Avoiding the Claims Denial Black Hole: Strategies to Accelerate and Maximize Claims Payments

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1 Avoiding the Claims Denial Black Hole: Strategies to Accelerate and Maximize Claims Payments January 30, 2013 Carmen Elliott, MS American Physical Therapy Association Senior Director, Payment & Practice Management

2 MediServe More than 25 Years Serving the Rehab and Respiratory Communities Rehabilitation IP, OP, IRF Respiratory 250+ Clients Chandler, Arizona CORE Focus (Compliance, Outcomes, Revenue, Efficiency) 2

3 A Few of Our Clients 3

4 Avoiding the Claims Denial Black Hole: Strategies to Accelerate and Maximize Claims Payments

5 Conference Objectives At the conclusion of this audio-conference, the participant will be able to: Identify components to a successful practice. Recognize the top 5 reasons for claims denial. Provide recommendations for eliminating denied claims. Identify gaps in data entry and front-end responsibilities. Identify best practices for revenue cycle management. Explain the purpose of denials management in relation to revenue cycle management. 5

6 Challenges Facing Today s Practice According to MGMA, the biggest challenges in running a practice are: 1. Maintaining reimbursement in an era of declining revenues. 2. Dealing with operating costs riding faster than revenues. 6

7 Market Trends Employer sponsored health insurance is decreasing and changing. Changes in health plan models and benefit plans, e.g. HDHPs, HSAs. Employer s increased interest in prevention and wellness. Development of high performance networks. Payment based on quality measures, eg. Medicare s PQRS. 7

8 Consumer Trends Assume a greater share of the risk and responsibility for their health care. Becoming smarter shoppers and seek out competitively priced services. Continue to have greater out-of-pocket expenses, e.g. higher copays/deductibles. 8

9 Employer Trends Costs will continue to rise. Expectancy workers to pay a greater share of their health plans. 42% will increase their workers' share of health care costs. 4% said will change the design of health care plans to increase medical cost sharing. ndex.htm 9

10 What does this mean for you? Less patients may have health insurance (expected to change with ACA). More patients will have greater out-of-pocket costs. Cost-shifting will affect patient compliance and frequency of attendance. Possible changing of health benefit design. 10

11 Revenue Cycle Management

12 Overview Revenue Cycle Management Patient Registration Coding and Documentation of Services Patient Check-out Claims, Processing and Posting Accounts Receivable Other Operational Processes APTA

13 What is Revenue Cycle Management? Effective management of processes and/or tasks related to ensuring payment for a patient encounter. Processes/tasks may include registration, billing and payment collection, management of ongoing reimbursement and quality issues, and identifying technology opportunities that can decrease days in accounts receivable. HealthLeaders, April 2007, APTA

14 Revenue Cycle Process by Pam Waymack 14

15 Signs that Revenue Cycle needs Improvement Shrinking cash flow. Decrease in the collection percentage. Increase in accounts receivable. Increase in claims denials (e.g. medical necessity, benefit exhausted, not a covered benefit). Increase in cancellations and no shows. Increase levels of staff stress. 15

16 Top issues facing Revenue Cycle Strapped for capital Collections Unclean claims Denials Audits Excellence in healthcare delivery 16

17 Cash is King! Renewed emphasis on collecting cash and reducing days in A/R. More hospitals are using credit scores and financial records in determining collections. Renewed focus on provider contracts. 17

18 Improving your revenue cycle Benchmarking basics Investments in patient access technologies. Processes such as insurance eligibility verification systems. Financial counseling staff. Pay closer attention to managed care contracts. 18

19 Improving your revenue cycle Establish a strategic/defensible pricing strategy. Increase up-front cash collections. Improve denials management. 19

20 Patient Registration Scheduling the Patient Collect patient s demographics and insurance information. Interview patient over the phone. Determine reason for the visit. Have patient complete the demographic/insurance information form in the office. Have patient fill out information form and return via mail. APTA

21 Patient Verification Verify prior to appointment date: Insurance and eligibility Determine if patient will be in-network or out-ofnetwork. Determine if the patient s insurance is current. Determine if the patient is eligible for the service(s). APTA

22 Patient Verification Benefits Confirm the patient s benefits, e.g. is physical therapy a covered benefit? Confirm applicable deductibles and/or copayments amounts. Are there any excluded benefits, e.g. non-coverage policies such as iontophoresis? Is pre-certification/pre-authorization required? APTA

23 Patient Registration Verify with the patient: Has insurance or demographic information changed for established or returning patients? -Does this case involve a third-party liability (e.g. workers comp, auto-liability, etc)? APTA

24 Patient Registration Confirm patient s appointment prior to appointment date: By phone call By Remind patient to bring referral/physician order if applicable. NOTE: Be sure patient understands any missed appointment fees. APTA

25 Patient Registration Collect co-pay/co-insurance/deductible at time of appointment. Remind patient of outstanding balances. Discuss methods of payment: Cash, check, debit, or credit card APTA

26 Patient Registration Make copies of: Insurance card (front and back) Secondary insurance card (front and back) Drivers license (to ensure proper identity) Provide patient with: Office policy brochure/patient financial responsibility brochure - Financial counseling before service delivery Education materials APTA

27 Patient Registration Monitor no-shows/cancellations Techniques to help reduce the number of noshows/cancellations: Have staff make telephone calls Send patients a reminder notice/post-card Use an automated teller system or outside vendor to make calls APTA

28 Coding for Services Rendering provider is responsible for coding. Complete coding process at time-of-service. Use well-designed super bill/encounter form/charge tickets or hand-held device. Use current CPT, ICD-9, HCPCS codes. APTA

29 Coding for Services Use appropriate modifiers if applicable. Assign ICD-9 code to the highest specificity (5 th digit). Refer to Correct Coding Initiative (CCI) edits if applicable. APTA

30 Documentation for Services Provide detailed notes of evaluation and each encounter. The patient s record should be complete and legible Document patient s history, symptoms, diagnosis, and treatment plan. Refer to Defensible Documentation (APTA Web site Perform chart audits. APTA

31 Documentation for Services Documentation can provide information for: Appealing denied claims. Continued authorization of services. APTA

32 Charge Capturing To prevent charge tickets for being misplaced, collect after each patient encounter. Be sure that each clinician has completed his/her charge ticket after each patient encounter. Financial staff can enter charges throughout the day or later in the day. APTA

33 Charge Capturing If using personal digital assistant (PDA), complete the form for each encounter and upload the information into the practice management system. Staff can also collect charge tickets, check them for accuracy, and run batch totals. Determine the patient s financial responsibility. Request and obtain payment. Discuss payment options. APTA

34 Patient Check-Out Collect co-pay/insurance/deductible if not collected during patient check-in. Schedule next appointment(s). Check if the patient has any questions regarding his/her visit. Provide the patient with details of the service(s) rendered and associated charges. APTA

35 Claims Processing Enter codes and charges as they appear on super bill/encounter form/charge tickets or download from hand-held device. Submit claims daily whether electronic format or paper Review each claim for completeness and accuracy before submitting to payer. APTA

36 Claims Posting Posting payment to accounts. Depositing checks and cash on the day of receipt. Lock Box Bank Review electronic remittance advice. Submit secondary claims following adjudication of primary. APTA

37 Accounts Receivable Medical Group Management Association (MGMA) defines calculating A/R as the summation of the amounts owed to the practice by patients, third-party payers, employer groups, and others for FFS activities, with days counted from the time the invoice is submitted for payment (not date of service). Expert Answers: 101 Tough Practice Management Questions, MGMA, 2007 APTA

38 Accounts Receivable Monitor outstanding account balances against contract terms (payer). Monitor outstanding account balances against state prompt payment laws/guidelines. Use web-based or web-access programs offered by the payers to review status of claims. APTA

39 Accounts Receivable Enforce the collection of interest payments for late payment by the payer, if applicable, according to state guidelines. Track and work denials, rejections, and requests for additional information immediately. APTA

40 Accounts Receivable To stay current with payer policies and procedures, attend educational sessions given by your top payers or invite a payer representative to your office. Consider turning over outstanding account balances to a third-party collector. APTA

41 Improving collections Have a defined financial policy. Send invoices promptly and send statements regularly. Contact patients with overdue accounts. Use your A/R sheet, not emotions. Insure that all staff are comfortable with discussing patient financial responsibility Follow state collection laws. Consider using a third-party collector. 41

42 Patient Access Metrics 1. POS collections as a percentage of all patient collections. 2. POS collections as a percentage of potential patient liability. 3. Percentage of accounts not financially cleared. 4. Cycle time. 5. Plan ID changes. 42

43 Using Predictive Modeling Use of automated tools to assess likelihood of payment and general data to flag potential problems. Used in hospital systems to identify potential abusers of the system. Must be calibrated to best fit your organization. Collected information is combined with credit and financial data to predict the likelihood of payment. 43

44 Other Operational Processes Provide the office staff with a summary matrix of all the major payers or payer reference log for easy review and reference. Make sure therapists do not see patients unless credentialed with the payer first. Load fee schedules into your practice management system. Know your contract renewal dates and be prepared to negotiate both financial and operational issues if needed. APTA

45 Other Operational Processes Set up quarterly or bi-annual meetings with your top payers to iron out process problems and resolve concerns. Establish a collection policy. Ensure your patient financial services staff is compensated based on their value to revenuecycle performance. Ensure your staff receives adequate training on data collection and billing requirements. APTA

46 Medical Cost Estimator Medicare Patient Responsibilities CAP Co-Pays Medicaid Cash Policies In-Network Fee Schedules Out-of-Network Fees Projecting a Plan Assurance of prompt refunds of any credits 46

47 Denial Management

48 What is Denial Management? A denial can be defined as a lack of expected payment from a payer. Two parallel processes: a prospectiveprevention process to avoid claims denials and a claims-recovery process to address claims that have been denied. Target the areas of greatest impact on the organization and provides a basis for identifying potential problems before they occur. 48

49 How Important is Denial Management? A key component of an effective revenue cycle process. Can have a more dramatic impact on improving the bottom line than any other single revenue-generation or cost reduction initiative. 49

50 Top Reasons Why Payment is Delayed According to MGMA: The provider incorrectly set up the account (15.2 percent) The provider did not follow up on denied claims (12.9 percent) The payer incorrectly processed the invoice (11.6 percent). 50

51 Top 5 reasons claims are denied Top 5 reasons claims are denied Data entry errors lack of attention to detail Insurance guidelines are not followed Diagnosis is missing or invalid Patient s insurance changed or terminated Patient billed under wrong account # 51

52 The Cost of Denials Nearly 13% of annual revenue is at risk due to payer denials. Over 15% of claims submitted require additional follow up, reducing likelihood of collection, increasing cost to collect, increasing A/R days. 52

53 GAO Report 53

54 2012 National Health Insurer Report Card Key findings include: Denials Payment timeliness Administrative Requirements Accuracy Cash flow Claims Edit sources & frequency Improvement of claims cycle workflow 54

55 Two Basic Types of Denials Soft Denial temporary or interim denial that has the potential to be paid if the provider takes the right follow-up actions "controllable" or "preventable" Hard Denial Considered to be lost or written off revenue. 55

56 Additional Types of Denials Clinical denial Disputes medical necessity Can be concurrent or retrospective Technical/administrative denial Reasons other than Clinical Usually identified in remittance advice using reason codes Short pay denial Issued when payer incorrectly pays claim Include invalid payment rate 56

57 Practice Management Tips

58 Questions to Consider How many denials have we had this quarter? How many were clinical versus technical versus short-pay? What has been our overturn experience for medical necessity denials? What claims (technical denials) were denied yesterday, and why? What are the top five technical denials across our major payers? What is the root cause for high-value denials? Most frequent denials? What are the denial and net revenue trends by department, payer, or service? Of all the denials, where should we focus our resources? 58

59 What to do if a Claim is Denied? It is not always the payer s mistake! Carefully check Explanation of Benefits (EOB) Compare EOB with the original claim Carefully check pre-authorization, insurance verification, and documentation Check patient demographics Check documentation against claim Check benefit language and payment policies 59

60 What to do if a Claim is Denied? If you don t understand the EOB: Discuss with Professional Services Representative Make a notation of their name, date and time of conversation, content of discussion 60

61 Practice Management Strategies Create a denial database Maintain follow up log Enhance payer relations Understand contracts Develop appeal letter and resubmit Collect resources CPT Manual, CCI edits, other references i.e. contracts, policies, editing software 61

62 Getting Things Right the First Time! 62

63 Resources Medicare Denials, Audits & Appeals Denials & Appeals Functional Limitation Reporting under Medicare onallimitation/ Coding and Billing Private Insurance 63

64 FREE Resource Claims-Based Outcomes Reporting Conversion Calculator

65 Modifier Scale (Visual Aid) % Impairment Not functional ability Impaired Limitation Restriction (% Impaired) CH 0% CI 20 1% CJ 40 20% CK 60 40% CL 80 60% CM % CN 100%

66 Questions?

67 Thank You!

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