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A project of the Network of Behavioral Health Providers (NBHP) in collaboration with Mental Health America of Greater Houston (MHA) 1 Thanks to the generosity.

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Presentation on theme: "A project of the Network of Behavioral Health Providers (NBHP) in collaboration with Mental Health America of Greater Houston (MHA) 1 Thanks to the generosity."— Presentation transcript:

1 A project of the Network of Behavioral Health Providers (NBHP) in collaboration with Mental Health America of Greater Houston (MHA) 1 Thanks to the generosity of our funders, Houston Endowment Inc., The Meadows Foundation and United Way of Greater Houston Community Response Fund, this event is offered at no cost. Network of Behavioral Health Providers

2 Presented by: Mandie Eichenlaub Director, Managed Care MHMRA of Harris County May 23,

3 Overview Revenue Cycle Management Before you can start you have to know where you are: Data analytics Understanding your patient population Knowing your payor mix How is your payment data currently tracked From where can data be extracted Analysis is important Relationships are key Set priorities based on the above 3

4 Revenue Cycle Management Insurance verification Should occur prior to the patient’s arrival. Have online and electronic forms available – even if it’s just via e- mail – and ask for those forms prior to the appointment Prior preparation speeds up the registration process Ask questions of the insurance company before the appointment: Is patient information correct? Are prior authorizations necessary? Verify covered services and CPT codes Obtain information about co-pays, coinsurance and deductibles Collect patient responsibility up front (if you have done proper insurance verification, this should be easy) Notify patients ahead of time what their responsibility will be (and if payment plans are available, etc.) 4

5 Revenue Cycle Management (cont’d) Clean claims Know the codes, modifiers and other information required Payor specific coding requirements lead most often to underpayments Promptly handle denials (we will talk about this later) Review payments for accuracy (underpayments can eat your lunch!) 5

6 Claims Follow Up Essential to make sure you are paid timely Some issues that require follow-up: The claim was never received The claim has been denied The claim is pending information from the member Do you need better training for front office staff? They are your first line of defense! Do you understand your contract or the out of network benefits available to the patient? 6

7 Appealing Denied Claims Follow up on claims 10 business days after electronic claims are billed and 15 days after paper bills to ensure the claim was received Set a dollar threshold – when does it cost more in manpower to appeal a claim than you would recover in an appeal? Review the denial reason – was it you or was it the company Do not delay – stay on top of issues so they do not snowball Get the patient’s help – especially for commercial insurance Know your contract – understand Covered Services and Compensation 7

8 Be Efficient in Following Up Be well prepared prior to your initial contact NPI TPI Member information: name, DOB, policy number Date(s) of service Ask for the insurance representative’s information including direct call back information if available. Get a call reference number 8

9 Be Efficient in Following Up (cont’d) Ask lots of questions: What is the status of the claim? When is the claim scheduled for payment? Where in the payment process is the claim? What is the amount of the payment? What is the check number? Why is the claim taking so long to process? Why is the claim pending or under review? Where do I need to send medical records? Who can I speak with to get this claim paid faster? Why is the claim not being paid according to contract? 9

10 Be Efficient in Following Up (cont’d) Be assertive and take appropriate action Make sure your staff knows how to handle each of the denial reasons listed in slide 11 Have appropriate policies in place that spell out how to talk to the insurance company about each one of these issues Involve the patient but only as a last resort Send a bill Contact the patient by phone Initiate a conference call with the insurer and the patient 10

11 Top Reasons Claims are Denied 1. FOR GROUPS: Roster not loaded properly 2. No claim on file 3. No referral on file 4. Missing or invalid CPT or HCPCS code 5. Timely filing 6. Member information is incorrect 7. Need primary insurance information/coordination of benefits 8. Information needed from the member 9. Service required prior authorization or precertification 10. Services not covered 11. No medical necessity 12. Medical records requested to pay the claim 13. Coverage has terminated 14. Accident details required (rarely for BH services) 11

12 Claims and Clinical Issue Resolution Review outstanding accounts receivable (see spreadsheet) Analyze claims data to identify issues Work with contracted payors to resolve root cause claims issues Identify new and existing issues with coding, billing and payment 12

13 When talking doesn’t work Escalate within the payor organization Demand letters to compliance and legal departments Issue resolution with industry groups Complaints to HHSC, TDI and CMS 13

14 Understanding Where You Are Patient Population: MHMRA Harris as an example: 25,000 patients with open cases 8,700 patients (approx 35%) have some form of third party coverage 14

15 Payor Blend amongst the Amerigroup (30%) United Behavioral Health (Optum) (23%) Texas Children’s Health Plan (13%) Community Health Choice (7%) Molina (6%) Blue Cross Blue Shield (5%) Aetna (3%) Superior (2%) United (Commercial) (2%) Cigna (2%) Others (4.5%)

16 Day X (X could be +/- 30 days) Appointment is scheduled by SAI Day 0 (2-3 business days prior to appointment) Patient Information and Insurance Information Verified by Business Office/Front Desk Staff - Authorizations received if necessary Day 1 Appointment – Clinician completes note and coding Day 2 Data Entry staff copy CPT code from DSL Day 3 Medical Records department completes data verification in Anasazi 5 Business Day Hold Time Quality Management to complete review of record and code to ensure appropriate documentation IMPACT: 5 day period may have to be extended to allow for review. Coders may be hired or existing staff re-assigned to review records Day 6 following Data Entry/Verification Revenue Management processes billing to appropriate payor IMPACT: If 5 day period needs to be extended, may occur later than Day 6. Patient Appointment Process, Impacts of CPT Code Changes MH Division

17 MHMRA Revenue Management Participants Front Office Staff (at each of ~10 clinics – typically 1 Business Office Supervisor and 1-2 Business Office Specialist(s) in addition to reception staff, etc.) Director, Managed Care Payor relations, strategic development, contracting, high level issue resolution Director, Revenue Management Assistant Director 3 staff - Billing/Claims Submission 1 staff - Business Office Support Manager, Payments 4 staff - receipt of payments, financial reporting Manager, Appeals 4 staff - follow up on all denials, rejections, etc. 17

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