REVENUE CYCLE PRINCIPLES SERIES

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1 REVENUE CYCLE PRINCIPLES SERIES Part 3 The Fundamentals of Producing Clean and Complete Claims Derek Morkel, President & CEO, GAFFEY Healthcare

2 REVENUE CYCLE PRINCIPLES SERIES Part 3: The Fundamentals of Producing Clean and Complete Claims A More Focused Approach to Reducing Denials Part One Recap The message of part one was simple our work is to collect cash in the most efficient manner possible. As complicated as it all is, revenue cycle work can be segmented in two focus areas on a daily basis: 1. Collect more cash 2. Collect cash more efficiently The two basic principles can then be broken down into three main areas of focus: 1. Clean claims 2. Bill efficiently 3. Collector productivity Part Two Recap Part two focused on matching your facility s resources both people and time to the key factors that improve clean claims and revenue cycle efficiency. Making sure that all business processes are well established and communicated regardless of the process is critical. Collecting receivables is no different. Billing efficiently and having superior collector productivity will be significantly enhanced if you get the first step 100% correct on a daily basis. Introduction The first two parts of our series focused on the broader aspects of why it is important to focus on clean and complete claims and the resources necessary to ensure success. Part three takes a step further to dig into the specific components of which processes produce both clean and complete claims. The end result of getting this right is not only better collections, but typically better net revenue, higher collections and greater efficiency. An examination of the most common reasons for claim denials almost always provides some insight into what needs to be fixed to correct the errors. Even though the reasons we discuss here come from national or regional analysis of claim denials, it is always useful to analyze your own hospitals denials (at least monthly) to make sure that you are addressing the root causes at your own facility. Page 1

3 Most common causes for claim denials Trailblazer Health Enterprises one of the largest Fiscal Intermediaries (FI) analyzed claim denials from its database and published (June 2010) the following listing of principal causes for hospital claims denials. 1. Duplicate claim/service 2. Non-covered service 3. Medicare Advantage plan 4. National Correct Coding Initiative (NCCI) 5. Screening/routine services 6. Patient supplies 7. Beneficiary eligibility 8. Medicare Secondary Payer (MSP) 9. Provider eligibility 10. Hospice As a comparison, an analysis of several studies of physician claim denials produced the following list of the top 10 reasons. Top ten reasons for physician claim denials are the following: 11. Incorrect or missing ICD-9 diagnosis 12. Incorrect or missing modifiers 13. Duplicate claim 14. Additional information needed to process the claim 15. Billed amount is correct 16. Incorrect/missing CPT procedure codes 17. Physician s name and/or NPI number is missing or incorrect 18. Incorrect or missing place of service code 19. Incorrect or missing quantity, multiples or services 20. Services are unbundled There are a number of different studies regarding the cost to rebill and rework a claim denial most of them identify the amount around $25-$35 per account. Whichever number you use, it is clear that it is very inefficient and expensive to rework a claim. Both of the listings also include a number of categories that would cost the provider additional reimbursement even if the claim is paid the first time. A grouping of the reasons by functional area is extremely revealing and proves the point that an intense focus on the front end is critical to efficiency. The physician breakdown is slightly different as significantly more work is done by the billing function to produce a clean claim. Category Hospital Physician Admitting 6 2 Coding 1 3 Billing 1 3 Charge Capture 1 1 Administrative/System Setup 1 1 Page 2

4 Focus areas to improve clean claim rates & reduce denials Admitting QA The claims process actually begins with preadmission and then the admission process. Admitting staff not only need to be trained to make sure the right forms are filled out, but they also need to be able to verify that the patient s insurance information is correct, collect any co-payments due and check that any necessary pre-authorization forms from physicians and insurances are on file. 70% of the data required to complete the billing process comes from admitting. As we can see from the denial analysis, 60% of the denials in a hospital can be directly attributed to admitting errors. With each error potentially costing $25-$35 to correct on the back end, it makes sense to have a robust QA function for admitting. 100% of all the claims should be checked for the denial reasons listed above and your own analysis of your facility s denials. The QA should also be done by someone who is knowledgeable about admitting. Quite often the task is relegated to a lower level employee and/or only done sporadically as an afterthought. Tip: It is sometimes good to rotate this function between your admitting staff so they can see the errors being made throughout the department. It is also good to periodically have them sit with the billers to see what the result of an error is in the billing cycle. On the back end, you need a clear understanding of where your denials are coming from in terms of both the reason for them and the payer involved. That means creating some type of denial management database. This will ensure that the QA process is always evolving and matching the current needs of your facility. Charge Capture & Coding Correctly documenting the services and procedures a patient receives during an inpatient stay or even in a visit to the emergency room i.e. charge capture is a vitally important step in the process. For example, if a clinician documents a medication the patient receives (by infusion) but forgets to record how the medication was delivered, the insurer won t pay for the delivery, just the medication. It s unlikely that the medication miraculously made it into the blood stream; thus, the fact still remains that the provider will not be paid correctly for the claim. Implant charges are another typical culprit. Not only can missing implant charges cause potential denials, but they can also result in lost reimbursement up to $40,000 for certain cardiac and neurological/spinal implants. Potentially a very costly error. Charge capture should be a daily discipline that is the responsibility of many different departments in the hospital. Much like the admitting QA function a review/reconciliation should be part of each department s responsibilities. If this is completed each day correctly by every department, then the amount of charge capture errors should be greatly reduced. Page 3

5 Technology Much of what we have discussed so far can be accomplished by improving the originating processes and having a review function. However, it is important to note that there are many applications available today that can aid in the review and control process and make it even more comprehensive. Almost all of the parts of the revenue cycle discussed within this series are prone to human error even the review/qa process. Technology applications like CDM maintenance software, Charge Capture, Medical Necessity, Bill Scrubbers, etc. should be an integral part of the front end of any hospital s revenue cycle. It is not possible for any human being to remember or review all the line items of a hospital CDM it can only be done properly by software. The same can be said for Charge Capture and Bill Scrubbing. These applications can scan thousands of claims in seconds looking for potential errors. It is for this reason that these should be integrated into the setup, review and QA functions at the hospital. Eliminating one $40,000 error provides an attractive ROI for all the applications listed above. Conclusion On the front end, a variety of seemingly unrelated steps in the process including payer contract negotiations, admitting, charge capture and billing all contribute to the potential success or failure of getting a claim paid correctly and on time. A process that focuses on the components discussed within this document will result in a much higher clean claims rate. 1. Clean claim focus by all departments not just admitting 2. Robust review/qa function including use of technology applications 3. Continuous feedback monitoring of QA results and denials keeps the focus on current issues By promoting a culture of cross-departmental cooperation that attacks the breakdowns in various steps in the claims life cycle, denial rates will begin to fall, collector productivity will increase and CASH will improve. For more information, contact us today at or GAFFEY Healthcare hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. GAFFEY Healthcare and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. Recipients of this information should consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters. Page 4

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