Optimize Healthcare Facility Revenue in minimum time. Billing /Coding/ Patient Management

Transcription

1 TALISMAN SOLUTIONS Optimize Healthcare Facility Revenue in minimum time Billing /Coding/ Patient Management We put together a team of healthcare, financial and management experts to identify ways to optimize cash flow for healthcare facility. This paper uses highly scientific approach utilizing techniques such as fish-bone and root cause analysis to get to the root of issues in revenue cycle management.

2 Table of Contents The Art of Medical Billing:... 3 Analysis to understand Revenue Cycle Management Aging Analysis:... 4 Reports monitored to calculate the Aging:... 6 Accounts Receivable Analysis:... 7 Improve AR Days with Claims Follow up:... 8 Top 10 denial reasons:... 8 Workers' compensation... 9 What we do: Appeal Process: Sample Appeal Letter: Accurate Coding & Audit guideline: Case Study Reduce Claims Processing Time A health billing system: Work flow & Productivity Assessment: ISO 27001:2005 Certified Page 2

3 The Art of Medical Billing: Each phase of the Revenue Cycle - from the moment a patient is scheduled for an appointment until the time payment is received from the insurance company - is equally important to maximizing insurance reimbursements. Understanding the Revenue Cycle Understanding the Insurance Companies Understanding co-ordination of Benefits Understanding Medical Billing Software Understanding HIPAA privacy and security Revenue Cycle Management encompasses everything from determining patient insurance eligibility and collecting copays to properly coding claims using ICD ISO 27001:2005 Certified Page 3

4 Revenue Cycle Management Analysis ISO 27001:2005 Certified Page 4

5 Aging Analysis: Most AR reports are set up to demonstrate aged claims in the following way: 0-30 days: Insurance claims should be billed within 72 hours of the discharge date. Claims unpaid during this period should be pending payment or denial from the insurance company. The electronic submission report should be reviewed daily to see which claims have been accepted and which have been rejected. Claims that have been rejected should be researched to find out why. Corrections should be made right away so the claim can be resubmitted. Initial contact with the insurance payers should also be made within the first 30 days. Follow up for electronic claims should be made 7 days after the claim has been accepted and paper claims should be follow-up after 14 days days: Claims that remain unpaid within this period have the greatest chance of being paid. Payers are required to respond to medical claims within 30 days of receiving them. During this time, if the claim hasn't been paid, the payer is required to respond to the claim in some way. Usually you will receive documentation with the following information: request for more information from the provider notification that more information has been requested from the patient notification that the claim needs further review the claim has denied Medical claims are unique to accounts receivable in other industries due to timely filing restrictions set by insurance payers. Depending on the payer, the medical office may have as little as 30 days to up to 1 year to file a claim to the payer. This window of opportunity makes it more risky as the days pass for the claim to get paid at all days: Although unpaid claims between days are easier to collect, unpaid claims between days should be the number 1 priority. These claims are at risk for becoming uncollectable. This is a critical time for medical billers to make certain that unbilled claims are filed in order to meet timely filing deadlines or resubmit denied claims. Over 90 days: Once claims have remained unpaid for over 90 days, the chances of being collected drop from 95-98% collectable to under 75% collectable. The longer a claim remains unpaid, the less chance it has to become paid. At this point in the revenue cycle, it is crucial to identify each claim based on its ability to get paid. If the claim has been identified as uncollectable, it should be written off to prevent valuable time from being spent that could be used on collecting on collectable accounts. Of the claims identified as collectable, the claims that have been billed and denied should be corrected and resubmitted as a corrected claim or should be re-filed with as an appeal. ISO 27001:2005 Certified Page 5

6 Reports monitored to calculate the Aging: Days in A/R Gross Charge Report Patient Mix Report Average Collection Cycle Gross Payment Report Average Daily Charges AR Aging Report Payment mix Report Accounts Receivable Mix Gross Collection Percentag e by Pay class Accounts Receivable by Payclass Adjustmet Percentag e of Gross Charges Adjustmet Mix Adjustmen ts by Pay class ISO 27001:2005 Certified Page 6

7 Accounts Receivable Analysis: Calculated AR Cumalitive Variance +Begining AR Reported AR -Charges -Calculated AR -Payments - Adjustments This is precisely where you are drawn to keep vigilance on Account Receivables (A/R) so that your Account Receivables are kept within the 120-day-limit. The best way to keep track on the age of your Account Receivables is to demand a monthly report from your medical billing department or outsourced Revenue Cycle Management (RCM) service provider. Such monthly reports should aid you in knowing how long your claims are languishing in A/R bracket 30, 60, 90, 120, or more days. But, having access to aging reports does not mean that they are reliable and acted upon for augmenting the process of claim realization. A good aging report need necessarily exhibit how your medical billing revenue management services es are matching up to the challenges in follow-up on patient accounts and insurance claims. ISO 27001:2005 Certified Page 7

8 Improve AR Days with Claims Follow up: 1. Claim Not on file: the claim was not received. This usually happens mostly with paper claims getting mysteriously lost. To avoid this, it is wise to send claims electronic when you can. If the claim hasn't been followed-up on quickly, it could be a month or longer before you would even know the insurance company hasn't received the claim. For paper claims, allow 10 business days before calling to see if the claim has been received. For electronically billed claims, you should be able to call within 5 business days. 2. Claim Denied: Depending on the denial reason, you can have the new claim sent out way before you even get the paper denial through the mail. By calling the insurance company and finding out the denial reason instead of waiting to receive the denial in the mail, you can possibly correct the reason the claim was denied. Resubmitting the claim days up to 7 days earlier than waiting for the denial in the mail will definitely shorten the turnaround time for your payment. 3. Pending for Additional Information: Sometimes claims can be placed in pending for a certain amount of time due to additional information needed from the member. Although, the insurer has probably sent the patient a letter in the mail, it would be wise for your collectors to contact him or her as well. One reason is that by calling the insurance, you can notify the patient before the letter ever reaches them. Also, if you can get them on the phone, you can hold a conference call with the member and insurer to make sure the information is given and received. Top 10 denial reasons: In order to count the number of denials by reason, we first determine the categories that we are utilizing to track all claim denials. The list below identifies the most frequent denial reasons that medical practices experience: 1. Registration: Insurance Verification, Incorrect Payer, and Cannot Identify Patient): We are verifying the patient eligibility and benefit prior to services to make sure we have all the correct information regarding patient policy. We provide our providers a standard patient registration form which patient can fill, so we are able to register the patient in our software correctly. We are doing front end quality of the claims to make sure there is no data entry error like invalid name or invalid ID. 2. Charge Entry (examples: Invalid procedure or diagnosis codes): Claim can be denied for non covered services if we bill the invalid ICD or CPT code on the claims. We have a system in place where we can check compatibility of the ICD with CPTs to avoid such denials 3. Referrals & Pre-authorizations: For Medical practices denials like services not authorize is very frequent, we verify with payer prior to services for authorization requirement and get the services authorize on behalf of provider. We do track the authorization in system against the services and notify the providers before it get exhausted ISO 27001:2005 Certified Page 8

9 4. Info from Patient (Claim is pending for additional info from patient): We are tracking the claims which are pending on payer side for any additional information from payer side like Coordination of Benefit. We update the patient on behalf of provider to make sure claims not pending for any information from patient 5. Duplicates (example: 2nd CPT on same date):before creating or billing a claim we always cross checked in the system for duplicate billing to avoid such denials. 6. Medical Necessity: We submit the proof of medical necessity on behalf of provider to get the claims processed if payer needs 7. Documentation: Claims for Workers compensation and No fault always needs to be submitted along with proper documentation, We are handling such cases and always submit the patient medical notes along with claims to avoid any denials like Improper documentation 8. Bundled/Non-covered (example: Modifiers):We are checking for Bundled procedure prior to billing and use proper modifier to separate the procedure to avoid such denials 9. Credentialing: We help identify correct payers for our providers to get credentialed with them to avoid any denials like non-participating providers. We check with payer prior to services to make sure provider is on file with payer. We are providing and sending the enrollments forms on behalf of providers to get our providers enrolled with payer. 10. Benefit Maximum has been reached: We are keeping a track of the patient visit or amount in the system and inform the providers in advance if patient is about to meet his/her annual maximum for a year to avoid such denials. Workers' compensation Is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment? The Process is as follows: 1. The injured worker tells the medical provider that the injury or illness is work related. The injured worker must be seen first by the employer s designated physician or medical facility if the employer has chosen a physician or medical facility. If there is no designated medical provider, or once they have seen the designated provider, the injured worker may choose to see a doctor of his/her choice. The doctor is to report the initial visit by Physician s Initial Report of Injury (Form 123) of the injured worker to the Labor Commission, the insurance carrier and give a copy of the report to the injured worker. 2. The insurance carrier will open a claim for benefits once they have received either one or both reports from the employer or doctor. The insurance carrier is to make a determination of compensability of the injury or illness within 21 days of having received the claim for benefits and can file for an extension of a total of 45 days. ISO 27001:2005 Certified Page 9

10 3. Compensable Claim: If the claim is compensable, and if the doctor determines that the injured worker will lose work time, the insurance carrier is to contact the injured worker and the employer to determine the rate of weekly pay that the injured worker is to receive for the time off work. All medical bills are to be paid by the insurance carrier or self-insured employer. The injured worker is not to pay anything toward the medical care received. In most cases the claim for medical benefits is paid, the injured worker returns to work and the claim is ended 4. Denial of the claim: If the insurance carrier denies that the claim is compensable, the insurance carrier is to send a denial letter to the injured worker and the Labor Commission. 5. Application for Hearing: If the claim is denied, the injured worker has the right to apply for a hearing at the Labor Commission to have an administrative law judge determine if the injured worker s claim is compensable. 6. Labor Commission Assistance: The Industrial Accidents Division has several intake staff, ombudspersons, and mediators to help claimants resolve claims without the need for a formal hearing. However, if the claimant has filed for a hearing, the case continues in the adjudication process until the case is either settled or heard by an administrative law judge. For assistance, an injured worker, employer, medical provider or insurance carrier may contact the Industrial Accidents Division What should be done? 1. After appointment call the designated adjuster of the WC insurance to check if any case is open on the insurance file for patient injury 2. Verify the assigned claim number with the payer and get the services authorized if authorization is required 3. Verify the number of visits patient can use under the assigned claim number or case. 4. Submit the claims along with all the required documents like Medical bills to WC insurance or adjuster of the claims. 5. If WC denies the claims than forward all the information to patient attorney on behalf of provider. 6. Do regular follow- ups with WC or Auto insurances for claim settlement 7. Once the settlement has been proposed by the insurance, negotiate with insurance for high reimbursement ISO 27001:2005 Certified Page 10

11 Appeal Process: In most medical billing disputes, our most efficient first step in the appeals process is to make a phone call to the payer. Ask the representative whether the issue can be resolved; if not, we initiate the appeal or reconsideration process. If dealing with a commercial payer, the payer may have a reconsideration form on its website that we can use to challenge a payment decision. Writing letters takes time, and then it takes even more time for the recipient to read the letter, verify the argument, and then forward the claim to be corrected. If the problem is simple then have the claim sent back simply by calling the payer. Before discussing the claim the insurance representative verifies for the following information: Your name. The name of your company and tax ID number or the NPI (National Provider Identifier) number. The NPI is the ten digit number required by HIPAA (Health Insurance Portability and Accountability Act) to identify providers in electronic transactions. The patient s ID (the identification number assigned by the payer), name, and date of birth. The date of service in question. The billed amount of the claim. (This is the dollar total of the claim, not what you are expecting to be paid.) After you verification we can ask why the claim has not processed correctly. Often the representative can look at the claim, look at provider contract, and verify what needs to be done. If that happens, the representative can usually send the claim back to the processor with instructions to reprocess. Sometimes, the phone call alone may be enough to resolve the issue. If it s not, we follow up with a letter. We document all phone conversations in the patient system or billing software like who you spoke with, what the agreement was, and the reference number it documents the conversation on the payer s end. This kind of documentation is essential when a potential filing issue arises. We are using a standard/template letter for some types of denials, such as those related to use of an invalid code, incorrect subscriber name, or incorrect modifier. However, other types of denials (e.g., those related to medical necessity) require a customized appeal letter. Our standard appeal letters include important details, such as the type of services rendered and the date of service, in order for payers to be able to process the information. If these details are missing, the appeal process is invariably prolonged, which creates more work for staff members at the practice. Also we quote industry guidelines, such as the CPT guidelines or CMS guidelines, as well as the payer s own reimbursement guidelines in your appeal letter. Any appeal should only include documentation that s relevant to the particular claim in question. Including too much information is not only time-consuming to compile, but it could also leave practices open to potential HIPAA violations In addition we are creating a spreadsheet that includes information about each appeal, such as: Date the appeal was sent Payer to which the appeal was sent Timely filing requirements for that payer ISO 27001:2005 Certified Page 11

12 We also consider and tracing the stages of appeals process, including: Stage 1: Contact payer by phone. Ask questions for clarification. Stage 2: Request a full and fair review. Contact state agencies, such as the Department of Insurance, Office of Ombudsman, if necessary. Stage 3: Consider legal action. We are regularly obtaining copies of each payer s medical policy and maintain a list of routine payer-specific denials based on those policies. This helps ensure that staff members don t appeal denials unnecessarily. Sample Appeal Letter: (Practice name and address) (Insurance Company name and address) (Date of appeal) Patient Name: Patient Identification Number: Date of service: Total claim amount: To Whom It May Concern; The above claim has been denied due to timely filing. However, this claim was originally sent within the timely filing limits. Please see attached claims report, stating that this claim was originally sent (electronically/paper) to the correct insurance company on (date). This date was within the timely filing limits and the claim should have been paid upon receipt. It has been incorrectly denied due to timely filing. Please see all attached documentation in support of this appeal. If you have any questions or concerns, please feel free to contact me at the below contact number. Thank you for your prompt attention to this matter. ISO 27001:2005 Certified Page 12

13 Accurate Coding & Audit guideline: From the technical perspective, medical coding stands for medical classification which is utilized for converting the services rendered at multiple health care facilities into a set of universal medical codes. It s in fact a systematic process to perform the statistical analysis of diseases of various geographical locations as well as calculating the health risk factors of their associated population. This medical classification system also helps in analyzing the cost of each rendered health care service, and utilized by multiple health care insurances across the globe to process the revenue cycle to facilitate the provision of appropriate payments to the health care providers for their rendered services. Various international medical coding classification systems are in place for the standardized transformation of the treatments and diagnoses. The most important & utilized resources to facilitate this transformation are CPT (Current Procedural Technology) & ICD-9-CM (International Classification of Diseases, 9th Clinical Modification), which are widely used for the coding and billing purposes across the United States. Medical Coding Impact: The impact of the medical coding transformation process is in fact based on balancing the cost and increasing the quality of care provided to the patients. It also keeps a stringent check on medical malpractice and helps in improving the patient outcomes at a reasonable cost. The medical coding process helps to establish and implement the fee for service reimbursement systems to compensate the providers for their provided services. The coding is done to the highest specific level to ensure that the providers don t lose their dollars for their rendered treatments. The multi-factorial and complex nature of the clinical decisions for the provided services requires the use of appropriate CPT and ICD-9 codes for getting the physicians paid for their provided services. To manage the health care costs and the revenue cycle, an efficient medical coding support system needs to be acquired and practiced in accordance with the Standard Coding Guidelines and Best Healthcare Practices. Background: As per analysis it was found that documentation is a time consuming process for providers. Physical documentation was lacking elements required for higher E/M levels. Hospital management was losing money because of lower levels billed due to documentation deficiencies. Talisman team suggested Hospital Management to opt for documentation improvement solutions. Suggested documented solutions allow: o Better documentation o Better Coding ISO 27001:2005 Certified Page 13

14 o o o o Instant Revenue Growth Comfort for Physicians Cost effective Time Saving Impact: Compliant Documentation. Physicians can concentrate only on patient care. Better storage of Medical records. Easy retrieval of Medical records during HAAD or insurance Audits Data Comparison (Figures): New Patient OP visits E/M Levels Before E/M Levels After E/M Codes Frequency Percentage E/M Codes Frequency Percentage % % % % % % % % Established Patient OP visits E/M Levels Before E/M Levels After E/M Codes Frequency Percentage E/M Codes Frequency Percentage % % % % % % % % ISO 27001:2005 Certified Page 14

15 Data Comparison (Graphical) Case Study Problem Statement: One of our hospital Clients would like to get his charts audited for documentation deficiencies as per HAAD Guidelines Action Taken: 3500 charts (OP/ER/IP) audited. Audit is based on HAAD guidelines. The audit focus is on Clinician Documentation and Coding Quality. Error Categorization based on HAAD guidelines:- Major, Moderate, and Minor Errors Root Cause Analysis - 5W1H used for analyzing errors Audit information was captured in Auditor Talisman s proprietary tool Findings & Solution: Estimated yearly Revenue Loss of AED 3,797,137 & 6,888,375 identified in OP & ER charts respectively. Detailed Provider & Department wise analysis submitted to management. Physician and In-house coders trained on coding guidelines based on findings. Truncated codes/incorrect coders were rectified in facility EMR Documentation improvements Templates were suggested and designed based on the physician s common set of codes and findings. Coding Frauds were identified related to infusions and hydration coding in inpatient charts. With the thorough understanding & insight of the specialized branches of the medical coding domain, the relevant education, certification and experience needs to be acquired to crack into and succeed in this ever growing healthcare industry. The Radiology and E/M Coding specialties are important elements in the roadmap for attaining success in the field of Medical Coding. Just an eye for detail is required to pitch in and acquire the revenue flow for establishing an era of growth and sustainability in this emerging medical coding business. ISO 27001:2005 Certified Page 15

16 Reduce Claims Processing Time: Getting your medical claims out of the door and paid as soon as possible is every health care provider's primary goal as far as finance is concerned. The faster the claim goes out, the faster the money comes in. Make sure your office is equipped with the necessary software to save time and money. There are three areas that can help you reduce claims processing time. Real time Benefit verification Electronic remitance Advice Eletronic Billing Choosing the best software for your office A healthy billing system: When looking for construction billing software, flexibility is the key to keeping your accounting department and more importantly your customers happy. As a physician you deliver healthcare but as a business person, you should be getting paid what is rightfully yours. Electronic medical billing software for submitting medical billing claims is now the norm and web based medical billing software is the future. Medical billing software is designed to help the medical biller to properly format and process the medical billing and get it ready to be submitted to the payers. Nowadays medical billing software should be HIPAA compliant and should be able to submit medical billing claims in an electronic format at the least. Although your billing software is primarily used for billing your health care insurance claims, it is not the only feature of a good billing system. Your medical office billing software system should enable you staff access to multiple features necessary to performing their job effectively and efficiently. In addition to electronically billing insurance claims, your billing system should consist of the following applications. ISO 27001:2005 Certified Page 16

17 1. Secondary Billing: To have secondary insurance capabilities based on the receipt of primary insurance payment. 2. Electronic Remittances: To allow 835 remittance files to be posted with insurance payments, adjustments and denials. 3. Pre Billing Claim Checks: To ensure claims contain all required information prior to submission to the payer. This will flag accounts that may be missing impertinent information specific to certain payers allowing staff to make proper corrections. 4. Contract management: To allow providers to evaluate expected reimbursement against actual reimbursement for payment review. Knowing whether claims are paying according to contract can prevent lost revenue. 5. Scanning: To allow the scanning of insurance cards and other billing information allowing staffs in different locations access the same information. 6. Standard and customized Reporting: Report management is imperative to any billing features your EHR system offers. An overall, at-a-glance feature for billing reports is something every practice should have. An add-on ability to print any report is a recommended feature for which you should inquire as well. The ease in which these reports can be queried and accessed is another indicator this feature can meet your billing needs. 7. Electronic tracking of payments; transparent payment process: Make the electronic tracking of payment process completely transparent to everyone involved. All details should be tracked in the payment process. Features should include the ability to log and communicate every action enlisted in order to get the claim paid. Claims processing improvement measures should be shared with all providers. Work flow & Productivity Assessment: Workflow and productivity is essential to the success of the medical office. A streamlined workflow will naturally improve employee productivity. A medical office without efficient ways to perform necessary job duties cannot perform them effectively. Having a detailed and well-developed policy and procedure manual in place that readily accessible to the medical office staff can greatly team. Be sure your policy includes a continuing education program to make sure all employees are kept up-to-date on office policies, compliance and job specific requirements. Front Desk: The success of the Medical Office largely depends on how well the front end staff performs. 1. Registration Accuracy: The cycle of a patient account originates with the initial entry of patient demographic information which includes patient demographics and insurance information. Invalid information can delay payment. 2. Scheduling Efficiency: Does your medical office have a high "no show" rate? One way to reduce no shows is by the use of online patient scheduling. Patients can manage, schedule or reschedule their own appointments which makes "no shows" less likely. 3. Patient Satisfaction: Providing high quality care and excellent customer service will prevent loss of revenue for the medical office due to a high level of patient satisfaction. ISO 27001:2005 Certified Page 17

18 Documentation and Coding: A documentation and coding assessment ensures that every patient chart is accurate, complete, and meets coding standards compliance. Proper documentation and coding is essential to accurate charge capture, effective billing and collections, and denials management. 1. Are you still using the old paper-based charting system? Switching to an electronic health record (EHR) can improve accuracy and reduce costs. 2. Proper assignment of emergency & management (E/M) level of service to the correlating diagnosis or ICD-9 codes are important for reimbursement and coding compliance. 3. Don't allow transcription and medical records coding delays affect the billing cycle. Set the timeframe for completion at a minimum of 3-5 days. Billing and Collections: Billing and collections best practices show four ways to manage the work flow for maximum reimbursement. 1. Work all accounts receivable accounts from high dollar to low dollar. This results in lower AR days meaning your medical office is collecting more money in a shorter period of time. 2. At least 90% of medical office claims should be billed electronically. Electronic claims usually process within 7 to 10 days. Paper claims can take 30 days or longer. 3. Use web-based tools to check claim status. This can take 2-3 minutes versus the minutes on hold with an insurance company. 4. Identify causes of denials and underpayments in order to avoid future revenue loss or delay. This also means making sure denials are resolved in a timely manner. Final Note: Hospital needs to improve its revenue cycle efficiency at every phase of the patient/provider interaction from initial contact to clinical documentation to collections. Because improvement takes time, people and resources when all three are stretched to their limit partnerships are an important strategic alternative. You ll reduce operating costs through enhanced efficiency while you improve patient and physician satisfaction. Through our compliance program, we remain vigilant of changing federal, state and local regulatory requirements affecting the revenue cycle. Talisman Solutions has been serving clients since 2004 and has grown consistently because of our excellent Customer Service, Quality, Turnaround Time and Cost Saving factor. We can help - Utilizing years of experience and a unique blend of healthcare and IT skills our team has a proven track record of implementing holistic solutions that maximize revenues, minimize expanses and gain operating efficiencies all at the same time. Proactively enable clients to focus on core activities by successfully owning up business activities on their behalf in an efficient, effective and persistent way and bringing value to the relationship by successfully leveraging our domain and technical expertise. ISO 27001:2005 Certified Page 18