Optimizing Your Billing System to Produce Clean Claims
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- Gwenda Armstrong
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1 Optimizing Your Billing System to Produce Clean Claims Chris Peters, ACL Laboratories Road to Billing Optimization Missing Billing Information Missing test modifiers Wrong billing address Insurance coverage lacking Data entry errors Failed Medical Necessity 1
2 ACL Laboratories Background The nations third largest hospital-based laboratory systems. Provide 21 million lab tests per year Parent Companies Aurora Health Care, Largest Integrated Health System in Wisconsin and Advocate Health Care the Largest Integrated System in Illinois Strategic Project Billing Optimization: To address these challenges our organization initiated a strategic project to enhance our billing systems to include: Auto fix & scrub claims based on custom rules. Automated eligibility checking Automate missing information requests. Create new online worklists that support claim scrubbing 2
3 Project Focus to Produce Clean Billing Claims What is a Clean Claim? A clean claim is one that does not require the Government or Commercial insurance carriers to intervene manually in the claim process and one that is not denied or returned to the provider for correction. Must pass all edits and is processed electronically. What are the Benefits of Clean Claims? Provides the Best Practice service to our patients & clients Allows the lab to submit the highest number of payable claims on the first try as soon as possible after the services are provided. Maximize cash flow & collections rate. Minimize claim re-work & rejections. Reduces the chance that the laboratory will come under scrutiny by government or other payers 3
4 Clean Claim Workflow Lab Orders Will Data Produce Clean Billing Claim? No Correct Data Electronic Billing System Yes Clean Claim Workflow Lab Orders Will Data Produce Clean Billing Claim? Yes No Correct Data Electronic Billing System 4
5 Top Clean Claim Challenges Missing Billing Information Medical Necessity Bad or Inaccurate Information Sent directly to lab from client office that By pass front-end system edits Data Entry Errors Wrong or missing test modifiers Inappropriate Duplicate Billing Payment rules that vary by payer/plan. Manual Processes Strategic Partnership Formed with In December, 2009 ACL signed a contract with the Rhodes Group to provide claim scrubbing software Fusion 100% claim scrubbing. Rhodes Group Proven Track Record in Building Clean Claim Scrubs for the Lab Industry. Fully integrated with our core billing system - Sunquest Clinical Financial Systems 5
6 Clean Claim Workflow Lab Orders Fusion Will Data Produce Clean Billing Claim? No Online Worklist to Correct the Data Yes Electronic Billing System Key Benefits of Rhodes Fusion Claim scrubbing software Flexible & Adaptive rule building for custom scrubs. Custom scrubs can be built using any orders or billing data element. Supports automation of missing information letter requests to ordering providers. Supports eligibility checking for top payers prior to billing Supports online worklists and automation to fix bad or inaccurate billing information 6
7 Tables/Scrubs Rules 70 + tables/ 200 active scrubs built to support Clean claim rules 100% Scrubbing Any lab orders or billing data field 200 active scrubs to support Each Scrub assigned an ID Automated Web Based Work lists Audit Review, Claim Check, Data Entry, Problem Tracking Paperless Billing with links to Lab requisitions Top Clean Claim Scrub #1. Is the Patient Eligible for Insurance? Lab Orders Fusion Is the Patient Eligible for Insurance? No Online Worklist to Correct Insurance Data Yes Electronic Billing System 7
8 Eligibility Rules National HIPAA Standards for Eligibility Checking HIPAA 270/271 (Health Care Eligibility Benefit Inquiry) transaction. Direct batch submission with top payers without transaction costs. ACL Goal check eligibility on 80% of all third party billing transactions. Eligibility Edits Claim Check Responses Validate: Patient s Date of Birth Patient s name Subscriber ID Another Payer is primary - The 271 acknowledged the patient and their eligibility but states that a different payer is to be billed first. Subscriber ID Auto updated from Claim Check Interface Policy number updated from payer database. 8
9 Eligibility Edits Skilled Nursing Medicare Logic - Checks the Medicare Part A status to determine to bill the nursing home or Medicare. Gender Updated - The correct patient gender information is provided based on the payer information. Address Updated - The correct patient address information is provided based on the payer information. Payer System Website Transmission Method Medicare IVANS Website: Medicare Inquiry Pro Software with auto 271 return Medicaid IL IL Medi Web Portal System IEC File Upload Medicaid WI Forward Health Portal Web Portal File Upload United UHC Web Portal File Upload Healthcare Connectivity Director Blue Cross/ Passport FTP Anthem IL Anthem WI Anthem EDI Web Portal Upload United Medical Passport FTP Resources Cigna Post n Track n track.com FTP Aetna Post n Track n track.com FTP Humana Availity Web Portal File Upload 9
10 Actual Medicare Eligibility Responses Another Payer to be billed first Part A coverage only Gender Updated Private Insurance Reponses Medicare to be billed first No Medical Coverage Date of Birth Updated Gender Updated 10
11 ACL Eligibility Checking -- Key Scorecard Results Insurance Denials for Eligibility are Down 80% 86% of all billing claims checked for Eligibility. 4,500 + accessions/ month auto fixed last month for the Policy Identification number Top Clean Claim Rules # 2. Does Lab Service meet payer payment rules? Lab Orders Fusion Does the Lab Service/Test Meet Payer Payment rules? Yes Online Worklist to Correct Claim Data N o Electronic Billing System 11
12 Top Scrubs # 2 -- Does Lab Service/Test Meet Payment Rules? Government vs Commercial Medicare /Government test payment rules well defined with quarterly updates Correct Coding Initiative (CCI) One or more of the tests on the claim is a component of another test on the claim. Services can not be billed together. Medical Necessity Edits (LMRP) (NCD) Local & National Polices No screening except by statue (Major source of DX faxes to Physician s office) Mutually Exclusive Edits (MEE) (2 comprehensive panels) Medical Unlikely Edits (MUE) services that are clinically or anatomically unlike for the vast majority of patients Top Scrubs # 2 -- Does Lab Test/Service Meet Payment Rules? Commercial Payers: Commercial payers Rules less defined (Medicare replacement/self funded Plans/HMO) Test payments rules vary and often change without warning i.e. bundle tests into a panel and pay lower panel rate. Constant revisions to keep lab billing edits current. Max Test Quantity Rules by Payer ( not always published) Tip: Review Insurance Remits to create new rules based on denials 12
13 Top Clean Claim Rules # 3. Is the Billable Party Correctly Assigned? Lab Orders Fusion Is the Billable Party Correctly Assigned? No Online Worklist to Correct Claim Data Yes Electronic Billing System Billable Party -- Scrubs Payer Assignment based on Policy ID. Useful for Commercial payers with unique numbering systems PolicyLike XOF% Then Blue Cross IL with Insurance Code: BlueIL Bill Client Account based on Client ID Useful for client that are 100% client bill Organization. ClientNumber: Client Bill Add or Delete Patient Billing Based on Payer This scrub automatically adds or deletes patient billing based on payer. Medicaid/HMO plans with no patient billing. Correctly Assign Insurance codes based on patient s state This scrub automatically assigns the correct payer insurance code based on patient state location.(wi or IL Medicaid, Blue Cross/Anthem) Correctly Assign Insurance codes base on Capitated insurance membership lists. Patient is member of a capitated insurance plan. This scrub integrates the membership database into the Scrub tables so that the correct insurance plan can be assigned. 13
14 Top Clean Claim Rules # 4. Is Required Billing Data Missing? Lab Orders Client Fax Automation Fusion Is Required Billing Data Missing? No Online Worklist to Obtain and Correct Claim Data Yes Electronic Billing System Missing Claim Automation Automated worklists for missing information requests sent to ordering clients. Options to autofax or requests to clients. Automated letters are sent every X days. The system tracks what letter has been sent 1 st, 2 nd or Final Letters. When a client returns the missing information the accession will be billed and auto removed from the Missing Information Letter Queue. If missing information is not returned after 3 faxes the client or patient will be billed depending on client setup. 14
15 Medical Necessity Multiple Edits 15
16 National Provider Identification Top Clean Claim Rules # 5. Can claim be Autofixed? Lab Orders Fusion Can Claim Data be Autofixed? No Online Worklist to Correct Claim Data Yes Electronic Billing System 16
17 Autofix Statistics Annual Count Autofix Patient Balance Billing 344,547 Autofix Cap Membership Billing 197,709 Assign Test Level Primary DX 163,806 Autofix Relationship Code for Responsible party 125,394 Autofix Payer 124,836 Autofix based on policy group 95,520 If a person could fix 2 of these per minute, these autofixes would represent 5 FTE S Key Scorecard Results for Billing Optimization C O S T S Increased cash collections by 5% while lowering Average Days Outstanding Value 17
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Patient name; Patient address; Patient Social Security number/medical Record number; Patient date of birth; Patient phone number; Diagnosis code(s);
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