 Regional Offices (ROs) and 4 consortiaNon-governmental agencies- private contracting agencies called Medicare Administrative Contractors (MACs)
21 Medicare Eligibility Age 65 or older Eligible to receive SS or RRB benefitsIf younger, eligible for disability benefits for at least 24 monthsReceiving dialysis or renal transplantation for ESRD
22 HospitalPart APhysicianPart BDrugPart DManaged carePart C
24 Training Knowledge: Medicare Overview Suffixes:A Beneficiary is wage earnerB Wife of wage earnerB1 Husband of wage earnerC Children, C1 - youngest child, etc.D Deceased spouse statusF Parent with aged dependentsJ&K Entitled based on SS quartersM Part B coverage, but not Part AT Chronic renal diseaseW Disabled & deceased spouse
25 Medicare Part A Satisfy eligibility criteria FFS insurance pays for hospital inpatient services, blood, SNF, home health, and hospiceBenefit period—Patients 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
26 Medicare Part A Coverage Approved Inpatient Stays:Includes:Acute care hospitalCritical access hospitalInpatient rehabilitation facilityLong-term care hospitalQualifying clinical research studyMental healthcareSemi-private roomMealsGeneral nursing servicesDrugs—related to inpatient treatmentComplete coverage first 60 days, next 30 days require co-insurance, days charged in full days
27 Training Knowledge: Medicare Part A Inpatient vs. OutpatientInpatientRequires physician’s orderOrder date is 1st day, last inpatient day is day before dischargeOutpatient—all observations services including overnights with no orderPayment differencesX-rays, drugs, lab testsSNF (covered if 3 days in a row as inpatient)
28 Medicare Part BMust satisfy Part A criteria and select enrollment - typically requires monthly premiumFFS insurance pays forphysician servicesoutpatient hospital services to include ASC servicessome home healthmedical equipment and suppliesdiagnostic testsambulance transportation & more…
29 More Part B Covered Services Clinical lab services Emergency department Surgical 2nd opinion Surgical dressing Diagnostic tests EKG – initial screening Hearing & balance exam Kidney dialysis serv/sup Kidney disease education Occupational therapy Cardiac rehabImplantable 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
30 Training Knowledge: Medicare Part B—Covered Services Blood—no charge from blood bankIf purchased, pay or replace first 3 unitsBeneficiary 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
31 Medigap Policies: Supplemental Insurance Purchased by Beneficiaries 3 categories:Pre-standard plans , OBRA 1990 standard plans, andWaiver state standard plans (3 states MA, MN, WI)Standardized plans - protect beneficiaries from out-of-pocket expenses: copayment, deductible, coinsuranceStandardized plans identified by letters—A,B,C,D,E, F etc. (M&N new) (E,H,I,&J no longer offered)Illegal to sell to persons with Medicare AdvantageMedicare SELECT, sold in some states, requires usage of certain hospitals & physicians
32 Part B Authorized Providers PhysicianPhysician assistant (PA)Nurse practitioner (NP)AudiologistCertified registered nurse anesthetist (CRNA)Clinical nurse specialist (CNS)Clinical psychologist (PhD-level)Clinical social worker (MSW)Occupational therapistPhysical therapist
33 Part B - Authorized Settings Physician officeHospitalASCSkilled nursing facilityPost-acute care settingHospiceOutpatient dialysis facilityClinical lab & home care
34 Covered Part B Services Must Meet: Medical Necessity CriteriaBe reasonably beneficial for patientBe proven to be effectiveBe appropriate for specific diagnosis
35 Medicare Non-covered Services Not medically necessary—inappropriate location, exceed LOS, exceed E&M level required, excess usage, diagnosis not warrantedBundled Services—fragmented services already covered, indirect prolonged care, physician standby, case manage services/phone calls, supplies included in allowable/surgical trayOther excluded services—acupuncture, cosmetic surgery, custodial care home or nursing home, most dental, routine eye, most care provided outside the US
36 Medicare Part B Requirements ABNSigned only when provider believes payment will be denied because service considered medically unnecessaryWritten notice in advance of care making patient aware of financial responsibilityABN related modifiers on claim formsGA - not likely coveredGY - service is not coveredGZ - beneficiary did not sign, likely deniedMandatory FilingCovered services must be filed within 12 months from DOS or deniedBeneficiaries not responsible for payment if timely filing requirement not met
37 Special Circumstances New PatientNew to practice or not received face-to-face services from physician or physician group in the three years prior to the visitMid-level providers / physician extendersBill under own NPI—85% of physician’s fee schedule-may reassign payment to employer (PAs no Medicare direct billing)Incident-to services—100% of physician’s fee schedule
38 Special Circumstances Incident-to servicesPhysician provides initial service & active in subsequent servicesBilling sent under physician’s name and NPIServices must be integral part of professional serviceAppropriately provided for setting and scope of licensureTreatment plan & diagnosis already established by physicianEstablished patients with new problems, must be seen by physician or billed under mid-level’s NPIUnder direct supervision of physician in same office suiteMay have collaborative agreement with more than one physician & Medicare considers physicians within group interchangeable—can treat patient of physician not in suite if another physician is in suite
39 Training Knowledge: Medicare Part B Benefit Enrollment PeriodInitial Coverage Election Period - 7 months, 3 months before, month of, and 3 months after 65th birthdayAnnual Coordination Election Period - Nov 15-Dec 31Special - certain life events occur, lose coverage, financial status changes, Medicare takes action to terminate a planTransfer - Beneficiary enrolled in Part C may enroll in premium Part A
40 Training Knowledge: Medicare Part B NPI application process - NPPES, website, , telephone, or letterMedicare Provider EnrollmentParticipation vs. non-participationOpt-out—contracting privately with patients, 2 yr. commitment, cannot file Medicare claims on any covered item except for emergency/urgent situationsMandatory filing—12 mos. DOS
41 Training Knowledge Must be eligible for Parts A & B Medicare Part CMedicare Part DMust be eligible for Parts A & BMedicare Advantage /Medicare Managed CareMedicare Part C eliminates the need for Parts A & BOffered by private healthcare carriersVoluntary drug programSeparate sign up from Part A and Part BPlan designs differ—coverage benefits differ such as deductibles, premiums, and co-pays
42 Preventive ServicesExpanded January 1, through Affordable Care ActNot subject to co-pay, deductible, or co-insuranceFate uncertainLearn more at
43 Medicare Beneficiaries: Medicare as Primary or Secondary Payer Patient covered GHP, employees under 20Patient on retirement plan or disabledPatient disabled, covered LGHP <100Patient ESRD, GHP, on benefits > 30 monthsPatient ESRD, COBRA, benefits > 30 monthsPatient covered GHP, employees 20 plusPatient disabled, covered LGHP >100Patient ESRD, GHP, on benefits < 30 monthsPatient ESRD, COBRA, benefits < 30 monthsPatient on work compPatient injured, covered by no-fault liability
44 CPT Modifiers:22 substantially more work billed with procedure of post op period of 0, 10, 90 days; not E/M code25 used with E/M code, occurring same day as procedure; substantiate with documentation57 used with E/M on same day as initial decision for major surgery was made59 independent, separate or different procedure. Not with E/M code54 transfer of operative care, used by surgeon to note transfer of care55 used by physician who assumes transfer of care post operatively
45 MedicaidProvides benefits to certain low income groups without health care insuranceFederal government establishes guidelines and requires certain mandatory servicesEach state is free to establish eligibility and benefits structure
47 Medicaid Eligibility Groups Defined by federal and state lawCategorically needyMedically needySpecial groups
48 Categorically NeedyFamilies who meet state eligibility requirements for Aid to Families with Dependent ChildrenLow-income pregnant women and children under age sixChildren ages 6-19 with family income below the federal poverty levelLegal caretakers of low-income childrenSupplemental Security Income (SSI) recipientsIndividuals living in medical institutions
49 Medically NeedyThose 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, orIndividuals who would be eligible if they were not enrolled in an HMO.
50 Special Groups Women who have breast or cervical cancer, People with tuberculosis (TB),Medicare beneficiaries, orIndividuals who may have lost their Medicare coverage though they are employed but are still below the federal poverty level.
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
52 Mandatory Services Physician, Medical and surgical dentistry, Home health if entitled to nursing facility,Nurse mid-wife,Pregnancy and complicating conditions, andPostpartum - 60 days.
53 Pre-visit: Revenue Cycle Educate self & staff re: federal & state regulations & agenciesUnderstand role of:Health Level Seven (HL7)Health Insurance Portability and Accountability Act (HIPAA)HIPAA Title II: Administration Simplification
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 exclusionHIPAA Title II: Administration Simplification -standardizes electronic transactions (code sets) & protects privacy by securing information
56 Regulations: CPT ICD-9 and ICD-10 Fraud and abuse Compliance Incentives / penaltiesHITECH ACT Meaningful Use—Stage 1 and 2Electronic prescribingPQRS
57 Pre-visit: Revenue Cycle - General Billing process starts before the patient comes inEstablish consistent message about payment expectationsDevelop system to get only preliminary information from referring physician’s officeMake conscious decision about full or abbreviated registration at appointment schedulingIf full registration, follow-up with patient
58 Pre-visit: Revenue Cycle - People Foundation of success starts with the peopleHire the right peopleBe clear of expectations through job descriptions, meetings, communication scripts, employee touch pointsDevote time to train & educate adequatelyReinforce education & training—change environmentGet comfortable with the idea of high turnover until the right people are in placeCross train so they know how their performance impacts the whole
59 Pre-visit: Revenue Cycle - Processes Evaluate & modify processes regularlyFormalize processesHold targeted meetings to reinforce processRequire consistency in gathering informationBe sensitive to community dynamicsLeverage relationship opportunities from information sources
60 Pre-visit: Revenue Cycle - Technology Know your needs via needs assessmentGreat technology will not fix problems perpetuated by the wrong people or broken processesCarefully review and purchase the best practice management system you can findUtilize it to fullest to get value for revenue cycle improvementAutomate as many processes as possible - especially high volumeInsist on great reporting system for tracking key benchmarking elementsKeep up with and utilize, when appropriate, new technology opportunities
61 Pre-visit: Revenue Cycle Overview for scheduling an appointmentCreate scripts for schedulers - no medical jargonFollow prescribed steps to ensure collecting consistent information and conveying a consistent message to patientsTrain schedulers to address patient’s prior behavior: no show appointments, unpaid balances, etc.Direct schedulers to instruct patients about where to look on their card to provide informationBe capable of answering questions about health plansClarify participation issues & misunderstanding
62 Pre-visit: Record information based on insurance filing fields Box 1 Type of insuranceBox 1a Insured’s ID number (or subscriber)Box 2 Patient’s name (as on card)Box 3 Patient DOB & SexBox 4 Insured’s name (same or differ box 2)Box 5 Patient’s addressBox 6 Patient relationship to insured(patient, spouse, parent, other)
63 Pre-visit: Record information based on insurance filing fields Box 7 Insured’s address (patient or differ)Box 8 Patient status (single, married, other)Box 9 Other insured’s name (secondary ins)Box 9a Other insured’s policy / group #Box 9b Other insured’s DOB & sexBox 9c Employer or school nameBox 9d Insurance plan name…through 11d
64 Pre-visit: Revenue Cycle - Scheduling Script scheduler’s conversation with patientsScheduler establish insurance statusReview organization requirements for insurance statusDon’t be shy about organization’s financial requirementsDisclose 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 Ask patient to have insurance card in hand to provide accurate informationScheduler directs patient where to locate information on cardEducate 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 Scheduler directs patient where to locate information on card
67 Pre-visit: Revenue Cycle- Scheduling Verify Insurance EligibilityOrganizational decision based on circumstances of practiceOnline verification preferred - avoid telephone eligibility verification when possible - too time consumingWhen online verification used, ensure that staff knows how to interpret information on screenAlways 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 Ensure that providers are credentialed with plansSchedulers know difference between participating and non-participating providersSchedulers able to explain ramifications of statusUtilize CAQHUse 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:
69 Pre-visit: Revenue Cycle Organizational Structure Creates policies that positively impact the revenue-cycle and requires them to be followedSupports policies by committing resources to training and broad education relevant to revenue-cycle efficienciesEstablish amicable relationships and contacts with payers, work collaboratively when possible, demonstrate open-mindednessDevelop excellent patient relationships, be fair, friendly, communicate well and appropriately
70 Visit: Revenue-Cycle Processes and Collections Start with accurate & complete information recorded in PMSFinancial Policy: written, developed in advance, communicated to all staff and patientsSignage in practice supports financial policy expectationsPerform essential tasks - don’t 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 Check in—Initial face-to-face touch pointGreet patient: immediately look up to acknowledge patient, verify appointment in friendly mannerAsk to see at every visit: Patient’s Insurance card and driver’s licenseLook at the patient: Verify that the photo on the driver’s license is that of the patientScan insurance card, front and back, each visit. Store in PMS.Scan driver’s license & keep on file. Store in PMS.
72 Visit: Revenue-Cycle Processes and Collections Check-in paperwork to include:A time to set the tone for a positive impressionFace Sheet—personal & demographic informationIf pre-visit functions were not carried out, perform nowVerify insurance coverageVerify benefits eligibilityReceive 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 Check-in paperwork for patient to sign:Authorization for release of information - permission to release information for insurance purposes, “Signature on File” on insurance claimAssignment of Benefits - allows carrier to send payment directly to medical practiceInsurance Coverage Waiver - patient agrees to be responsible for payment for services if insurance carrier determines patient is not eligible for coverageScan and retain all paperwork for insurance and collection purposes
75 Visit: Revenue-Cycle Processes and Collections General IssuesUse automated processes whenever possibleIf patient information was gathered prior to visit, verify correct content with patientEnsure that front-desk personnel have the skills, ability and personal characteristics to effectively perform the duties requiredEstablish follow-up processes that monitor the intended behavior from front desk personnel is being carried outProvide continuing education and training to staff
76 Visit: Revenue-Cycle Processes and Collections Check-out processA time to set the tone for another positive impression at partingSchedule the next appointmentSchedule any follow-up procedures or testing from the appointment based on circumstances within the organizationInform patients about follow-up intentions - future actions of provider organization and needed actions from patient
77 Visit: Revenue-Cycle Processes and Collections Check-out processesCollect all time-of-service payment due by the patientHave processes in place to establish all legitimate payments that are due or past dueUse this face-to-face time to reiterate financial expectations from the patientAny unresolved payments due by the patient should be settled in a private setting by the organization’s collections department
78 Visit: Revenue-Cycle Tools and Technology PMS automated tools to monitor internal control processesRun encounter ticket resolution reportManage co-pays, track collectionsTrack insurance claims denied based on registration processRegistration dataEligibility dataDeductible data
79 Visit: Revenue-Cycle Tools and Technology 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 practiceReports to track patient demographicsReports to track chargesReports to track office visits with procedure charges at same visit
80 Visit: Revenue-Cycle Script Time-of-Service Collections 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, let’s go ahead and settle the fee for today”“You may pay for today’s charges with cash, check, debit or credit card”
81 Visit: Revenue-Cycle Processes and Collections GeneralPrepare written organization wide financial policyFollowed by all staff – such as no agreements to accept insurance onlyFollowed for all patients - such as discounts for self-pay patients follow established criteriaTake all controversy away from the front desk as quickly as possibleMeet with organization’s financial counselors/ collectors in private area
82 Post-Visit: Revenue-Cycle Optimization Concentrate on processes in the entire organization - looks for gapsIs 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 Common billing mistakesWrong ID numberIncorrect CPT codeClaim sent to incorrect insuranceIncorrect date of serviceTimely filing not metEligibility requirements not metCharge applied to deductibleNon-covered service
84 Post-Visit: Revenue-Cycle Optimization Sarah J Holt, PhD, FACMPEPost-Visit: Revenue-Cycle OptimizationAre the right people in the right place?Behavioral characteristics of insurance staff are persistent, responsible, self-reliant, good communicators, and emphasis on experienceIs 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?
89 Post-Visit: Revenue-Cycle Optimization Individual account follow-upHave clear assignments of responsibilityWork A/R buckets weeklyManagement meet weekly with staff for accountability
90 Post-Visit: Revenue-Cycle Optimization Immediate follow-up on incorrect payment amountCall carrier for direction if unclear,Fix claim and resubmit, orAppeal claim immediately
91 Post-Visit: Revenue-Cycle Optimization Begin account follow-up with 15 day bucketWas 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 30 day follow-upWorked by payer (not by provider)Research and resolve insurance issuesReview & make requests additional informationReview & respond to request additional informationResolve payment issues, make notes in system based on organizationally agreed to style
95 Post-Visit: Revenue-Cycle Optimization Denial management of no-paysPost all no-pays, without delayTransfer balance to patient responsibility as appropriateResearch reason for no-payCorrectResend corrected claim
96 Revenue-Cycle Track: Post-Visit Optimization Denial management: appeal claims individuallyFollow payer’s process for appealCreate standardized letters used by everyone in insurance departmentUse appropriate standardized letterCreate teaser file to follow-up on appeals
97 Revenue-Cycle Track: Post-Visit Optimization Insurance resolution: individual accountsTransfer balance to patient after insurance paysSend statement to patient immediatelyFollow-up in short time frame based on expectation already established with patientCollect based on organizational timeframe as established in financial policy—already communicated to patientFollow established policy, turn accounts over to collectionProcess credit balance refunds promptly
98 Carrier’s Claim Appeal Process Tool Anthem2 Levels of Appeals—60 days from claim remittance to fileInstructions:Medicare5 Levels of Appeals—120 days from claim remittance to fileInstructions:United Healthcare2 Levels of Appeals—12 months from date of EOBInstructions:
99 Timely Filing Tool Carrier’s Name: Plan Type Timely Filing Time Frame Sarah J Holt, PhD, FACMPETimely Filing ToolCarrier’s Name: Plan TypeTimely Filing Time FrameNotes:Medicare12 monthsBeginning January 1, from DOSBCBS180 daysFrom DOSUHC120 days(claims & appeals )MedicaidHealthLinkVariesPolicy dependent
100 Track Financial Key Indicators Share Information with Insurance Staff ChargesAdjustmentsReceiptsCollection rateAccounts Receivable balanceDays in A/RA/R > 90 daysA/R > 120 days
101 You can’t pick cherries with your back to the tree. JP Morgan Sarah J Holt, PhD, FACMPE