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Training Your Billing Office for Revenue Success

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1 Training Your Billing Office for Revenue Success
Sarah J Holt, PhD, FACMPE 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 Sarah J Holt, PhD, FACMPE 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

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

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

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
Encounter Filing a claim Elements of payments Types of insurance

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

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

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

10 Elements of Health Insurance
Premium Copayment 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. Amount stipulated by benefits package to pay when accessing health care services. Paid by insured before insurance pays.

11 Elements of Health Insurance
Deductible Insurance Payment The 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 or out-of-network.

12 Elements of Health Insurance
Coinsurance FACTS ABOUT ELEMENTS 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. 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, FACMPE Framework of Health Insurance: Types Government Commercial For Profit Non-Governmental Not-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-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.

16 Managed Care Spectrum (least restrictive to most restrictive)
Health Maintenance Organizations (HMOs) Designed to cut cost by controlling access—referrals & 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

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
Medicare Medicaid TRICARE Children’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 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

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

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

22 Hospital Part A Physician Part B Drug Part D Managed care Part C

23 Medicare Insurance Card

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

25 Medicare Part A Satisfy eligibility criteria
FFS insurance pays for hospital inpatient services, blood, SNF, home health, and hospice Benefit 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 hospital Critical access hospital Inpatient rehabilitation facility Long-term care hospital Qualifying clinical research study Mental healthcare Semi-private room Meals General nursing services Drugs—related to inpatient treatment Complete coverage first 60 days, next 30 days require co-insurance, days charged in full days

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

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…

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 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

30 Training Knowledge: Medicare Part B—Covered Services
Blood—no 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

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 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 Advantage Medicare SELECT, sold in some states, requires usage of certain hospitals & physicians

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

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

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

35 Medicare Non-covered Services
Not medically necessary—inappropriate location, exceed LOS, exceed E&M level required, excess usage, diagnosis not warranted Bundled Services—fragmented services already covered, indirect prolonged care, physician standby, case manage services/phone calls, supplies included in allowable/surgical tray Other 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
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

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 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 services Physician provides initial service & active in subsequent services Billing sent under physician’s 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-level’s NPI Under direct supervision of physician in same office suite May 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 Period Initial Coverage Election Period - 7 months, 3 months before, month of, and 3 months after 65th 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

40 Training Knowledge: Medicare Part B
NPI application process - NPPES, website, , telephone, or letter Medicare Provider Enrollment Participation vs. non-participation Opt-out—contracting privately with patients, 2 yr. commitment, cannot file Medicare claims on any covered item except for emergency/urgent situations Mandatory filing—12 mos. DOS

41 Training Knowledge Must be eligible for Parts A & B
Medicare Part C Medicare Part D 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 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

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

43 Medicare Beneficiaries: Medicare as Primary or Secondary Payer
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 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

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

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

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

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

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

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.

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.

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, and Postpartum - 60 days.

53 Pre-visit: Revenue Cycle
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 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:

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

57 Pre-visit: Revenue Cycle - General
Billing process starts before the patient comes in Establish consistent message about payment expectations Develop system to get only preliminary information from referring physician’s 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
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 & training—change 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
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
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
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 patient’s 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
Box 1 Type of insurance Box 1a Insured’s ID number (or subscriber) Box 2 Patient’s name (as on card) Box 3 Patient DOB & Sex Box 4 Insured’s name (same or differ box 2) Box 5 Patient’s address Box 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 & sex Box 9c Employer or school name Box 9d Insurance plan name …through 11d

64 Pre-visit: Revenue Cycle - Scheduling
Script scheduler’s conversation with patients Scheduler establish insurance status Review organization requirements for insurance status Don’t be shy about organization’s 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
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 Scheduler directs patient where to locate information on card

67 Pre-visit: Revenue Cycle- Scheduling
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
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:

69 Pre-visit: Revenue Cycle Organizational Structure
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
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 - 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 point Greet patient: immediately look up to acknowledge patient, verify appointment in friendly manner Ask to see at every visit: Patient’s Insurance card and driver’s license Look at the patient: Verify that the photo on the driver’s license is that of the patient Scan 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 impression Face Sheet—personal & 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
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
New Patient Present to patient - Notice of Privacy Rights and Organization’s 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 Organization’s Privacy Policy Record - patient’s consent of individuals to whom information can be released

75 Visit: Revenue-Cycle Processes and Collections
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
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
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 organization’s collections department

78 Visit: Revenue-Cycle Tools and Technology
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
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
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
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 organization’s financial counselors/ collectors in private area

82 Post-Visit: Revenue-Cycle Optimization
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
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
Sarah J Holt, PhD, FACMPE Post-Visit: Revenue-Cycle Optimization 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
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
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
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
Payment: daily bulk management Balance individual batches Balance collective batches Create daily deposit Deposit daily income

89 Post-Visit: Revenue-Cycle Optimization
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
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
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
30 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
Continue individual account follow-up 60 day 90 day 120 day 150 day 180 day +

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

95 Post-Visit: Revenue-Cycle Optimization
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
Denial management: appeal claims individually Follow payer’s 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
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 policy—already communicated to patient Follow established policy, turn accounts over to collection Process credit balance refunds promptly

98 Carrier’s Claim Appeal Process Tool
Anthem 2 Levels of Appeals—60 days from claim remittance to file Instructions: Medicare 5 Levels of Appeals—120 days from claim remittance to file Instructions: United Healthcare 2 Levels of Appeals—12 months from date of EOB Instructions:

99 Timely Filing Tool Carrier’s Name: Plan Type Timely Filing Time Frame
Sarah J Holt, PhD, FACMPE Timely Filing Tool Carrier’s Name: Plan Type Timely Filing Time Frame Notes: Medicare 12 months Beginning January 1, from DOS BCBS 180 days From DOS UHC 120 days (claims & appeals ) Medicaid HealthLink Varies Policy dependent

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

101 You can’t pick cherries with your back to the tree. JP Morgan
Sarah J Holt, PhD, FACMPE

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