How To File A Claim Electronically

Transcription

1 Revenue Cycle Management: Tips & Tools 2010 Annual Educational Seminar March 10, 2010 Presented By: Cindy Tipton, Coding & Compliance Director

2 What is the Revenue Cycle or Life of a Charge? Important to understand the operations of your practice When and How does patient information get collected and verified? How do charges get processed by your office? Do you have a standard process for charges, payments and denials? Are claims submitted daily? Understand the full process within your office.

3 Tips for filing electronic claims Verify, file, and keep all transmission reports Track clearinghouse claims to ensure successful transmission Verify that your computer software is consistent with the clean claims rules Verify that your software correctly prints a claim Monitor, review, and correct daily all fatal errors

4 Tips for filing paper claims Do Use only original claims forms (printed in red drop-out ink) Avoid folding claims if possible Do not use terms such as re-filed claim, second request, or corrected claim Avoid handwritten claims Use all UPPERCASE letters Stay inside the lines of each block Verify that claims are readable

5 Tips for filing paper claims Don t Use any punctuation or decimals Send unnecessary attachments Use staples or paperclips Attach post-it notes Use highlighters Circle or additional markings Attach labels Add notes or instructional assistance Don t give insurance companies a reason to reject your claim!

6 Additional Tips Always include the providers federal Tax ID & NPI numbers Include the referring physician if applicable Include prior authorization if applicable Include the provider s signature The admitting diagnosis is required for all inpatient claims ICD-9 codes should be coded to the highest level of specificity (4 th & 5 th digits) Correct Place of Service

7 Revenue Cycle ANSWER TELEPHONE Standard Greeting Identify Self Identify Location "May I help you" P & P PATIENT CALLING? P & P Triage Protocol NON PATIENT CALL TRIAGE NO YES PATIENT CALL TRIAGE Personal Call Identify Caller Review "VIP" List Determine availability of physician/ staff member Transfer call/take message, as directed by physican/ staff member Deliver message Another Physician Determine availability of physician If physician w/patient, "Would you like physician interrupted?" If physician unavailable, "Can clinical staff member help?" Transfer call/ take message, as directed caller Deliver message Physician Office- (non physician) Identify Caller Determine nature of call Determine availability of appropriate recipient Transfer call/ take message, as directed Deliver message Hospital/ Ancillary Provider Identify Caller Determine nature of call Pull Patient Chart Determine availability of appropriate recipient Transfer call/ take message, as directed Deliver message Laboratory Determine nature of call "STAT" Results Determine availability of appropriate recipient Transfer call/ take message, as directed Deliver message Pharmacy Call Identify Patient Determine if patient waiting for Rx Determine availability of appropriate recipient Transfer call/ take message, as directed Pull Patient Chart Deliver message Business Call Identify Caller Identify Recipient of Call Determine availability of requested recipient Transfer call/ take message, as directed Deliver message Outgoing Call Patient Cancel Ask reason Re-Book Post Cancel to System (with reason) If no rebook, Chart cancellation Non-Urgent Calls Est Pt NO Presenting Problem Scheduler Next Available for Est Patient NonUrgent Set up Reminder New Pt NO Presenting Problem Scheduler Next Available for New Patient Non Urgent Send New Pt Package Fill out New Pt QuickInfo Est Pt Sick Sick/Urgent Calls Protocol Question 1 Protocol Question 2 Protocol Question 3 Scheduler New Pt Sick Next Available within 1-2 days Pull Chart TX to Clinical Scheduler SDS slot Emergent Calls New/Est Patient Emergent Pull Chart Tx to Clinical Come to Office Go to Emergency Dept Call Copyright 1999 by MED3OOO Group, Inc. Now OV

8 Revenue Cycle

9 Revenue Cycle

10 Revenue Cycle

11 Charge Capture Get Paid For What You Do! 1) Ensure there is a reconciliation process through the practice management system or daily schedule to ensure all office charges have been entered. 1) Use scheduler in practice management system or daily schedule 2) Office charges should be entered daily no lag time! 3) Ensure encounter form is representative of commonly used procedure codes 2) PDA s can be used for daily inpatient charges, if this is not an option print daily census and use as reconciling tool. 1) Inpatient charges should be turned in daily 2) Ensure practice staff have appropriate access for patient demographics, test results, etc. 3) Surgery charges should be reviewed by a certified coder to ensure all services are billed for. 1) Surgery charges should be entered as soon as the dictated operative report is available for coding. 2) Surgery schedule can be put into practice management system to ensure no missing surgery cases!

12 Managing the Revenue Cycle INDICATOR CALCULATION BENCHMARK Days in Accounts Receivable: how many days on average does it take to liquidate a receivable item? 12 months gross charges/365 Primary Care: <50 days Specialty Care< 60 days % of Accounts Receivable >120 days: the older the receivable, the more difficult it is to collect Net Collection Percentage: how much money was collected on the money that could have been collected? Denial Percentage: why are claims not being paid? Total Accounts Receivable/Total Accounts Receivable +120 days Payments/(Charges+ Contractual Adjustments) Total Zero Payments-Denials/Total Payments <20% >95% <7% Bad Debt Total bad debt adjustments (one year)/total charges (one year) <2%

13 Importance of the Front Desk/Check In First Impressions of your office The collection of accurate demographic and insurance information. Registration staff should be well educated with the various insurances your practice participates with. Insurance verification process should be established for your practice.

14 Policies, Procedures and Education of Staff Keeping your staff informed is critical to the AR process Should have established policies and procedures to ensure standardization Have meetings with staff to keep them educated of changes with insurances, processes etc.

15 Charge Capture and Claim Submission Importance of Clean charges Charges should be entered timely (even hospital charges) Scrub charges before they are submitted to the carriers Claims should be sent electronically and daily Clearing House or vendor should provide reports of claims sent and status of claims

16 Accounts Receivable Process How does your staff monitor un-paid claims? When does your staff review un-paid claims? Do you post denials, and how do you track your top denials? Do you have a standard set of monthly reports for the practice? Do you review the reports with your staff and use them as educational tools? Does your current billing system provide the necessary reports to work the AR? Do you monitor staff productivity? Do you have thresholds set for your practice?

17 Information and Reports Turning Data into Information for Improvement Identify Strengths and weaknesses Provide objective, measurable information Establish trends Improve performance

18 Top 5 Reports A/R Reports Unpaid Claims Lag Time Denial Productivity

19 Accounts Receivable Reports Days in AR A/R over 120 days

20 Unpaid Claims Review at days Follow-up with payer

21 Lag Time Submission of claim within hrs. of service Improve cash flow Faster Submission = Faster Payment

22 Denial Denial reason Patient detail

23 Productivity Benchmarks Track trends

24 Checklist for Improving Accounts Receivable What is the 1 st impression of your office Insurance verification Updated Policy & Procedures monthly staff training on updates Staff informed of the A/R process Scrub charges prior to submission Send claims daily Send hospital and/or nursing home claims daily or weekly Review reports from clearing house on denied claims work daily Review monthly reports

25 TOP TEN Most Common Professional Fee Billing Errors Always assigning same level of service Misinterpreted abbreviations No chief complaint listed for each visit Billing of service(s) included in global period Inappropriate or no modifier used No documentation for services billed No signature on documentation Unbundling of procedure services Billing Consult vs. New Patient Visit Invalid codes billed-due to charge ticket not being updated with new/revised codes

26 Documentation of an encounter dominated by counseling or coordination of care In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E&M services.

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28 Frequently Used Modifiers 22 Unusual Procedural Service 53 Discontinued Service 24 Unrelated E/M service during post-op 57 Decision for surgery 25 Separately Identifiable E&M 59 Distinct procedural service same day as a procedure service 26 Professional Component 76 repeat procedures 50 Bilateral Procedure 80 Assistant Surgeon 51 Multiple Procedures 91 Repeat clinical test 52 Reduced Service

29 Diagnosis Coding(Do s & Don ts) Non Specific Diagnosis Codes A thing of the past V Codes Preventative Medicine, Screening, Secondary diagnosis code to explain the primary diagnosis code Avoid Rule out codes Guidelines advise us against coding the following: Probable Suspected Questionable Rule Out Code the condition to the highest degree of certainty Using rule out indiscriminately makes it look like a practice is treating a higher level severity of patients- when in fact they were actually follow-up visits to determine whether conditions had subsided. Red Flag for an Audit

30 At the End of the Day, It s Outcomes that Matter! Outcomes for your Practice: Enhanced Revenues Operating Efficiency Stable, Integrated System Ability to Focus on Patient Care Outcomes for your Patients: Increased Accessibility of Practice Recalls and Reminders for Needed Care Evidence-Based

31 Questions?