Contracting and Clean Claims: Billing Techniques for Success!

Transcription

1 Contracting and Clean Claims: Billing Techniques for Success!

2 Top 5 Things to Know for CE: Make sure your BADGE IS SCANNED each time you enter a session, to record your attendance. Carry the Evaluation Packet you received on registration with you to EVERY session. If you re not applying for CE, we still want to hear from you! Your opinions about our conference are very valuable. Pharmacists, Pharmacy Technicians and Nurses need to track their hours on the Statement of Continuing Education Certificate form as they go. FOR CE: At your last session, total the hours and sign both pages of your Statement of Continuing Education Certificate form. Keep the PINK copies for your records. Place the YELLOW and WHITE copies in your Evaluation packet. Make sure an evaluation form from each session you attended is completed and in your Evaluation packet (forgot to pick up an evaluation form at a session? (Extras are available in an accordion file near the registration desk.) Put your name and unique member ID number (six digit number on the bottom of your badge) on the outside of the packet, seal it, and drop it in the drop boxes in the NHIA registration area at the convention center.

3 Disclosures Jacqui DeFranzo is Reimbursement Manager and Brenda Langlais is Reimbursement Manager at Advantage Reimbursement, LLC a Mediware company. The conflict of interest t was resolved by peer review of slide content. Julie Keegstra and Jennifer Notch declare no conflicts of interest or financial interest in any service or product mentioned in this program. Clinical trials and off-label uses will not be discussed during this presentation.

4 Importance of Contracting and Payer Relations in the Front End Process Jennifer Notch Fairview Home Infusion

5 Contracting & Payer Relations Considerations: Payer Contracting and Negotiation Strategiest Inventory Setup Insurance Setup Pricing Setup Payer Policies and Changes Front End Billing Representative ti

6 Payer Contracting and Negotiation Strategies Payer Mix Identify Problematic Areas Split billing Part D Identify all revenue opportunities Identify correct coding and billing procedures HCPC versus NDC Nursing (Infusion Suite, In Home)

7 Payer Contracting and Negotiation Strategies Review Current Contracts and Payment Methodologies Reimbursed according to terms Payments below other payers reimbursement Review Reimbursement Rates per code across all payers Pay close attention to those therapies that generate significant revenueen e

8 Inventory Setup Drug Item Information NDC# Package versus Vial Qty per package versus Each Dispensing Unit Cans, Mcg, Pricing AWP Cost List Price

9 HCPC Information HCPC Codes Inventory Setup Units Pricing per HCPC Unit Quarterly Updates HCPC Code Changes HCPC Code Discontinued Pricing Changes

10 Provider Numbers IV DME NPI Insurance Setup Billing Units HCPC NDC Modifiers Per Diem or Line Item Part D

11 Price Matrix HCPC AWP Special Codes Modifiers Shared Contracts Commercial Payers Pricing Setup Percentage of Charges

12 Payer Policies i and Changes Payer Policies Billing Requirements Varies by Payer Medical Documentation Authorizations ti Policy Changes Without notice Frequently

13 Solutions Payer Policies and Changes Departmental Procedures Dedicated d Staff to Monitor Creation of Intranet/Wiki One Place for All Payer Information Manuals Authorization Forms Websites Departmental Process and Procedures

14 Front End Billing Representative Compliance Medicare Medicaid Part D Authorizations Rejections Billing Requirements Varies Payer State

15 Intake Department: Front End Key for Success Julie C. Keegstra Fairview Home Infusion

16 Key Front End Considerations: Intake Department Creation and Functionality, Financial Clearance Intake Communication/ Cooperation with Billing Success Story Reduction in DSO

17 Case Study: Departmental Reorganization to Align with Company Objectives

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19 Goals Clinicians - Clinical work Support staff Non-clinical work Department focus on one aspect of home infusion Better communication Referral sources, patients, nursing agencies Referral sources, patients, nursing agencies and internal departments

20 Results Creation of Intake Department Financial clearance of patient Clinical clearance of patient One Call to patient

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22 Insurance Verification Intake receives all referrals Verifies insurance coverage On-line and phone NCPDP test claims Part D and Medicaid Communicates insurance coverage to referral source and/or patient Self pay quotes Data entry of patient into software system Demographics and insurance

23 Prior Authorizations (PA) and Primary Care Clinic (PCC) Referrals Requests PCC referrals at new referral PAs obtained within 24 hours of start t of care Negotiate rates with non-par insurance companies Daily reports Recurring PAs/PCC referrals Prescription Dispensed Report

24 Advance Beneficiary Notice (ABNs) Medicare criteria Creation of all ABNs Interdepartmental cooperation Report Unreturned ABNs

25 Prescriber Database (MDs, DOs, PAs, CNPs) Intake data enters all prescribers Verifies State license, NPI, DEA and PECOS before data entry Weekly report Any entries without above information Monthly report State license re-verification

26 Insurance Newsletters or Listservs Subscribe for all contracted and in-network insurance companies Changes in prior authorization requirements and coverage criteria

27 Intake Communication/ Cooperation with Billing

28 Billing/Collection Notes Internal software system communication Intake claim problems to resolve Terminated insurance ID#/Group# invalid PA/PCC needed

29 Denial Feedback Denials patterns Attend each others department staff meetings

30 Insurance Payer Sequence Sequence of insurance payers in software system for maximum efficiency in processing claims Insurance payer of drug listed first NCPDP claims Enteral DME payer listed first Medicare payer listed first to obtain denial

31 Monthly Medicaid id (MA) Eligibility Verification Report of all active patients with any type of MA insurance Straight MA, PMAPs (Prepaid Medical g, ( p Assistance Plans)

32 Success Story Reduction in DSO Between September 2003 and September 2005 DSO reduced from to 76.2 Significantly increased cash collected Decreased reserve requirements Created processes for denial feedback Education improved on information required for billing and collections

33 FAIRVIEW HOME INFUSION DAYS SALES OUTSTANDING (DSO) Jun 03 Sep 03 Dec 03 Mar 04 Jun 04 Sep 04 Dec 04 Mar 05 Jun 05 Sep 05 Dec 05 Mar 06 Jun 06 Sep 06 Dec 06 Mar 07 Jun 07 Sep 07 Dec 07 Mar 08 Jun 08 Sep 08 Dec 08 Mar 09 Jun 09 Sep 09 Dec 09 Mar 10 Jun 10 Sep 10 Dec 10 DSO

34 DSO Level Current DSO Level el and Percentage of Bad Debt Industry Average 75.0 Goal 50.0 Actual (12/31/10) 43.5 Percentage of Bad Debt to Net Revenue Industry Average 2.00% Goal 1.50% Actual (12/31/10) 1.85%

35 Customer Service and Employee Satisfaction Annual Referral Source Satisfaction Survey Purpose/Vision Statement Patient Advocacy

36 Technology and Clean Claims Brenda Langlais Advantage Reimbursement, LLC.

37 What is a Clean Claim?? Billed and paid timely No unexpected denials (No surprises!) Paid at the rate you expected

38 Increasing your numbers Knowing your payer s requirements Learning what your software can do Understanding how a clearinghouse can help

39 Know your payer s requirements How do you know what the payer requires? Review Contract Fee Schedule Payer Sheet Contact your Provider Representative

40 Know your payer s requirements What does the payer require? Claim Format Billing format Is it by line item, kit or per diem What is included or excluded Billing Units HCPCS versus Actual? Are there Exceptions to Standard HCPCS code Is the NDC number required with HCPCS code( ie J3490) What is the Max Billing Quantity 3,4 or 5 digits? Billing date Single date or a date span? Ship date or Service date?

41 Know your payer s requirements Documentation Prior Authorization ABN Advanced Beneficiary Notice DIF DME Information Form CMN Certificate of Medical Necessity LMN Letter of Medical Necessity Purchase Invoice Whether the document is sent with the claim or filed, If audited you MUST be confident the necessary documents for that payer are in place!

42 Who can keep track of all of the requirements? Did you say you rely on your biller?

43 Did you ever hear about the Biller who won the Lottery? Better get to know your billing software!!!

44 Getting to know your software Proper training of your staff to understand the system capabilities is KEY!

45 Getting to know your software What can your software do for you? Can it track Authorizations? What type of Alerts does it have? Are they tracked by service? By item? Number of Units? Billable versus non billable items Documentation DIFs, LMN, CMN,RX, Signed ABN s Can it create Per Diem Charges (based on days, frequency) Does it track overlapping days or interruptions of service? How does the system handle multiple per diems?

46 Getting to know your software Can it split billing between Payers ie. the drug is billable to Part D plan and while the supplies are billed to another payer. Months / years Quantities ie. dealing with maximum quantities does the system facilitate splitting the claim. Does it offer An edit for pre billing review. Check coverage, contracts, dates, pricing, billable vs not billable charges A last chance view prior to sending the claim. Review HCPCS, modifiers, Physicians NPI etc Can it transmit Electronic claims to the Payer minimizing paper claims or rekeying of claims.

47 Let s face it we need software where we can Set it And Forget it

48 How can a clearinghouse help? Prescreen claims based on the payer requirements prior to sending them, thus minimizing payer denials. Provide response and error reports to ensure all claims are processed. Claims can be corrected within their software. Claims can be resubmitted within their software. Provide you historical data and trending information for improvement with your future billing.

49 You don t know what you don t know! Good - Receive a Payer denial Better Clearinghouse rejections Best - Billing System alerts, edits, claim review

50 Get Educated It all starts with getting to know your payers

51 Identifying and Correcting Billing Errors Jacqui DeFranzo Advantage Reimbursement, LLC.

52 Identifying Billing Errors How do you identify what is a billing error due to incorrect billing or inefficiencies? How often do you look at tools that may summarize or identify errors? How do you measure and monitor the staff that does the billing in your facility?

53 Identifying Billing Errors How are you currently identifying billing errors? Denials are you logging them? The value in logging specific denials is endless.. Time savings - not making unnecessary collection calls Track denials that have not been worked or resolved Managing your staff for accuracy (or lack thereof) Ability to sort by denial reason to identify and solve any denials from reoccuring For accountability you can report number of denials and follow through on how they were resolved Nothing will go past timely filing

54 Identifying Billing Errors Partial Payments How are these being resolved/finalized? Who are they assigned to? How timely are they being worked? Are they being worked or adjusted off? H f l i h d i l How often are you analyzing the denials or partial payments to identify trends?

55 Analyzing Trends How often are you analyzing trends and what are you looking at? By Denial code Same denial code over and over By Payer Same payer processing incorrect By Collector/Biller Is it human error? Billing, collections error By HCPCS code Same code continuously denying

56 Setting Expectations for the Staff Working Denials Do you have guidelines on how often they are worked? Partial Payments Do you have guidelines on how often they are worked? Collection activity How clear are the collection notes that are added? Were there any notes logged at all? Do you have guidelines on timeliness and how often notes are added? Content of the notes are they clear and detailed enough?

57 Monitoring Your Staff Are you Auditing Your Staff? Who is performing the audits on your billing staff? What type of detail is provided from the auditor? How often are the audits performed? What type of review do you do with each individual biller? Do you set goals for improvement if a problem is identified? Do you give sufficient time for improvement?

58 Plan of Action Determine Your Plan of Action to Resolve Issues Do you need to look at your system setup? Do fee schedules need to be updated? Do you need to update your HCPCS? Is it a user error? Do you need to re-educate the staff? Is it a payer error? Do you need to contact a provider representative?

59 Preventative Processes What processes do you have in place to ensure: Accurate Billing Are you checking pre-billing edits? Correct HCPCS are on the claims Are you reviewing claims before they are sent on paper or electronically? Correct quantities are billed Are you making sure what was dispensed matches the RX? Authorizations are on the claims Are you using your system capabilities to warn you of missing authorizations? QA is done on new patients Are you checking for missing contracts, incorrect ID # s etc?

60 And the Cycle Continues.

61 Questions?