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Brad Lund, Executive Director Sherri Dumford, Past President and Residing Chair Commercial Payer Relations Committee.

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Presentation on theme: "Brad Lund, Executive Director Sherri Dumford, Past President and Residing Chair Commercial Payer Relations Committee."— Presentation transcript:

1 Brad Lund, Executive Director Sherri Dumford, Past President and Residing Chair Commercial Payer Relations Committee

2 Copyright Healthcare Billing and Management Association  Founded in 1993  Not-for-Profit 501(c) 6 corporation  Member-led trade association  26 Educational offerings annually

3 Copyright Healthcare Billing and Management Association  650+ member companies  Employ over 30,000 employees  Represent nearly 30% of all healthcare providers  Submit 360 million claims annually  Represent all medical specialties

4 Copyright Healthcare Billing and Management Association  HBMA is committed to advancing the healthcare billing and management industry through advocacy and by providing education, information and other valuable resources to its members while promoting high ethical and professional standards.

5 Copyright Healthcare Billing and Management Association  Education  Industry Resource  Advocacy

6 Copyright Healthcare Billing and Management Association  AAFP  AAPC  ACA  ACMCS  AHIMA  AHRA  AMA  ARC  CAQH & CORE  Cooperative Exchange  HASC  MBP  MGMA  RBMA  WEDI

7 Copyright Healthcare Billing and Management Association  Came about as part of our outreach  Reciprocal exchange of ideas, knowledge and ACTION  We feel it is essential to work together to achieve “administrative simplification”

8 Copyright Healthcare Billing and Management Association  What specific action items would have a measurable impact on improving efficiency and would drive down administrative costs for providers and health plans?

9 Copyright Healthcare Billing and Management Association  Our Recent Survey  AMA’s National Report Card  NXHS Data

10 Copyright Healthcare Billing and Management Association What percentage of insurance companies provide more than half their denial information using HIPAA standard denial codes? 46% of our respondents indicated that only 60% of payers utilized standard denial codes.

11 Copyright Healthcare Billing and Management Association

12  What percentage of submitted claims are denied (in part or in full) on the first submission? ◦ 36% of respondents said 20% ◦ 28% of respondents said 10% ◦ 14% of respondents said 30%

13 Copyright Healthcare Billing and Management Association

14  Used data from 10/1/2008 through 12/31/2008  Total claims lines of 6,123,675  # lines denied 629,949  % denied claims 10.3%  % denied excluding duplicates 6.9%

15 Copyright Healthcare Billing and Management Association  We know insurance companies HATE duplicate claims!

16 Copyright Healthcare Billing and Management Association  What % are ultimately paid by the insurance as a result of your appeal/intervention?  44% of respondents said 80-90%  24% of respondents said 60-79%

17 Copyright Healthcare Billing and Management Association

18  The most challenging (and costly) aspects of handling claim denials? ◦ Cumbersome and non-standard protocol for filing appeals ◦ Denials without reason codes ◦ Unclear or confusing EOB’s ◦ Bundling edits

19 Copyright Healthcare Billing and Management Association

20  What are the most common or difficult (and costly) problems encountered with insurers in the past year? #1 – Appeals and denials - Provider enrollment #2 – Unusual coding rules and/or non- compliance with CPT protocols #3 – Slow payment/adjudication

21 Copyright Healthcare Billing and Management Association

22  Commercial Payer Relations Committee ◦ Payer outreach ◦ Association and task force participation ◦ Surveys ◦ Upcoming focus groups ◦ Education and Payer contacts

23 Copyright Healthcare Billing and Management Association  ICD-10 and 5010 Standing Committee ◦ Gathering of industry experts with a working knowledge of change consequences ◦ Providing the education for transition readiness ◦ Providing the integration information and resources ◦ Providing the innovation knowledge needed for transition readiness

24 Copyright Healthcare Billing and Management Association  Identified opportunities to drive down costs and produce efficiencies  Consistent use of standard remark codes  Description of remark codes and potential steps for claim resolution  Consistency in appeals process across payers  Consistency in telephone responses within and across payers  Electronic transparency

25 Copyright Healthcare Billing and Management Association Question? Is there a direct correlation between the number of duplicate claims received by payers versus the use or non-use of standard remark codes?

26 Copyright Healthcare Billing and Management Association  How can we eliminate reprocessing and rework?  HBMA believes a good place to begin is with the adoption and use of standard denial and remark codes.

27 Copyright Healthcare Billing and Management Association HBMA is willing to allocate the resources to work with AHIP in achieving cost reductions for payers and providers. Billing companies are entities of structure and we can help bring structure and validation to the process.

28 Copyright Healthcare Billing and Management Association QUESTIONS? ??????????

29 Copyright Healthcare Billing and Management Association Contact Sherri Dumford 770/ Brad Lund 877/


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