Revenue Cycle. Management. The AdvancedMD Training & Companion Guide

Revenue Cycle Management The AdvancedMD Training & Companion Guide How to Use the Tools and Reports within AdvancedMD to Support Industry Standard Best Practices in Revenue Cycle Management

Table of Contents Acknowledgements... 1 Chapter 1 Financial Clearance... 2 Chapter 2 Check-in and Check-out... 5 Chapter 3 Charge Capture... 8 Chapter 4 Coding... 11 Chapter 5 Charge Entry... 14 Chapter 6 Claims Management... 17 Chapter 7 Patient Statements... 23 Chapter 8 Payment and Denial Posting... 26 Chapter 9 Insurance Follow-up... 29 Chapter 10 Denial Management... 33 Chapter 11 Patient Collections... 37 Chapter 12 Payor Management... 40 i

Acknowledgements At AdvancedMD, our goal is to help your medical practice or billing service achieve its highest revenue potential. To further leverage your AdvancedMD practice management system and secure reimbursements, we have created AdvancedMD Training and Companion Guide to step you through our product suite. We recognize that the authors of the Medical Group Management Association s best-selling book, The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, have set the industry standard for revenue cycle management best practices and we consider them to be the country s experts in providing guidance to effectively manage the entire accounts receivable process. To maximize the benefits of your own billing processes, we highly recommend that you read the MGMA book, and use our Training and Companion Guide to help you leverage the numerous tools and reports available in the AdvancedMD product suite to achieve the best practices as defined in the book. To obtain a copy of The Physician Billing Process, visit the MGMA.com book store and enter the promotional code billing to earn a 15% discount. The link to the MGMA website is www.mgma.com/store. Once you re there, enter item number 8079 to read more information about the book or to buy it directly. We know that running a medical practice or billing service is a highly complex process and we hope our Guide will help you use AdvancedMD s numerous tools and reports. As you work through your own billing processes and the AdvancedMD product suite, we welcome and encourage your ideas and feedback. Best regards, The AdvancedMD Product Teams 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 1

Chapter 1 Financial Clearance Overview Before any patient visits your practice, your office should institute a financial clearance policy to determine the amount each patient owes for copays and outstanding balances. Use your AdvancedMD system to implement a financial clearance regimen in your office. To learn more about managing the financial clearance process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals AdvancedMD can be instrumental in helping you manage a financial clearance process in your front office. Use AdvancedMD to: Maintain and Verify Patient Information Check Insurance Eligibility and Track Authorizations Remind Patients of Outstanding Balances Encourage Prompt Payment from Patients AdvancedMD Tools Appointment Scheduler Chart Files/Patient Photos Confirm Appointments Screen eeligibility Insurance Additional Information Screen Patient Demographics Module Patient Memo Payment Plans Preauthorization Tracking Report: - Appointment Confirmation Detail AdvancedMD Help Files and Video Training Library Maintain and Verify Patient Information In the Patient Demographics module of AdvancedMD, chart information is stored for each patient. This information includes the patient s name, address, social security number, insurance and other billing information, and financial history for the patient and the family. AdvancedMD makes it easy to collect or verify demographic and financial information when a patient is being scheduled for an appointment. When an existing patient is selected in the Appointment Scheduler, demographic, insurance coverage, primary insurance copay, and current balance information are displayed so you can verify this information as part of the scheduling routine and prepare the patient to make payments on copays or outstanding balances. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 2

As a way to avoid insurance fraud, many medical practices have adopted a policy of checking patient identification prior to service. Using the Chart Files tab, picture identification can be scanned or patient photos can be uploaded and made available in the patient s demographic file. By keeping a patient photo or ID on file, office staff can verify a patient s identity using information in the system rather than asking established patients to present ID at each appointment. Check Insurance Eligibility and Track Authorizations AdvancedMD s eeligibility module allows you to check eligibility on-demand in real-time or automatically on a batch basis. Verification of insurance eligibility can be done in real-time for last minute appointments or walk-in patients after you have gathered the required pre-visit information, or during appointment check-in. Batch eligibility checks are done prior to the appointment on a periodic basis for patients with scheduled appointments. The most current eligibility information (based on the last time eligibility was checked for a patient) is available to view on the Confirm Appointments screen or on the patient s Insurance tab. Eligibility information may also be accessible from the carrier if the carrier offers access to their database. It is important to note however, that not all payors offer the same information, and some carriers provide more information than others. If you are going to preauthorize certain services as part of your standard workflow, the carrier s website may offer an automated way to obtain the authorization. AdvancedMD s Patient Demographics Referrals tab assists you with preauthorization tracking by providing fields where the preauthorization number can be stored and visits covered under that authorization can be tracked. Checking your patients insurance benefits and obtaining authorizations prior to providing services will help guarantee that you will be paid by the carrier for services you provide. It also helps to ensure patients will be willing to pay for expenses incurred because they are already aware which services are not covered. Most carriers create payor guides that you can access on the carrier s website, or that can be sent to you upon request. As an AdvancedMD client, you have access to the RelayHealth website, which offers carrier policy information. All carriers in the Carriers master file include a Clearinghouse Website link. Any AdvancedMD user can register to browse this site. By entering a CPID, you will see all of the information that RelayHealth has on file for that carrier, including policies and claim edits. Remind Patients of Outstanding Balances Prior to an office visit you should prepare to collect money from scheduled patients. Use the following tools to view copay, balance, bad-debt, and deductible information in AdvancedMD: Appointment Confirmation Detail This report contains patient appointment, contact, and balance information. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 3

Appointment Scheduler If you do your reminder calls by looking at the AdvancedMD scheduler for an upcoming date, you can select the patient via the patient appointment and the Scheduler will display the patient s contact information as well as copay and current balance information. Hover your mouse over the patient s appointment to display a tool tip with comments entered when the appointment was made. Confirm Appointments screen This screen displays the patient s home and work phone numbers, and comments entered when the appointment was made. Hover your mouse over the Patient column (as well as other specific columns) to display a tool tip with copay and outstanding balance information. Insurance Additional Information screen This screen allows you to note and track deductible amounts. Insurance Tab Copay information can be stored and viewed for each coverage on the Insurance tab. Additionally, deductible information may be available when you are viewing eligibility details for a carrier. Patient Memo If you have chosen to use the Patient Billing Wizard to write off bad debts or small balances, and you want the patient to be responsible for these monies, you can look for these write-offs on the Patient Memo. Encourage Prompt Payment from Patients Checking insurance eligibility, obtaining pre-authorizations, and informing patients of copays and deductibles while scheduling or placing reminder calls are good ways to encourage patient payments. These efforts will be even more effective if they are coupled with well-communicated payment expectations. Looking at the patient s financial history in AdvancedMD s Patient Demographics module, you can assess how reliable a patient has been in making payments. If it appears the patient is unlikely to pay, your office should refer them to any hardship financial policies you have. This can help eliminate unnecessary collection efforts. To help you manage situations where patients need to pay large balances over time, AdvancedMD allows you to set up patient payment plans with or without interest. Payment plans can be created that break the total due into equal payments with a pay-off date, or that set up an agreed upon amount the patient will pay each month. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 4

Chapter 2 Check-in and Check-out Overview If your check-in and check-out processes are well managed and organized, you will be able to obtain the proper financial obligations from the patient, as well as the necessary financial information, paperwork, and signatures, etc. Use your AdvancedMD system to manage and organize the checkin/check-out process in your office. To learn more about managing the check-in/check-out process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals AdvancedMD can help your check-in/check-out processes run smoothly. Use AdvancedMD to: Confirm Patient Information Check In/Check Out Patients Determine Eligibility Collect Prior Balances Collect New Balances AdvancedMD Tools Chart Files/Scan Feature Collect Copayment Screen Confirm Appointments Screen eeligibility Forms Tab Forms Templates Multiple Check In/Check Out Methods Patient Document Templates Print Documents with Charge Slips Referrals Tab Reports: - Appointment Confirmation Detail - Unapplied Transactions AdvancedMD Help Files and Video Training Library Confirm Patient Information It is important that the medical practice has the most current information and all necessary signatures for each patient in order to bill insurance and/or the patient. Be sure the necessary paperwork is ready for patients to review, fill out, and sign when they arrive for their appointment. The following are examples of paperwork to present to the patient at check-in: Patient Demographics Form Insurance Information Medical Practice Policies 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 5

Medical History Form The Patient Demographics form is a standard form in AdvancedMD that contains both the patient s demographic and insurance information. The form is easily accessed from the Forms tab in Patient Demographics, and can be printed prior to patient check-in so it is available for the patient to review and make changes on, if necessary. In AdvancedMD there are several ways to customize, personalize, and manage the patient forms and/or documents that you need to collect from patients. Use the feature below that works best with your office s workflow. Forms Templates Patient forms can be built using forms templates and printed individually from the patient Forms tab. Patient Document Templates Documents can be built using Patient Document Templates and printed individually or in a batch as part of printing charge slips. Check In/Check Out Patients Once the patient is in the office, there are multiple check-in/check-out methods to help you easily track patient movement through the practice. Check In Appointments screen This screen displays all appointments scheduled for the day and allows you to track what time patients have been checked in and checked out. You can also cancel and mark appointments as a no-show from this screen. Appointment Scheduler Using the appointment menu, you can quickly check in and check out a patient directly from the Appointment Scheduler. You can also cancel and mark appointments as a noshow from this menu. Patient Checkout screen This screen allows you to check the patient out and schedule a recall for the patient, as well as post prior balance payments and other time-of-service monies. Use this screen in conjunction with a process that posts charges prior to check-out, as only visits with charges will display in this screen. Determine Eligibility If insurance coverage and eligibility were not verified during a pre-visit process, verify them during the check-in process. eeligibility allows you to check benefits in real-time by simply clicking the Check Eligibility button on the patient s Insurance tab in Patient Demographics. When you receive the patient s insurance card, it is better to scan the card than to copy it. Scanning insurance cards into the AdvancedMD application gives your front office staff easier access to insurance information and eliminates the time and effort needed to search the patient s medical chart. Insurance cards can be scanned into the application using the Chart Files tab and can be quickly accessed at any time from the patient s demographic record on the Insurance tab. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 6

If patients are referred by another physician, it is important to ensure that you have accurate referral information and authorizations. Referrals and authorizations can be recorded in AdvancedMD s Referrals tab, along with the number of authorized visits. Collect Prior Balances When confirming appointments, the front-office staff should be aware of patients prior balances and time-of-service responsibilities. If front-office staff are consistent in reminding patients of their financial responsibilities prior to the visit, the chances are better that monies will be collected during check-in. Collecting payment at the time-of-service may reduce the number of statements that must be sent later, saving the practice time and money. Front-office staff can view the patient s copay and any prior balances from the Confirm Appointments screen, and can communicate this information to the patients when confirming appointments. Appointment comments entered in the Make Appointments screen can be used to indicate that a patient was made aware of monies owed during the appointment confirmation process. Patient balances and any appointment comments are displayed in a tool tip when you hover over the patient s name on the Confirm Appointments screen. Front-office staff can also use AdvancedMD s Appointment Confirmation Detail report to view the patient s copay and any current patient balances. Collect New Balances Insurance copayments and any other current patient balances should be collected at either check-in or check-out. Practices that collect payments at check-in have more success in their collection efforts. Some practices collect copayments and patient balances at check-in and then collect monies at check-out based on charges incurred for the visit. After collecting the patient s copay, you can easily post the copay and print a receipt using the Collect Copayment screen. Depending on your system default settings, copayments posted using the Collect Copayment screen can be automatically applied to charges later posted to the visit. If copayments are posted using alternate methods, it is important to be able to reconcile the payment and charge. The Unapplied Transactions report monitors unapplied payments. Run this report to reconcile charges with unapplied patient payments. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 7

Chapter 3 Charge Capture Overview You cannot collect money for charges never captured and never billed, so smart practices have tools and reports available to ensure that charges are entered and addressed promptly, and that no charges are missed or misplaced. Use your AdvancedMD system to effectively manage your charge capture process. To learn more about managing the charge capture process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals To ensure that you regularly capture all charges correctly, you should: Use a Charge Capture Process that Matches Your Workflow Compare Scheduled Services to Charges Entered Review Charges Entered with the Provider Track the Time it Takes to Get Charges Billed AdvancedMD Tools Anytime, Anywhere Charge Entry Appointment Types Charge Review Handheld, Online, or Paper Charge Slips No-show Tracking Quick Charge Entry Reports: - Analysis of Services - Elapsed Time: Date of Service to Billed - Missed Visits AdvancedMD Help Files and Video Training Library Use a Charge Capture Process that Matches Your Workflow The first step in your charge capture process is to ensure that all charges are recorded when services are performed, so no services or incidental charges will be missed. Develop a charge capture workflow that enables those responsible for capturing charges to capture them quickly, easily, and conveniently. To make entering or marking charges as simple as possible, all types of AdvancedMD charge slips can be customized and displayed or printed based on Appointment Type. This flexibility makes working with charge slips easier and more accurate as you can omit procedures and diagnosis codes not relevant to the type of appointment. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 8

Additionally, for situations where you have staff assisting the provider with coding/charge entry, charges entered can be held in Charge Review based on the type of user that entered the charges into the system. Paper Charge Slips If your office workflow dictates the use of paper charges slips, you can print charge slips by the batch in the Report Center or individually from the Appointment Scheduler, accommodating walk-in or last minute appointments. Charge slips can be numbered sequentially by the system to help ensure you are not missing charges for any appointment. Online Charge Slips For situations where the provider is entering charges at the time of the encounter, AdvancedMD provides two electronic charge slip options (charge slips displayed onscreen): Online Charge Slips on a handheld device (PDA), allowing anytime, anywhere charge entry. With the handheld device, the provider does not have to have a computer available. This makes it easy for the provider to enter charges during off-site or in-room encounters. Online Charge Slips on a computer, allowing charge entry anytime and anywhere the user has access to a computer and the Internet. Compare Scheduled Services to Charges Entered Regardless of your chosen charge entry method, the next step in your charge capture process is to verify that all encounters have associated charges. The surest method of guaranteeing all encounters have associated charges is to schedule a visit for every patient that receives services and then compare your scheduled visits against charges entered into the system. Comparing scheduled visits with entered charges is easy in the AdvancedMD application because all appointments in the scheduler are associated with a visit. Using the Missed Visits report, you can identify any appointment visits that have not been associated with a charge. You can run the Missed Visits report at any time for any date range, allowing you to research missing charges at the end of each day, week, or month, based on your workflow. If you do not wish to charge the patient for a no-show visit, simply mark the visit as a no-show in the Appointment Scheduler and that visit will be excluded from the Missed Visits report. If you are using paper charge slips, or your provider is not entering charges at the time of the encounter, AdvancedMD s Quick Charge Entry feature gives you an easy way to enter charges based on scheduled visits. Quick Charge Entry displays all visits for the day, allowing the biller to simply click an appointment to load demographic information needed for charge entry. Any appointment that does not have associated charges will display in Quick Charge Entry until it is dismissed, cancelled, or marked as a no-show. Review Charges Entered with the Provider Another step in the charge capture process is to review the charges entered with the provider. The Analysis of Services reports are powerful tools to use in the charge capture process. You can run these 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 9

reports to count or list procedures entered. This report has versatile filter options so you can run it to support the audit type you are performing. The report can pull just one procedure if you are comparing to a count you have recorded of that specific procedure, or for just one provider if you are conducting an audit for a specific provider. Track the Time it Takes to Get Charges Billed The Elapsed Time: Date of Service to Billed report shows you, step-by-step, exactly how long it takes charges to be billed after service is provided. If you are a medical billing service, use this report to analyze the time it takes the practice to get charges to your billing service. Additionally, the report enables you to analyze how long, from the time you receive the charges, it takes your staff to bill charges. Knowing where the bottlenecks are in your billing process can help management focus on fixing the worst problems first. For at-a-glance information on the time it takes to get charges billed, you can review Dashboard KPI Service to Billed figures on the Claims Efficiency tab. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 10

Chapter 4 Coding Overview It is important that claims are sent with the correct procedure and diagnosis codes in order for them to be paid correctly and quickly. Use your AdvancedMD system to develop and manage a well run coding process. To learn more about managing the coding process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals Use AdvancedMD in your coding process to: Manage Procedure and Diagnosis Codes Leverage Coding Tools Manage Specific Coding Situations Perform Audits Manage Procedure and Diagnosis Codes AdvancedMD Tools Charge Codes Master File Charge Review Claim Inspector Diagnosis and Procedure Codes Import Edit Visit Screen Global Periods Macros Reorder Screen Unbilled Tab Reports: - Diagnosis Codes Production - Procedure Codes Production Summary AdvancedMD Help Files and Video Training Library The codes required to submit on claims are available in AdvancedMD through the Procedure Code Import and Diagnosis Code Import features. These features allow each office to review the complete AMA CPT and AMA ICD-9 code lists (including full descriptions) and import the codes as desired. These files are automatically updated each year by AdvancedMD (at no additional charge to your practice) with any new, changed, or deleted codes. You can create your own codes in the Charge Codes master file for services that will not be billed to the insurance, such as no-show fees, product sales, etc. Some payors use local or proprietary codes for specific services, and will deny claims if these codes are not used. The Charge Codes master file allows you to enter substitute carrier codes for standard procedure codes. When the standard carrier code is linked to the payor, the local/proprietary code will be submitted on the claim in place of the standard code. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 11

Leverage Coding Tools Your medical practice may have standard sets of procedure codes that are billed for certain services. For example, you may have a set of codes that are billed for a well child check. The Macros master file allows you to create a single code for the well child check that has all of the procedure codes you bill for that service attached to it. When the single code is entered in the Charge Entry screen, all of the attached codes are added to the charge as separate line items. This useful tool makes the coding of these services quick and easy. A production summary of diagnosis and procedure codes can help determine the most commonly billed items for your office. The Diagnosis Codes Production reports list the diagnosis codes attached to patient accounts in your practice. The report lists the ICD-9 code and description, and displays the total number of patients within your practice who were assigned the ICD-9 code, based on the date range specified. The Procedure Codes Summary report summarizes the procedure code usage in your practice. It can be used to analyze the number of procedures performed and the profitability of each procedure. AdvancedMD has edits in place to help prevent claims from being submitted with known formatting or coding errors. The Unbilled tab in Claims Center displays claims that have not been billed because of errors such as invalid zip codes or missing addresses. Claim Inspector scrubs your claims for accuracy and compliance with specific coding edits. If you find that you have not entered procedure codes in the correct order for payment, or if you have multiple diagnoses that need to be linked to the correct procedure codes, you can use the Reorder screen to move the procedure codes or link diagnoses. The Reorder screen can be accessed from the Charge Entry screens, as well as from the Edit Visit screen, accessed from Charge Review. Manage Specific Coding Situations Global Periods When billing for surgeries, you will often use global periods. When the Global Period feature is turned on, warnings appear in various areas of the application when a patient is selected who has days remaining in a global period. When these warnings appear, the biller can enter charges for the patient appropriately. PQRI If your medical practice participates in the Physician Quality Reporting Initiative (PQRI), and you report the PQRI correctly, you can receive an increase in professional fee reimbursement based on a percentage of your Medicare payments. AdvancedMD allows you to attach PQRI data collection worksheets to specific appointment types that can be printed along with a patient s charge slip. You can also create merge fields in the document so the patient s information automatically prints on the document. Local Use Codes If there is a service provided by your physician that has no procedure code, you can use Field 19, which is designated as Reserved for Local Use. Medicare specifies that you can enter a concise description if one can be given within the confines of this box. If the code is entered in the Note field on the Charge Entry screen, this code will be printed on the CMS-1500 claim form in Field 19. It will also be submitted electronically in its corresponding loop. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 12

Perform Audits It is important to do random audits. You can use the Charge Review function to hold claims prior to submission so they can be reviewed for accuracy. Post-payment audits are equally important. You can run the Diagnosis Code Production and Procedure Code Production reports based on diagnosis code or procedure code frequency for a targeted audit or take a random sampling of returned remittance advices to select claims for audit. Audits should be done on each provider and each location where they work. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 13

Chapter 5 Charge Entry Overview Proper charge entry practices are imperative for reducing billing times. Use your AdvancedMD system to implement an effective charge entry regimen in your office. To learn more about managing the charge entry process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals AdvancedMD can help you by providing tools to do the following: Develop and Manage Fee Schedules Enter Charges Review and Audit Charges Control Who Can Edit Charges Develop and Manage Fee Schedules AdvancedMD Tools Batch Entry Charge Codes with RVU Values Charge Review Claim Inspector Financial Class Exceptions Multiple Charge Entry Methods Robust Fee Schedule Functionality Unbilled Claims Tab User-level Security Reports: - Batch Trial Balance - Fee Schedule Listing -Net Collection Rate - Reimbursement Analysis - Unbilled Claims AdvancedMD Help Files and Video Training Library There are many ways to determine a fee schedule and each office has to decide which approach works best for their situation. Some offices base fees on a relative value scale using a multiplier. If you use this method, it is important to ensure you agree with the work unit for each procedure. As part of this process, AdvancedMD allows you to store the relative value unit (RVU) in the Charge Codes master file. Other offices determine their fees based on a version of Medicare s allowable fee schedule that is multiplied by 200-400 percent. AdvancedMD provides copies of the most current fee schedule from Medicare for your state, carrier number, and locality. These fee schedules are updated every year and automatically loaded into your office key. Fee schedules are an important part of the charge entry and payment entry process in AdvancedMD. When entering charges, fees default into charge entry screens based on the provider s assigned fee 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 14

schedule, and an allowable amount is assigned to the charge based on the allowable fee schedule tied to the patient s financial class. The Fee Schedules master file allows you to create and manage multiple charge and allowable fee schedules. Using multiple allowable fee schedules, you can create an allowable fee schedule for each carrier contract. Additionally, for those instances where providers in the same practice have different contracted rates with the same carrier, the Financial Class Exceptions feature allows you to override the allowable fee schedule for a financial class based on provider. Once a fee schedule has been created and saved, the office can copy any saved fee schedule. The newly copied fee schedule will be an exact copy except for the name and fee schedule type (charge or allowable). This prevents having to create a new fee schedule from scratch each time you have need for a new, similar fee schedule. Once the new schedule is copied and saved, you can make any necessary changes. Fee schedules can be updated at any time. Sometimes you will need to modify a fee schedule based on contract changes, fee increases, etc. To help you manage this process, AdvancedMD allows you to create multiple versions of the same fee schedule, each with a different assigned date range. As a result, when you input charges, the system will automatically select the correct version of the fee schedule, based on the date of service. You should review fees associated with procedure codes at least annually by running the Fee Schedule Listing report. As part of your fee schedule review, you can run the Reimbursement Analysis reports to evaluate how much you are writing off for each procedure and help you identify which fees should be updated so that you aren t charging fees that are under or close to your expected reimbursement amounts. Enter Charges Charge Entry involves entering the procedure and diagnosis codes that were documented at the time of service. Because each office has its own workflow, AdvancedMD has multiple charge entry methods, one or more of which will fit your office s needs. Quick Charge Entry a quick method of entering charges; contains a list of patients with appointments for the selected date. This method supports CMS-1500 and UB professional charges. Professional Charge Entry a more comprehensive charge entry; accessed through patient demographics. This method supports CMS-1500 and UB professional charges. Online Charge Slips a quick method for providers to enter charges and diagnoses, and to create a recall via a PC or Handheld device Institutional Charge Entry a more comprehensive method to enter UB charges Review and Audit Charges It is important to make sure that all charges are entered, entered correctly, and that any entry errors are resolved prior to claims being submitted. This will result in a faster billing and payment cycle because there will be fewer denials due to charge entry errors, and therefore less claims rework. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 15

AdvancedMD s Batch Entry feature is a running ten key calculation of the charges, payments, and writeoffs posted by a user. Although batches can be used in whatever way works best for your office s workflow, typically each user will use a separate batch to enter their set of daily transactions and then balance those transactions at the batch level using the Trial Balance report. Once each batch is balanced, it is much easier to balance the entire day s transactions. By using the AdvancedMD Charge Review function a certified coder or senior staff member can review or audit claims for missed line items and modifiers, and verify that the charges are billed in the proper order of descending value. In addition to the Batch Entry and Charge Review features, AdvancedMD has automatic edits in place that will prevent claims with errors or omissions from being submitted. A list of these unbilled claims is found by running the Unbilled Claims report or by working visits from the Unbilled tab in the Claims Center. Claims are also scrubbed for coding errors in Claim Inspector. Control Who Can Edit Charges To help mitigate fraud risk within the office, users who are allowed to enter charges should not be allowed to edit or delete them. AdvancedMD allows for user-level security in the Role Setup screen for the charge entry function. You can set security levels for the various roles within your office so users have access only to those functions they need. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 16

Chapter 6 Claims Management Overview Claims management is the process of creating a claim that correctly reflects the services delivered, presented in a form that meets all the requirements of the insurance company. Use your AdvancedMD system to meet the requirements of each carrier you bill. To learn more about the claims management process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals Regardless of the size of your billing office, AdvancedMD has the tools to help you collect the most money for your medical practice. To help your practice achieve a profitable claims management process, AdvancedMD software offers: eclaims Submission and Frequent eclaims Status Updates Secondary Claim Processing Compliance with Carriers Claim Format Requirements Multi-tiered Claims Edit Checks Assistance with Edit Tracking and Error Resolution An Easy Rebill or Corrected Claim Process Analysis of Delay Times in Billing Process AdvancedMD Tools Carriers Master File Charge Detail Charge Review Claims Submission Wizard Customizable Paper Claim Templates Demand Claims Multi-tiered Claim Edit Checks Paper Claim Profiles Patient Demographics Run Alerts Reports: - Claim Submission Analysis - EDI Reports - Elapsed Time AdvancedMD Help Files and Video Training Library eclaims Submission and Frequent eclaims Status Updates When you enter patient data into AdvancedMD, patient information as well as charges, you are contributing to the creation of a claim. AdvancedMD Patient Demographics stores all information required for billing a patient or a patient s insurance. AdvancedMD pulls the information from the patient demographic file to populate a claim. Additional information needed for the claim is then pulled from the charge file created for services. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 17

After charges are entered and claims are submitted, you will receive updates from RelayHealth, the clearinghouse that handles AdvancedMD claims. EDI reports are electronic reports either from the clearinghouse, or from the carrier through the clearinghouse, which let you know the following: when the clearinghouse has received claims, if the claims have passed clearinghouse edits, when the carrier has received the claims, and if the claims have passed through the carriers automated edit system. Many carriers send an EOB file to the clearinghouse, which will be forwarded to your office key. Should you not receive timely acknowledgements from the clearinghouse or carrier regarding the receipt of your claims, AdvancedMD will work with the clearinghouse on your behalf to determine what has occurred. Please review the information in Chapter 9 Insurance Follow-up section of this Guide for more complete information on AdvancedMD claims tracking. Secondary Claim Processing AdvancedMD is equipped to handle secondary claims as seamlessly as it handles claims submitted to a patient s primary carrier. In the patient s Insurance tab in Patient Demographics, you can specify the patient s primary insurance, secondary insurance, and any other payors the patient has. Furthermore, should a charge for a patient need to be billed differently than normal, as in the case of charges covered by auto insurance, the insurance billing order can be changed at the charge level to reflect special circumstances. If you bill claims to the secondary carrier after you receive the payment from the first carrier, you can set up patient accounts so that after the primary payor payment is entered, a claim will automatically be generated for the second carrier the next time you generate a claim batch. Additionally, using the Demand Claim feature, you may generate a claim for a secondary carrier at anytime. Many primary carriers submit claims to the secondary carrier for the patient. This is called a cross-over claim. When you know this is the case for a charge, change the payment status to cross-over when you enter the primary payment. This will prevent AdvancedMD from unnecessarily creating a secondary claim. Compliance with Carriers Claim Format Requirements Whether you are billing claims in the HIPAA-compliant electronic ANSI format, or sending them on paper, AdvancedMD provides you with several standard and customizable paper claim templates so you have a way to meet all carrier formatting requirements. Paper Claims Carriers that accept or require charges on paper have expectations regarding where data will appear within the paper claim form. Carrier requirements vary, so you will need to check specific requirements on your carriers websites to make sure you are billing paper claims appropriately. Once you know what the carrier requires, you can choose from predefined Paper Claim Profiles or you may customize an existing paper claim template to bill a carrier. Once you know which paper claim profile is right for a carrier, select this as the profile to use for that carrier in the Carriers master file. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 18

Electronic Claims AdvancedMD compiles the data you have entered in the patient s file, the insurance carrier s master file, and the data you enter on charges, and uses that information to create an electronic claim file to send to the carrier. To comply with HIPAA regulations, AdvancedMD sends claim files in a code called ANSI. ANSI code files display information in loops. Each loop on the file conveys different portions of information to the carrier, and sometimes carriers have their own specific requirements for what information should be found in a loop. AdvancedMD billing experts continually research carrier requirements and ensure that AdvancedMD software remains compliant with ANSI standards. If you have questions about specific requirements, the carrier s website or EDI department will supply you with information regarding the data the carrier requires in an ANSI file and in which loop that data should be sent. If you need assistance to determine where to enter data in order to bill according to a carrier s specification, contact AdvancedMD Support. A Support representative will guide you through creating a claim to meet the carrier s requirements. Multi-Tiered Claims Edit Checks Your practice will save significant time, effort, and revenue if you invest in a claims process that results in the highest volume of clean claims, as opposed to concentrating your efforts on tracking and resolving errors and denials. A clean claim is a claim that is sent to the carrier error free and can be processed and paid on the first submission. The easiest way to ensure your claims are clean is to check them for errors before they are submitted. AdvancedMD has a number of features and tools that help you create and transmit claims that are error free. If you submit claims through AdvancedMD, have a knowledgeable charge reviewer on staff, and use Claim Inspector, your claims will be checked for errors up to four times before they reach the carrier s automated edit system. Unbilled Tab Charges you enter in AdvancedMD are given a status of unbilled if, after running the Claims Submission Wizard, your charges could not be billed for some reason. Unbilled charges will appear on the Unbilled Claims report and on the Unbilled tab. There are numerous reasons that charges become unbilled, and not all reasons are related to the potential for claim errors. The unbilled feature flags claims with glaring data problems that are unlikely to be accepted by the carrier. For instance, a claim would not be created for a charge if the provider s NPI number did not meet the NPI format, or if the dates of service for the charges do not correspond to dates of coverage for the patient. This feature allows you to see and correct basic billing mistakes before the system even generates a claim. Charge Review As billers become more experienced, they can recognize errors in the coding of charges, and may know more about the requirements of specific carriers. Some offices find it advantageous to have a more experienced biller review the charges of newer billers. Using the AdvancedMD Charge Review feature, you can manage the charges entered by a data entry staff member who may still be learning the coding process. You can determine who can review and approve 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 19

the charges of others, and also determine, by staff member, whose charges should be reviewed before the system will generate a claim based on the charges. Claim Inspector Claim Inspector is an advanced claims scrubbing tool that checks your claims extensively for possible errors. Claim Inspector checks for errors based on the most current claims edits for major carriers. RelayHealth Edits After claims have gone through all of the checks your office uses, they are submitted to RelayHealth. The clearinghouse checks them for potential errors based on the information the carrier has provided to the clearinghouse. Claims are checked not only for errors but also for compliance with carrier requirements. If it is determined that the claim will not be accepted by the carrier, the clearinghouse returns the claim to you with information about the problem so you can fix the claim and resubmit it. This final check at the clearinghouse prevents you from having to sacrifice time and expend effort to send corrected claims or to appeal a denied claim with the carrier. Assistance with Edit Tracking and Resolution A Claim edit differs from a claim denial in one key way: a denial means the claim reached the carrier and was rejected. An edit means the claim did not pass a claim check along the way. Edits can be fixed before the carrier sees the claim. If the claim error was found by Claim Inspector or by the clearinghouse, the claim can be corrected and then sent on to the carrier for payment as an initial billing. Aside from checking each individual charge and claim before it leaves the system, AdvancedMD also creates Run Alerts, which let you know if a problem occurred with an entire batch of claims. Use the Claim Submission Analysis report periodically to determine if your claims errors are being resolved in your office before claims are submitted to the carrier. This report shows you the percentage of claims paid by the carrier on the first submission. An Easy Rebill or Corrected Claim Process You do not need to rebill claims that were held in the Unbilled tab or Claim Inspector. Once you have resolved the problem or problems that held the claim in the system, the claims will be sent out automatically with the next claim run. If you fix an error found on a claim at the clearinghouse, the claim will need to be rebilled. When you rebill a claim in AdvancedMD, this means you resend a claim that has already been sent out as a first billing to the carrier. The Rebill feature in the Charge Detail screen allows you to submit charges in the next claim run that have already been submitted on a claim. Generally you should only rebill claims when you have received and corrected clearinghouse edits, when the carrier confirms the claim was never received and the clearinghouse no longer has the claim, or when you have spoken to the carrier and they specifically request that you resend the original claim. A corrected claim is a claim that has been received by the carrier but that was not accepted. In this case you send a corrected claim because if you rebill the claim, the carrier is likely to reject the claim as a 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 20

duplicate. Select the Corrected Claim check box on the Charge Detail screen to indicate that a claim should be submitted as a corrected claim. If you are appealing a claim denial or fixing a claim error, you need to know the carrier s policy. Many carriers need an indicator in the claim file flagging the claim as corrected. Some carriers may also require a copy of the first claim or other additional documentation sent with the corrected claim. Review the carrier s appeals and corrected claims policies when you need to resend a claim. If you know what the carrier requires, but are unsure how to meet the requirements on an electronic or paper claim file, AdvancedMD Support can assist you. Analysis of Delay Times in Billing Process You should track the reasons and the dollar amounts of claims that are unbilled or that are denied by the payor. This will allow you to determine if there is a primary cause of errors that can be resolved by changing your process. The Elapsed Time reports in AdvancedMD allow you to analyze your work flow during a particular time range. The reports show you a review of all charges and the time it took them to clear various billing check-points. Essentially, they can identify your billing process bottlenecks, so management knows where to focus their attention first. Elapsed time refers to the amount of time claims are held between processes. The time between when charges are entered and when claims are sent reflects the time a claim is held for revisions. This time adds to your A/R, and the longer claims are held, the more likely you are to miss important deadlines. The best way to protect your revenue is to process held claims quickly. Since timeliness is crucial to the claims management process, it is valuable to analyze the time it takes your staff to enter claims and resolve claim edits. AdvancedMD offers three reports to help you do this. Elapsed Time: Date of Service to Billed This report calculates how long it takes a charge, from the time of service, to be billed to a carrier or to self-pay patients Elapsed Time: Held in Unbilled This report calculates the average time it takes for unbilled charges to be resolved and billed Elapsed Time: Held in CI (Claim Inspector) This report calculates how long Claims Inspector edits are taking your staff, on average, to resolve For at-a-glance information on possible areas of delay in your billing process, you can review the following Dashboard KPI Claims Efficiency figures: Service to Received Received to Posted Service to Posted Posted to Billed Service to Billed Held in Unbilled Held in Claim Inspector 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 21

2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 22

Chapter 7 Patient Statements Overview A well organized patient billing process is important to your practice s bottom line. Although it is good to collect as much money as possible from patients at the time of service, there are going to be times in most practices when you have to bill patients after the fact for services rendered. Use your AdvancedMD system to automate and track patient billing for your office. To learn more about managing the patient billing process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals AdvancedMD can help you with your patient billing process by providing tools for the following: AdvancedMD Tools Automated Billing Cycles Collections Module Dunning Notices estatements Patient Billing Rules Patient Billing Wizard Patient Memo Patient Notes Tab Patient Statement Notes Statement Hold Feature AdvancedMD Help Files and Video Training Library Cycle Billing Clear and Concise Statements Notes on Patient Statements Automated Holds on Statements Final Notices Cycle Billing It is a good idea to send statements as soon as an amount becomes the responsibility of the guarantor. The Patient Billing Wizard allows you to easily set up automated billing cycles. If the patient has insurance, send the statement for the patient balance after the primary (and secondary or tertiary, if applicable) carrier has paid its portion. If the patient owes the entire account balance, send the statement as soon as services have been provided. AdvancedMD has the ability to send statements each day. Based on the number of Statement Billing Cycle Days on the Responsible Party tab, a statement can be sent the day a charge becomes the responsibility of the patient (or guarantor). The next statement will be sent after the appropriate number of days has passed, thus allowing statements to go out as quickly as possible. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 23

Using the Patient Billing Rules in AdvancedMD, a practice or billing service may create a set of rules that will control how many statements and letters are sent before an account goes to collections. This helps improve efficiency when collecting on the patient balance. Clear and Concise Statements To avoid confusion about what they actually owe, it is important to send statements to patients only when they are responsible for the full balance. This not only makes the statement more clear to patients, but it saves on mailing costs. Make sure the statement clearly states accepted payment methods. Within the AdvancedMD software, electronic statements are transmitted through RelayHealth. The estatements feature includes a credit card option, which enables patients to pay via credit or debit cards right from the statement for greater convenience and to improve payment collections. If a patient sees multiple providers in your medical practice, it is best to send a single statement to the patient. Not only does this make it easier for the patient to know the exact amount owed, it is also more cost-effective. AdvancedMD allows you to set up the system to send a single statement to your patient regardless of who renders the service. A good way to track the performance of the statement mailings and ensure that your statement vendor is mailing statements according to their contract is to set up a fictitious patient account using the billing manager s (or a practice executive s) address, so the manager receives the same mailing your patients do. This is easy to accomplish in AdvancedMD. Simply set up the fictitious account, enter a charge on the account, and after the statement has been received, void the charge. Notes on Patient Statements Using patient statement notes and dunning notices on statements to communicate with patients can help you avoid the cost of mailing separate letters. AdvancedMD has several areas where a note can be entered that will appear on the statement. A note to the patient can be added in the Payment Entry screen at the time the payment is posted. Dunning messages can be created in the Statement Messages master file to remind the patient how old (30/60/90 days) their balance is. You can add a general message to all statements in the batch from the Patient Billing Wizard. You can also add an individual message to a patient from the Patient Billing Wizard and from the Memos tab in Patient Demographics. If you receive a response from the patient regarding their account balance, make sure to act on this correspondence and record the information into the patient s account before the next statement is sent to the patient. You can record any correspondence from the patient in the Notes tab in Patient Demographics. These notes can be categorized into types making it easy to find statement information on each patient. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 24

Automated Holds on Statements Statements sent to the wrong address will be returned to the medical practice. You will want to obtain the correct address before sending out another statement. If a statement is returned due to an incorrect address, you can put a statement hold on the account from the Responsible Party tab in Patient Demographics or from the Patient Billing Wizard until the address is changed so that future statements or letters are not sent to the incorrect address. If for this reason, or for any reason a statement is put on hold, a Patient Memo can be added to the patient s record from the Memo tab in Patient Demographics. Going forward, each time the patient record is accessed, the Patient Memo screen will appear with the note to remind you to get a correct address from the patient. Final Notices When larger patient account balances become delinquent they are often turned over to a collection agency. Prior to turning the account over to collections, some offices will attempt to get the patients attention with a hand addressed statement envelope and a customized final notice. In instances where you want to deviate from your automated patient billing routine, your final notice letter can be manually generated from the Collections module. This action and the context of your notice can be recorded in the module for future reference. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 25

Chapter 8 Payment and Denial Posting Overview Posting payments for a medical practice is complicated business and if it isn t done carefully and correctly it can cost your practice a great deal of lost revenue. Use your AdvancedMD system to implement an effective payment and denial posting process. To learn more about managing the payment and denial posting process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals AdvancedMD provides tools to help you as you do the following: Enter Payments Manage Contractual Write-offs Process Insurance Reversals Resolve Credit Balances Review Denials and Adjustments Control Who Can Edit Payments AdvancedMD Tools Allowable Fee Schedules Insurance Reversal Screen Multiple Payment Entry Methods Payment Reasons Refund Check Printing User-level Security Reports: - Claim Submission Analysis - Insurance Allowable Discrepancies - Payment Reason Codes Carrier Reimbursement Comparison - Refund Report - Unapplied Transactions AdvancedMD Help Files and Video Training Library Enter Payments Payment Entry involves posting payments received from insurance carriers and patients. Payments should be entered promptly no more than 24 hours after receiving payments. If a payment is received at the time of service, it should be posted immediately. This ensures that patients don t get another statement for an amount they have already paid. Because each office has its own workflow, AdvancedMD has multiple payment entry methods, one or more of which will fit your office s needs. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 26

Collect Copayment allows you to post an upfront copayment before the charge is posted. As the charge is posted the payment can automatically be applied. eremittance provides an automated process for matching payments received electronically from carriers with their existing charges. In addition to payments being posted, payment reasons are added for each denial that is sent from the carrier. Payment Entry a full-feature payment entry screen. It allows you to post both patient and insurance payments. This payment entry screen also has fields that are not available on other payment entry screens in the application. Patient Checkout a payment entry screen that also allows you to check the patient out and schedule a recall for the patient. Use this screen in conjunction with a process that posts charges prior to check-out, as only visits with charges will display in this screen. Quick Pay a quick and efficient way to post payments from both small and large EOBs Responsible Party Payment Entry allows you to post payments by responsible party to more than one family member in a single transaction Manage Contractual Write-offs The Financial Class master file allows you to select whether or not you want the system to auto-populate your payment entry screen with write-offs based on the allowable amount tied to the charge. Use this feature in conjunction with your allowable fee schedules to help alert you when contractual write-offs are not being paid according to your carrier contract. By letting the system assign an allowable amount to your charges based on your contractual fee schedule and then letting the system calculate your write-off s based on that allowable amount, you will be able to see when the write-off populated on screen is not the same as that listed on the insurance EOB. If the carrier write-off is greater than the system indicated write-off, the carrier is probably not paying the provider the contractual allowable amount. You can use the Carrier Reimbursement Comparison report to review the average charges and the average payments of your top 25 procedure codes either by your top five carriers or by carriers you specify in the parameters. This report allows you to view the top procedure codes either by frequency or by amount. By running this report frequently, you can be sure that you are being paid the amount due to you. Some practices participate in capitation plans. AdvancedMD allows you to set up a financial class as a capitation plan that will automatically write off all charges that are subject to capitation to a specific write-off code. By doing this, amounts can be tracked but do not remain in accounts receivable ad infinitum. Process Insurance Reversals Sometimes the payor withholds a portion of the payment due to a previous overpayment on another account. When this happens you will need to perform a reversal (also known as a takeback). In the process of reviewing an insurance reversal for accuracy and timeliness, the Insurance Reversal screen allows you to reverse (negate) the payment (by posting an equivalent opposite payment amount), 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 27

reflecting what is displayed on your carrier EOB. This also makes it much easier to balance payments at the end of a batch or day. Resolve Credit Balances The payment posting process will generate outstanding credit balances that you should regularly research and resolve. By running the Unapplied Transactions report at least monthly, you can ensure that all of the unapplied payments are either posted to the correct visit or refunded to the correct entity. The refund feature in AdvancedMD allows you to quickly give unapplied money back to patients or the payor. After the overpayment has been researched and a refund applied to the account, the Refund report can be generated which lists all refunds to be processed. You can then use the refund checks printing feature to print checks directly from the system. Review Denials and Adjustments Incorrect denial posting can result in lost revenue to a practice. Every effort should be taken to ensure that the correct denial and adjustment information is being posted. Establishing separate allowable fee schedules for each contracted carrier will aid in tracking the correctness of the payments and denials. Run the Insurance Allowable Discrepancies report at least weekly to ensure that adjustments that are not within an acceptable range are reviewed for accuracy in posting and processing by the payor. This also allows a manager to evaluate the effectiveness of a payment poster. Run the Claim Submission Analysis report to determine which denial categories are problem areas that need to be addressed. Next run the Payment Reason Codes Summary report at least weekly to find payment denial reasons that are of concern. Once specific areas have been identified, run the Payment Reasons Codes Detail report to further research and areas of concern. Control Who Can Edit Payments To help mitigate risk issues within the office, users that are allowed to enter payments should not be allowed to edit or delete them. AdvancedMD allows for user-level security to be set up in the Role Setup screen for the payment entry functions. You can set security levels for the various roles within your office so users have access to the functions they need, but not more than they should have. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 28

Chapter 9 Insurance Follow-up Overview To make sure your practice is receiving what is contractually due, you should be diligent in monitoring the progress and flow of your claims, and have the tools and reports in place that enable you to track claims when they are not paid in a timely matter. Use your AdvancedMD system to implement an insurance follow-up regimen in your office. To learn more about managing the insurance follow-up process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals AdvancedMD helps you manage your insurance follow-up process. Use AdvancedMD to: Verify Carriers Are Receiving Claims and Claims Are Being Processed Work A/R by Priority Work A/R More Efficiently Audit Staff Collections Actions Know Your Average Days in A/R and Net Collections Rates AdvancedMD Tools Claims Submission Wizard Collections Module Collections Worklists Dashboard KPIs Denial Tracking Module Reports: - Carrier A/R - Collection Actions - EDI Reports AdvancedMD Help Files and Video Training Library Verify Carriers Are Receiving Claims and Claims Are Being Processed After you bill claims, one of four things can occur: they can be paid accurately, they can be paid inaccurately, they can be denied, or they can vanish into thin air. Handling inaccurately paid or denied claims in AdvancedMD is discussed further in other sections of this Guide. But it is the last occurrence that can be most frustrating to your staff and costly to your practice. Claims that receive no response are often more problematic than denied claims. When a claim is denied you are alerted that there is a problem and there is potential for revenue to be lost. When you send a claim and do not receive a response, it is easy to let it slip through the cracks until you realize it has been outstanding past the timely filing deadline. To protect your practice from this type of revenue loss, you may call the carriers to confirm they have received all claims. You may find that in some cases, this is a 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 29

beneficial practice, although it is time consuming. The great news for AdvancedMD users is that AdvancedMD offers electronic claims submission tools and services that will save you time and effort, while offering you the peace of mind that comes from knowing your claims have been transmitted to the carrier. When you transmit electronic claims through AdvancedMD, the Claims Submission Wizard displays the number of claims being sent. The clearinghouse that handles your claims responds quickly to let you know if your claims have been received, the number of claims received, and if they appear to be formatted in a way that the carrier will accept. When the clearinghouse is notified that the carrier has received claims, the clearinghouse then forwards the carrier acknowledgement to you. If there is a failure in the transmission of claims from the clearinghouse to the carrier, the clearinghouse will send you a notification. If you monitor and sort the EDI reports sent back to you each time you submit claims, you will be aware of the status of your claims batches, and you will come to learn over time how quickly specific carriers respond to and pay claims. In the event that a claim you send does hang in limbo with no response from the carrier, and with no clearinghouse report to explain the reason, AdvancedMD support representatives are trained to partner with you to track missing claims. The AdvancedMD representative works with the clearinghouse to determine where the claim was held up, why the claim was held up, and how to resolve the problem. Work A/R by Priority Many offices work their accounts receivable by printing an aging report and starting at A. If the alphabet is not completed by the end of that month, they compensate by starting with Z the next month. This haphazard way of working accounts ensures each outstanding account is only checked once every other month, if not less frequently. A better way to way to work your A/R is by priority. You can determine what claims qualify as your practice s top priority. Usually the claims are considered high priority if they are older and approaching filing deadlines, or if they have a high dollar amounts outstanding. Claims that have been pending the longest are in the most danger of not being paid because they have surpassed timely filing deadlines. Carriers may have different timely filing deadlines, so it is important to know your carriers policies and work your claims in carrier groups. One potentially beneficial way to examine your carrier A/R and set priorities is to run the Carrier A/R reports. These reports can be run for each carrier or carrier category individually, or can be run for all carriers. Using these reports you can determine which carriers have the highest or oldest outstanding total balances. Looking at the total A/R for each carrier on the summary version of this report may help you determine if one carrier has inordinately high outstanding balances. Once a summary for all carriers has been completed, run the detail version of the report for the carrier with the highest balance. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 30

Work A/R More Efficiently AdvancedMD s Collections module allows you to create collections worklists you can configure to show accounts with balances broken down by carrier, aging dates, financial class, provider, and other criteria. Also, worklists can be assigned to staff members to reflect procedures. For example, if your procedure is to work A/R by assigning a carrier to an individual staff member, this can be easily managed in the Collections module. Once a worklist is created, you can sort by highest dollar or oldest outstanding balance. It is recommended that you set up work lists for carriers based on filing limit so that those with shorter filing limits can be systematically worked prior to the deadline and those with longer filing times can be worked next. Tracking the number of additional information requests from carriers can help determine a root issue related to coding, or may indicate a payor contract issue. To resolve this issue, it helps to know the number of accounts for which additional information has been requested. This can either be done via a follow-up action in the Collections module or as a prompt from a payment reason code in the Denial Tracking module. Audit Collections Actions Office managers should audit the actions of their staff as they follow up on insurance claims and A/R. This helps to avoid any surprises by discovering a claim batch or carrier left outstanding for too long. One way to audit is to track the number of accounts outstanding, the number of accounts that have been worked, and the collections actions associated with these accounts. If you are using the Collections module, you can tally the number of accounts on each worklist and either track them separately or check the complete total of all worklists, and then run the Collection Actions report to find out how many accounts are being worked by each user daily or weekly. This can be used as a benchmark for the number of account representatives needed in your practice. This knowledge can also be used to set production goals for the number of accounts that should be worked within a given time period. Know Your Average Days in A/R and Net Collections Rates Well performing practices should also track financial indicators such as the number of days in A/R. Your practice is doing well if you are generally being reimbursed in as little as 35-40 days although these metrics vary by specialty and geographic location. Review Dashboard KPI figures in AdvancedMD to determine how your practice is doing. The average number of days your charges are open and unpaid is posted on the Financial Health tab as Days in A/R. Using the Net Collection Rate report you can see what percent of money is actually collected on the amount that is due on an account. The Physician Billing Process recommends that you strive for an overall net collection rate of 97 percent or greater, noting however, that in instances where a practice 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 31

has an above average number of financial hardship accounts, a rate in the high 90s may be difficult to achieve. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 32

Chapter 10 Denial Management Overview Understanding claim denials, why they occur, and how to avoid them will save you money. Use the denial management tools offered in AdvancedMD to greatly minimize the impact of claims denials on your staff s time and your overall revenue. To learn more about managing claims denials and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). AdvancedMD Tools Claim Inspector Denial Categories Master File Denial Tracking Module Payment Reason Codes Reports: - Carrier Denial Analysis - Claim Submission Analysis AdvancedMD Help Files and Video Training Library Goals Using AdvancedMD, you can track and address your denials easily. AdvancedMD Software can help you: Know if Your Claims Denials Rate is Excessive Understand the Claims Denials You Receive Analyze Your Common Denial Causes to Improve Your Processes Resubmit Denied Claims if Payment Can Still be Collected Know if Your Claims Denials Rate is Excessive Having some claim denials is inevitable in most medical practices. But it s important to know where your practice stands when it comes to efficiency of claims submission. Of all claims submitted, more than 93% should be clean. A clean claim is one that is accepted by the carrier and paid the first time you submit it. AdvancedMD offers a report called the Claim Submission Analysis. This report shows all claims for a specified time period that do not meet the clean criteria, and calculates a percentage to show if you have less than a 93% clean claim rate. Use this report to track your progress in improving your clean claims rate. Claims that do not meet the clean criteria include claims that have not been paid within 45 days of 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 33

being billed, claims that are sent more than once before they are paid, and claims identified as denials after entering payment reason codes when processing those claims. Understand the Claims Denials You Receive Claims are initially reviewed by a carrier s automated system and can be denied because they are flagged by one of the initial edits the carrier has in place in their electronic reviewing system. If the claim does not pass the initial electronic edits, it is sent back to the provider. If you are using Claim Inspector you may avoid denials due to payor edits. Improperly formatted claims will be flagged by Claim Inspector enabling you to correct them before they are submitted to the payor. When you use Claim Inspector to resolve errors before submitting claims, you reduce the amount of time your staff spends reworking claims. This may have a significant positive impact on the productivity of your billing professionals and the speed at which the practice records revenue. Since each carrier has different policies, the possible denial reasons that can occur are innumerable and it is inevitable that some claims will be denied. Once you receive a denial, you need to know what it means, how to correct it, and how to avoid it in the future. Each carrier will word denials differently, or you may only receive coded denials, so when you receive a denial, it may take a little deciphering. Here are some examples of denial reasons you may receive: There appears to be a discrepancy in the name, birth date, gender or relationship code of the patient Services were not within the specified time period as outlined in your agreement The student/handicap certification information previously requested is necessary before we consider this claim for payment. Please submit the requested information. Expenses related to cosmetic surgery are not eligible under agreement Analyze Your Common Denial Causes to Improve Your Processes Obviously, knowing why a specific claim was denied is imperative for correcting that claim. Likewise, knowing the most common types of denials you receive is essential to improving your claims billing process. Some common denial types are: Errors in charge entry or coding Missing documentation required by the carrier Procedures deemed not medically necessary Incorrect dates of service Ineligible charges By analyzing your denial types, you may discover that a large percentage of your claims denials occur for similar reasons. Making improvements to your workflow or increasing staff training in that area can have a significant positive impact on your claims processing. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 34

You may find it helpful to group similar claims denials in order to better analyze them and address the most troublesome denial types that occur in your practice. For instance, expenses not eligible under agreement and services not within the specified time period outlined in your agreement may have occurred due to eligibility issues. If, after reviewing the report, you find that eligibility issues are a top cause of denials, you can focus on improving your process for checking eligibility prior to patients appointments. In AdvancedMD you can create and customize Payment Reason Codes to help you track denied claims. Your payment reason codes can be assigned to Denial Categories. In addition to the set of standard denial categories, you can define as many denial types as you want. If you specify a payment reason code linked to a denial category when you enter your payments, you can track the types of denials you are receiving. If you are entering a denial as a zero dollar payment, or a reduced payment from the insurance, you should also enter a code that indicates why the claim was not paid in full. Denials are easy to track and analyze using the Carrier Denial Analysis report, which enables you to look at similar payment reasons grouped together as one type of denial. Use the Carrier Denial Analysis report to see which types of denials are most frequent in your practice, as well as which payors are generating the most denials. Resubmit Denied Claims if Payment Can Still be Collected Sometimes you can still collect money on a claim after it has been denied. Some practices habitually write off the unpaid portion of claims when it is unnecessary to do so. With proper research, you may be able to collect on claims that have been denied, or collect charges that were not initially paid on the claim. Knowing how to follow up on your denials will help you minimize revenue loss. Working denials to collect the most money possible is time consuming for your office staff and requires a bit of expertise. No matter the size and organization of your practice s staff, AdvancedMD offers you the tools to improve the process of working denials. The Denial Tracking module allows you to track your denials electronically so you can easily see records of denials by carrier, by reason for reduced or non-payment, and by date, so you can work your older denials first. Also, each user can work denials specifically assigned to him or her if this is the method of denial tracking you use. Through the Denial Tracking module, users can record any actions taken on denials and monitor the denial s status. If the denial has occurred because of a mistake in billing, you will often be able to correct the claim and resubmit it to the carrier for payment. The requirements for resubmitting a corrected claim vary by carrier so you will need to check the policy of the denying carrier before you resubmit the claim. If you are contacting the carrier about an electronically submitted denied claim, you should contact the carrier s EDI department, as that department will likely have the most information about electronic denials. AdvancedMD Support can help you correct a claim and resubmit it for payment, but in most cases, the Support representative will be unable to tell you exactly what caused the claim to be denied by the 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 35

carrier. 1 Again, you will get the most accurate and helpful information directly from the carrier. When speaking to the carrier, be sure to find out: What data was missing or inaccurate on the claims that caused it to be denied How long you have to resubmit the claim If the carrier needs any additional documentation sent with the claim If the carrier requires any specific indicators on a claim when it is resent to indicate it is a corrected claim Once you have the information from the carrier about a denial, if you are unsure how to resend the claim through AdvancedMD, an AdvancedMD Support representative will be able to assist with meeting the carrier s requirements using the AdvancedMD system. 1 Note: AdvancedMD Support can track and tell you the cause of claims Exclusions, which occur at the clearinghouse before the claim reaches the carrier. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 36

Chapter 11 Patient Collections Overview Once services have been delivered and the patient leaves the office, collecting what is due the practice can become a tedious process that requires rigorous attention to detail. Use your AdvancedMD system to maximize patient collections. To learn more about managing the patient collections process and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals AdvancedMD can help you by providing tools for the following: Patient Billing Collection Letters Collections Payment Plans Pre-appointment Balance Review Account Types Management Analysis of Productivity of Collectors AdvancedMD Tools Account Types Master File Collection Letters Collections Module Collections Worklists Confirm Appointment Screen Patient Billing Rules Payment Plans Reports: - Appointment Confirmation Detail - Collector User Productivity AdvancedMD Help Files and Video Training Library Patient Billing Each office needs to establish a patient collection cycle. There may be more than one collection cycle for different types of patients in your office. The Patient Billing Rules screen allows an office to set up predefined billing rules for each account type created in the practice. These rules control how many statements to send before the collections process begins, and if the statements should continue once the collection process has started. It defines specific letters to send, and when to turn the account over to a collections service. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 37

Collection Letters AdvancedMD allows the practice to add as many collections letters as necessary to be used in the patient billing and collections processes. Each letter can pull information from the patient s account into the letter. The letters can be addressed from a collector, or from the physician so the patient will feel that the physician has an interest in the account collection. Collections The Collections module assists in tracking outstanding insurance and/or patient balances by responsible party, collector, last action, or follow-up action. Collection Worklists can be created according each collector s workflow, and can be sorted by account balance so that a collector can work on the larger balances first. A collector can track each action taken on an account, and make notes about the action with a suggested follow-up action and follow-up date. Letters sent from this module are stored so the collector knows which letters have been sent, and the collector can refer to the contents if the patient calls regarding the letter or the account. Payment Plans Your medical practice should establish a policy for payment plans. This policy should include acceptable payment thresholds, with a goal to collect all balances in six months or less. The patient s monthly payments on the payment plan should not be less than your billing cost. AdvancedMD allows you to set up a payment plan for patients who have difficulty paying the full account balance. Payment plans can be calculated based on desired payment amount, or duration of payment plan, and interest can be added. Pre-appointment Balance Review In the Confirm Appointment screen, as well as the Appointment Confirmation Detail report, the patient balance is displayed so that a user can contact the patient a day or two before the appointment and attempt to collect the balance, or at least encourage the patient to bring in the payment for the balance on the day of their appointment. Account Types Management AdvancedMD allows you to set up as many different account types as necessary in the Account Types master file to ensure timely billing of all patient balances. Statements can have a finance charge or statement billing fee attached to it based on the account type. Self-pay account types can have billing cycles and dunning messages different from other account types. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 38

Analysis of Productivity of Collectors Run the Collector User Productivity report at least weekly to determine how effective each collector is with the accounts that have been assigned to them. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 39

Chapter 12 Payor Management Overview Many billing professionals do a poor job of managing the terms of the payor agreement. Use the information and tools your AdvancedMD system provides to better manage payor contracts. To learn more about payor management and other industry benchmarks, refer to The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2 nd Edition, published by the Medical Group Management Association (MGMA). Goals Once you negotiate and complete a contract with payors, AdvancedMD helps you manage those relationships so you can bill for each carrier according to the carrier s unique terms, which includes managing: Fee Schedules Carrier Provider Numbers and NPI Assignment of Benefits Settings Carrier Communications and Contract Dates Documentation to Support Claims Carrier Analysis AdvancedMD Tools Carrier Contact Screen Carrier Provider IDs Carriers Master File Customized Claim Templates Fee Schedules Master File Financial Class Exceptions Financial Class Master File Providers Master File Reports: - Analysis of Visits - Insurance Allowable Discrepancies - (Patient) Profile Detail - (Patient) Start Date Detail AdvancedMD Help Files and Video Training Library Fee Schedules Each payor contract includes a schedule of fees the carrier will pay for each procedure. These fee schedules can be maintained and monitored through the AdvancedMD Fee Schedules master file. In the master file you can create allowable fee schedules reflecting your contracted rates for each carrier. Based on Financial Class, the allowable amounts you specify will be associated with the entered charges. When entering payments you will be able to see if the amount the carrier pays is equal to the allowed amount 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 40

you are expecting. If you have a carrier that has a different contracted rate per provider, AdvancedMD allows you to override allowable fee schedules based on provider using Financial Class Exceptions. Carrier Provider Numbers and NPI Sending your NPI number and maintaining carrier specific provider numbers is easy in AdvancedMD. The Providers master file allows you to associate an NPI number with each provider so the number can be populated where it is needed on claims. In addition to the NPI number, you may need an additional provider number for a specific carrier. The Carrier Provider IDs screen is equipped to handle a unique ID for each provider contracted with the carrier. Assignment of Benefits Settings Assignment of benefits settings can be configured to match your carrier contracts and financial policies using the Financial Class master file. This master file allows you to indicate accept assignment settings based on the type of financial class assigned to the patient. These settings can be overridden based on provider using Financial Class Exceptions. Carrier Communications and Contract Dates The Carriers master file is equipped to help you maintain contract dates on its Carrier Provider ID Setup screen. On this screen you can enter the contract dates for each provider with each carrier. You can also enter contact information to be stored in the master file for each carrier on the Carrier Contact screen. This screen has fields for general contact information, and fields for any specific contact numbers such as those for eligibility or preauthorization. There is also a Notes field provided in the Carriers master file where you can keep contract notes or other specific information about the carrier and its contracts. Documentation to Support Claim For claims sent on paper, if the carrier requires an additional document, you can create a Customized Claim Template which includes a second page. This second page could be a copy of the document the carrier requests and would print when claims for this carrier are generated. When you use customized claim templates, you have access to data fields that pulls specific information from the patient s file. These same data fields can be used on the second page of the template if you need it to be populated with certain patient information. Contact AdvancedMD Support for help to set up a specialized claim template of this type. 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 41

Carrier Analysis Knowledge about a carrier s payment trends will help you know which contract elements you should focus on as you negotiate future contracts with the carrier. To monitor the payments from carriers, you can run the Insurance Allowable Discrepancies report. This report shows you by date range and carrier your fee for procedures compared to the expected allowable amount and compared to the amount the carrier actually paid for the service. If you run this report periodically, your attention will be drawn to any carriers that are habitually underpaying for charges and who should be monitored more closely. You should also take note of how much business you are doing with a carrier so you know how much revenue you potentially have to generate by continuing to contract with the carrier. There are three Patient Management reports that will help you determine this: Analysis of Visits displays the number of visits for your practice or a specific provider received from each carrier s beneficiaries during a date range Profile Detail displays a list of all patients you have in the system for each carrier Start Date Detail displays a list of patients and their coverage starting dates 2010 AdvancedMD Software, Inc. All rights reserved. Version 3.1 42