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DENIAL CLAIM ANALYSIS WEBINAR MONDAY, MARCH 29, 2010 Optimizing Billing Practices Billing Claims Self Assessment.

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Presentation on theme: "DENIAL CLAIM ANALYSIS WEBINAR MONDAY, MARCH 29, 2010 Optimizing Billing Practices Billing Claims Self Assessment."— Presentation transcript:

1 DENIAL CLAIM ANALYSIS WEBINAR MONDAY, MARCH 29, 2010 Optimizing Billing Practices Billing Claims Self Assessment

2 Your presenters Presenter Stephanie Ceponis, Lead Site Financial Analyst ext. 4534, Moderator Chuck Marquardt, Director of Training ext. 4583,

3 3 Tools you can use – Feedback Toolbar Raise Hand NoEmoticonsYes Feedback Results 2

4 4 Floating Toolbar Use the floating toolbar to communicate in todays session. Use the floating toolbar to communicate in todays session. Participant List Q&A Polling 3

5 5 Q&A Click Send Type Question 4

6 Polling 5

7 Webinar etiquette All phones are muted. Questions can be asked via chat throughout the session or raising your hand in WebEx. Lines will be opened at the end for additional questions.

8 Objectives The participant will be able to do the following: Complete the Excel workbook, CFHC Billing Claim Denials Analysis; Analyze data to identify problem areas in billing claims; Describe plans of action for a variety of possible denial scenarios.

9 What are we going to learn? How to utilize the CFHC denial analysis tool. Some common denial codes and the key pieces to review to help reduce the frequency of the particular code. Action plans – ways to reduce denials.

10 Rejects & Denials Poll #1 Does your agency work or follow up on rejected or denied claims as part of standard practice? Yes No

11 Rejects & Denials Poll #2 Has anyone analyzed the rejects and denials to see where they are coming from? Yes No

12 Rejects & Denials Poll #3 What is a common denial code your agency receives? Write in your response to the right of your screen.

13 Rejects & Denials Poll #4 What is the purpose of rejects and denials? Write in your response to the right of your screen.

14 Start thinking… Poll #5 What can we do to eliminate or minimize the number of rejected claims? Write in your response to the right of your screen.

15 Start thinking… Poll #6 Which group in your agency originates the most rejects? Clinicians Front desk/receptionists Eligibility workers Billers Multiple sources

16 What You Will Need All RADs from 6 months or less. A Staff person to enter data. This does not have to be a biller, and could be administrative staff. 10 – 20 hours of data entry time, depending on the number of claims submitted.

17 5 Simple Steps The Billing Claim Denials Analysis can be completed in 5 simple steps: 1. Collect data 2. Enter data 3. Analyze data 4. Create a plan of action 5. Implement the plan

18 5 Simple Steps The Billing Claim Denials Analysis can be completed in 5 simple steps: 1. Collect data 2. Enter data 3. Analyze data 4. Create a plan of action 5. Implement the plan

19 5 Simple Steps The Billing Claim Denials Analysis can be completed in 5 simple steps: 1. Collect data 2. Enter data 3. Analyze data 4. Create a plan of action 5. Implement the plan

20 The Analysis Tool

21 Overview of the Analysis Tool An Excel workbook with 5 sheets 1. Summary denials sheet Data entry with some formulas 2. RAD denial data sheet Data entry tab where the meat of the denials gets entered 3. RAD denial summary sheet Populated from RAD denial data tab – no data entry unless you need to customize

22 Overview of the Analysis Tool 4. Chart Data table is on RAD denial summary tab 5. Collection Report Data entry

23 Summary Denials Worksheet

24 Automatically sums the paid, duplicate and denial claims Divides the number of denials by total number of claims Divides the number of duplicate and denied claims by the total number of claims.

25 Recap – Summary Denials Worksheet Enter data in cells A through F. Cells G, H and I use formulas. Gives you summary data for the whole RAD not just denials.

26 RAD Denial Data Worksheet

27 For the code breakdown on the next sheet only one denial code can be entered You must put a 1 in this column to feed the code breakdown on the next sheet

28 Recap – RAD Denial Data Worksheet Enter data from RAD into cells A, B, D, E and F. Only one denial code can be entered into cell G. A number 1 must be entered into cell H for each completed row.

29 RAD Denial Summary Worksheet

30 Cells B and C have formulas that use information from the cells in the RAD Denial Data Worksheet Lets see a zoom view of this!

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32 Recap – RAD Denial Summary Worksheet All information is populated from the RAD denial data sheet. No data entry is needed unless customizing the denial code list. If customizing, remember to copy the formulas from prior cells.

33 5 Simple Steps 1. Get the data 2. Enter the data 3. Analyze data 4. Create a plan 5. Implement the plan

34 Pie Chart

35 Lets see a zoom view of this!

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37 Clinical 40% Billing 20% Other 20% Registration 20%

38 Collection Report Worksheet

39 $ Owed column has conditional formatting to highlight amounts $50 and above.

40 Analysis Tool Recap Summary denial and RAD denial data worksheets are the primary data entry sheets. RAD denial summary worksheet does not have any data entry unless you need to customize the denial codes. Data table for chart is already formulated – chart will automatically be created from data entered.

41 TIPS TO REDUCING THE NUMBER OF REJECTED AND DENIED CLAIMS Common Denial Codes

42 RAD #0117 This procedure is payable only twice per month Ongoing education and counseling codes (any combination of HCPCS codes Z9752-Z9754) can only be billed twice in 30 days, per recipient, per provider

43 RAD #9518 The referring provider must be a Family PACT certified provider The referring Doctor must provide their NPI# to the rendering Doctor to be reimbursed on Family PACT services. The NPI# must be in correct field on claim form.

44 RAD #0315 Recipient information on claim does not match eligibility information on file for this person Verify the name, sex code, date of birth and clients ID #

45 RAD #9655 The frequency limits for this procedure have been exceeded. Resubmit claim with documentation indicating medical necessity for the test Verify if the frequency limit has been reached prior to rendering services Lab reservation must be made via the Laboratory Services Reservation System (LSRS) with NPI Claims must be billed with same NPI reservation was made under

46 5 Simple Steps 1. Get the data 2. Enter the data 3. Analyze data 4. Create a plan 5. Implement the plan

47 Planning Staff training Change how information is collected Change the superbill Get specialized training

48 Possible Changes Staff training regarding the completion of the Client Eligibility Certification form. Modify the superbill to reflect only those procedures your agency provides. Clearly separate what is in-house lab versus outside lab. Perform quarterly chart billing audits.

49 Possible Changes Create a daily chart review prior to billing. Create clear steps to rectify questions prior to billing. Provide training to clinicians regarding coding.

50 Resources: Family PACT billing-instructions.aspx (PPBI, Provider Bulletins, Superbill)

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53 Resources (cont.) Medi-Cal (Provider manual, Bulletins, CMC info)

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58 5 Simple Steps 1. Get the data 2. Enter the data 3. Analyze data 4. Create a plan 5. Implement the plan

59 Questions????


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