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,

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

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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

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Utilize Assessment Tools:

• Hire the Right People - Behavioral Characteristic Assessment • Insurance Staff• Front Desk Staff

• Train Every New Employee - Knowledge Assessment • Insurance Staff• Front Desk Staff

• Implement the Right Processes • Organizational Impact Assessment

• Pre-Visit• Time-of-Service• Post-Visit

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Effective Medical Billing Staff:Characteristics

Responsibility

Self-Reliance

Value of Experience

Effective Communication

Persistence

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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.

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Training Knowledge: Fundamentals of Insurance Work

•Encounter•Filing a claim•Elements of payments•Types of insurance

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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

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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

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Elements of Health Insurance

Premium Co-Payment Deductible

Insurance Pays

Co-insurance

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Premium

• 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.

Copayment

• Amount stipulated by benefits package to pay when accessing health care services.

• Paid by insured before insurance pays.

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Deductible

• The self-insured portion of health insurance. Re-sets with each plan year and must be met before insurance benefits kick-in.

Insurance Payment

• 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.

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Coinsurance

• 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.

FACTS ABOUT ELEMENTS

• 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.

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Framework of Health Insurance: Types

Government

Commercial For Profit

Non-Governmental

Not-for-Profit

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Source: “Medical Office Billing: A Self-Study Training Manual.” Used with permission from the Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado 80112. www.mgma.com. Copyright 2012

http://www.mgma.com/

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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.

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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

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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.

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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

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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

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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)

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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

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• Part D

• Part C

• Part B

• Part A

Hospital

PhysicianDrugManaged care

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Medicare Insurance Card

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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

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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

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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

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Training Knowledge: Medicare Part AInpatient 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)

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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…

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More Part B Covered Services

Clinical lab servicesEmergency departmentSurgical 2nd opinionSurgical dressingDiagnostic testsEKG – initial screening Hearing & balance examKidney dialysis serv/supKidney disease educationOccupational therapyCardiac 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

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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

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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

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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

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Part B - Authorized Settings

• Physician office• Hospital• ASC• Skilled nursing facility• Post-acute care setting• Hospice• Outpatient dialysis facility• Clinical lab & home care

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Covered Part B Services

Must Meet: Medical Necessity Criteria• Be reasonably beneficial for patient• Be proven to be effective• Be appropriate for specific diagnosis

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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

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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

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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

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Special CircumstancesIncident-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

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Training Knowledge: Medicare Part BBenefit 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

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Training Knowledge: Medicare Part B

• NPI application process - NPPES, website, email, 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

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Training Knowledge

Medicare Part C

• 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

Medicare Part D

• 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

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Preventive Services

• Expanded January 1, 2011 - through Affordable Care Act

• Not subject to co-pay, deductible, or co-insurance• Fate uncertain• Learn more at www.healthcare.gov

http://www.healthcare.gov/

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Medicare Beneficiaries: Medicare as Primary or Secondary Payer

Primary

• 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

Secondary

• 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

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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

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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

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Funding Medicare vs. Medicaid

• Mandatory contributions

• General tax revenue• Beneficiaries

• Federal government• State governments• Beneficiaries (some states)

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Medicaid Eligibility Groups

Defined by federal and state law•Categorically needy•Medically needy •Special groups

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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

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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.

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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.

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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

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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.

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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

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• 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

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Regulations:

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Regulations:

• CPT• ICD-9 and ICD-10• Fraud and abuse• Compliance• Incentives / penalties

• HITECH ACT Meaningful Use—Stage 1 and 2• Electronic prescribing• PQRS

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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

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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

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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

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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

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Pre-visit: Revenue CycleOverview 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

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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)

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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

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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.

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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.)

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Scheduler directs patient where to locate information on card

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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.

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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:

http://www.cms.gov/MedicareProviderSupEnroll/02_EnrollmentApplications.asp#TopOfPage

http://www.cms.gov/MedicareProviderSupEnroll/02_EnrollmentApplications.asp

http://www.cms.gov/MedicareProviderSupEnroll/02_EnrollmentApplications.asp

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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

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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.

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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.

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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

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• 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

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• 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

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• 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

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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

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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

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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

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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

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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”

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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

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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?

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Post-Visit: Revenue CycleKnow 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

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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?

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Daily processes: bulk claims management• Claims generated• Claims scrubbed• Claims corrected before submission• Claims submitted• Confirm electronic claims submission

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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

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Manage secondary claims• Batch • Send• Follow-up on Medicare cross-over claims• Send letter

• If two carriers paid as primary• Ask for carrier resolution

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Payment: daily bulk management•Balance individual batches•Balance collective batches•Create daily deposit•Deposit daily income

89


Individual account follow-up•Have clear assignments of responsibility

•Work A/R buckets weekly•Management meet weekly with staff for accountability

90


Immediate follow-up on incorrect payment amount•Call carrier for direction if unclear,•Fix claim and resubmit, or•Appeal claim immediately

91


•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


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

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Continue individual account follow-up•60 day•90 day•120 day•150 day•180 day +

94


Denial management• By practice

• Categorize reasons• Practice driven?• Payer driven?

• By payer• Categorize• Practice driven?• Payer driven?

95


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

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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

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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

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Carrier’s Claim Appeal Process Tool

Anthem• 2 Levels of Appeals—60 days from

claim remittance to file• Instructions: www.anthem.com

Medicare• 5 Levels of Appeals—120 days from

claim remittance to file• Instructions: www.medicare.com

United Healthcare

• 2 Levels of Appeals—12 months from date of EOB

• Instructions: www.unitedhealthcare.com

http://www.anthem.com/

http://www.medicare.com/

http://www.unitedhealthcare.com/

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Timely Filing ToolCarrier’s Name: Plan Type

Timely Filing Time Frame Notes:

Medicare 12 months Beginning January 1, 2010 - from DOS

BCBS 180 days From DOS

UHC 120 days From DOS (claims & appeals )

Medicaid 120 days

HealthLink Varies Policy dependent

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Track Financial Key IndicatorsShare Information with Insurance Staff

• Charges• Adjustments• Receipts• Collection rate• Accounts Receivable balance• Days in A/R• A/R > 90 days• A/R > 120 days

You can’t pick cherries with your back to the tree. JP Morgan

Sarah J Holt, PhD, FACMPE

[email protected]

573.579.5999

mailto:[email protected]

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,

Documents

insurance payment

portion of health insurance

indemnity insurance

insurance requirement

framework of health

medical office insurance

insurance benefits kick

coinsurance percentage