Unpaid Claims Management

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1 Unpaid Claims Management National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD FAX

2 AGENDA Introduction Clean Claim Components Denials vs. Unpaids (Critical Claims) Acceptable Denial Reasons Methodology Plan the Work Work the Plan Payer Payment Schedules Deadlines Trends & Solutions Benchmarks & Tools Feedback to Clinic Operations Summary

3 UNPAIDS: HOW DO THEY OCCUR? Charge Entered Claim Produced Claim Level Failure File Failure Claim Denied Claim Ages Out

4 UNPAIDS: File Failure 997 acknowledges receipt of a file and confirms whether or not, the file has successfully passed our initial processor edits. Accepted Rejected Claim Level Failures Payer Validation Failures Specific explanation of errors Correct and re-bill

5 CLEAN CLAIMS Objective: Paid all the money anticipated on first claim submitted Top Reasons for Non-Payment Demographic Issues Eligibility Prior-Authorization/Referrals Medical Necessity (ICD) Enrollment First Pass Rate: Clearinghouse (EDI) Level Report Next Slide Example Clean Claim Rate: Post Pay Adjudication

6 REJECTED EDI ANALYSIS **EDI: Electronic Data Interchange

7 DENIALS VS. UNPAIDS Denials Worked at time of payment posting Quick, easy to correct NOT time consuming Examples Fifth digit of ICD Demographic or NPI fix POS fix (E.g., 31 to 32) New insurance info Unpaids (Critical Claims) More challenging Not able to fix easily at time of payment posting Project work Examples Credentialing Batch Failure Clearinghouse Issue Timely filing appeal

8 ACCEPTABLE DENIAL REASONS EACH CHC MUST DEFINE ITS OWN OK to adjust balance without further follow up EXAMPLES: Paid at less than charge but OK Medicare as Secondary Payer Eligibility/COB transfer claim to correct payer Medicaid T1015 include claim detail in denials Contractual Adjustment Correct Coding Initiative (CCI) Bundle Capitation Non-covered services

9 UNACCEPTABLE DENIAL REASONS EACH CHC MUST DEFINE ITS OWN NOT OK to adjust balance follow up expected EXAMPLES: Correctable NPI issue Prior-Authorization missing (when its clearly listed) Additional information needed POS issues ICD missing digit/not valid for DOS CPT not valid for DOS Medical Necessity

10 PLAN THE WORK: PAYER SCHEDULE Learn schedule of expected check run dates or EFTs Medicare 10 days from billed date Medicaid Check Write schedules or adjudication timeline Known Facts Billed Date Payer Timelines for Payment Payer Claims Filing Limits Unpaid Schedule by Payer is predetermined

11 PLAN THE WORK: PAYER SCHEDULE Billed Date Payer Payer Timelin e Work Unpaids no earlier than But no later than 1/15/2011 Medicare A 10 1/28/2011 2/4/2011 1/16/2011 Medicaid 14 2/2/2011 2/6/2011 1/27/2011 MCO 21 2/20/2011 2/27/2011 Comment/ Trend Things to consider. Allow processing time Allow for flexibility in schedule Look for trends

12 WORK THE PLAN: STAFFING Consider. Payer Claims Filing Limits Payer Expertise Payer Timelines for Payment Assign unpaid claim project on at risk claims Approaching filing limit Assign unpaid claims to staff based on payer expertise Greater efficiency Less redundancy

13 WORK THE PLAN: STAFFING Assign unpaid claims to staff based on payer timelines for revenue maximization in current month. Week days payment timelines Week 2 14 day timelines Week day timelines Set schedule and adjust back to original timeline if needed.

14 WORK THE PLAN: TRENDS & SOLUTIONS Trends Must identify monthly trend and offer solution Preventive E&M service with Problem E&M Visit 1. Add modifier 25 to problem visit and re-bill 2. Charge Entry rule POS mismatch SNF code used in POS office 1. Change POS to SNF and re-bill 2. Charge entry rule to enter correct POS for code range 3. Restrict CPT/POS combination PM system Utilize all Practice Management denial and aging reports available.

15 BENCHMARKS & TOOLS Measuring success and effectiveness Aged Trial Balance Days in AR Payment Percentage Net AR Net Collection Rate

16 ACCOUNTS RECEIVABLE - AR Aged Trail Balance (ATB; a.k.a., aging, accounts receivable) Date of Service (DOS) vs. Bill Date Buckets/Categories: 0-30 (Current), 31-60, 61-90, 91+ Any item more than 90 Days old a potential issue Acceptable amounts Current thru 90 Days 80% Over 90 Days Less than 20%* Careful management of patient balances and strong billing processes should afford this amount to be less than 20%

17 DAYS OFAR (DAR) What is Days of Accounts Receivable (DAR) Average number of days it takes to collect payment Best Practices - < 50 Example in a year (365 days) $1,000 in charges per day $365,000 in annual charges If AR = $47,000, DAR = 47 Example Jan to June Charges = $1,500,000 Total days (365 divide by 2 (half a year) = days Average Daily Charge ($1.5M divided by 182.5) = $8, If AR = $723,723. DAR = this number divided by $8, DAR = days

18 PAYMENT PERCENTAGE ANALYSIS Payments (Numerator) as a Percentage of Payments plus Adjustments (Denominator) = Payment Percentage

19 NET AR ANALYSIS The Net AR measures the growth of the AR from month to month. A healthy AR holds steady or decreases. Month Charges Payment Adjustments AR Net AR $ 534, January $ 278, $ 126, $ 164, $ 522, $ (12,400.00) February $ 314, $ 145, $ 187, $ 503, $ (18,403.00) March $ 271, $ 114, $ 184, $ 475, $ (28,069.00) April $ 237, $ 131, $ 162, $ 419, $ (56,374.00) May $ 251, $ 104, $ 126, $ 440, $ 20, June $ 242, $ 138, $ 147, $ 396, $ (43,497.00) Net AR = Previous Month AR + Charges Payments Adjustments

20 NET COLLECTION RATE - NCR What is anticipated amount due? Hard to determine Payments divided by charges (no ) Payments as Percent of Charges Posted (See Payment Percentage Slide) Over how many months? By Payer? Scenario: Jan to Jun payment percentage = 73% Current AR = $1 million Of $730,000 expected income (73% of $1M) WHAT WAS ACTUALLY COLLECTED?

21 FEEDBACK TO CLINIC OPERATIONS Jul Aug Sep Oct Nov Dec TOTAL STATUS # $ # $ # $ # $ # $ # $ # $ No Claim Found -Rebilled 135 $24, $ $25, Claim on File -In Process 16 $1, $1, $3, Claim on File - Set to pay 82 $9, $2, $12, Suspense 7 $ $ Sent back to office for info 11 $1, $1, Denial: Demographics 2 $ $ $ Eligibility 7 $ $ PCP 7 $ $ Diagnosis/CPT 1 $ $ $ UGS Rev Code Correction 0 $0.00 Duplicates 0 $0.00 EOB Needed 0 $0.00 Adjustments: Global 17 $1, $1, Non-covered 6 $ $ Free Care 1 7 $ $ Capitation 10 $ $8, $8, Small Balances 0 $0.00 Other (see comments) 34 $1, $ $2, Transfer Balance to: Secondary 6 $ $1, $1, Tertiary 1 $1, $1, Patient- 37 $4, $1, $5, Ded/Coins 10 $ $ $1, Mental Health Vendor 0 $0.00 Totals 383 $49, $20, $ $ $ $ $70,029.15

22 SUMMARY Identify areas at risk for loss Develop processes to stop loss Define schedule and stick to it Monitor and measure progress Adjust work plan and assignments as necessary Quantify and educate all levels of staff

23 Disclaimer: 1. The guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding/billing decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Neither NACHC nor Priority Management Group, Inc. accepts any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter may have a significant financial interest/relationship with the organization that provides this product/service.

24 Speakers: Ray Jorgensen, MS, CPC, CHBME Raymond T. Jorgensen is President and CEO of Priority Management Group, Inc. (PMG). Ray is responsible for oversight of consulting operations as well as coding, reimbursement, and payer related issues for the out-sourced billing component of PMG s services (more than one million annual encounters). He has personally trained thousands of providers from over 35 states on coding, billing, and reimbursement in addition to authoring two books and dozens of articles. Ray s health care experience and education is unique in that he was schooled by the payers. Having worked for Blue Cross and Blue Shield as well as United HealthCare Corporation, primarily in professional relations and contracting, Ray has an understanding and perspective on the payer s objectives and process unlike other medical business consultants groomed from the provider side. BA from The College of the Holy Cross (Worcester, MA) MS from Northeastern University (Boston, MA) CPC from the American Academy of Professional Coders (Salt Lake City, UT) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)

25 Speakers: Robert Skeffington, CHBME Robert Skeffington, a founding partner and Executive VP of Sales and Marketing for Priority Management Group, Inc. (PMG). Responsible for PMG s overall business development strategy, Robert also works with staff to assess the impact of Health Care Reform on PMG and its hundreds of clients. Robert works diligently to enhance relationships with the National Association of Community Health Centers, state and regional CHC organizations, and individual community health sites. In addition to his role in PMG Billing, Robert also leads marketing and sales efforts for PMG Consulting which provides CHC centric education, operational assistance, and training services around revenue cycle management, coding, and other health care finance related matters. During his more than 17 years in health care Robert has worked with CHCs in the 48 contiguous states with an exclusive focus on revenue cycle management for the past 12 years with PMG. He is a speaker for NACHC and other regional CHC associations on a variety of health care revenue cycle related topics. BS from Salve Regina University (Newport, RI) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)

26 Speakers: Caroline Peucker, CPC, CPC-H, CPC-I PMG s Vice President, Consulting and Compliance Caroline has more than 25 years experience in the physician billing and coding industry. Her extensive experience includes serving as the Vice President, Coding and Compliance, Manager of coding and Billing Operations Manager for physician billing companies that serviced a wide range of specialties and practice types. She has broad experience with hospital-based physician and private practice where she was integral to coding and compliance education and training for clinical providers, practice and billing office staff members. She has performed and managed chart audits with objective of both compliance and optimizing reimbursement through correct coding and thorough documentation. Caroline holds a Bachelor of Science degree in Health Service Administration from Providence College. She is an AAPC certified coder and PMCC instructor.

27 Contact Information Priority Management Group, Inc. (PMG) 700 School Street Pawtucket, RI P: F: Raymond Jorgensen, President & CEO Robert Skeffington, CHBME, Partner and Co-founder Caroline Peucker, Vice President, Consulting & Compliance

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