Optimizing The Revenue Cycle 10 of 12: Denial Management

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Feb 13, 2019 7:53:00 AM

It seems payers these days are finding more and more reasons not to pay clinics in full for submitted claims. From non-covered services to ineligible diagnosis, these reasons for denied claims are varied and differ from payer to payer. What one payer will allow, another requires prior authorization. Administrators and managers must assure their staff know how to read, understand, track and correct denials. Staff must be able to read and clarify an explanation of benefits (EOB) and electronic remittance advice (ERA). 

 

Denial management is the act of managing the claim denials for a practice by determining their cause, correcting them, and putting plans into place to reduce their number. Staff must have the initiative and problem-solving skills to best handle these duties. Managers and administrators should encourage team members to question denials and find new workflows to assure they do not occur. Reporting denials reasons and trends to other teams within the clinic – reception, clinical, providers – will also help with this.

 

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Topics: revenue cycle management, Medical Practice Improvement, Medical Coding Services, Denial Management

Optimizing The Revenue Cycle 9 of 12: Payment Posting

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Feb 6, 2019 6:45:00 AM

You’ve done the service, sent the claim, now time to post the incoming payment. This is not a step in the revenue cycle to be taken lightly or overlooked. There are a few keys to optimizing payment posting:

 

  • Utilizing electronic remittance advice (ERA) to post directly to the electronic practice management (EPM) system. This removes a degree of human error in regards to data entry. Whenever possible administrators should look to combine electronic funds transfer (EFT) with ERA submissions. This allows clinics to see quicker payments. Staff will still need to verify EFT matches ERA and reconcile each payment. When looking to collect payments via EFT, administrators should be aware of any additional fees payers may add on for this feature.
  • If manually posting payments to EPM assure high attention to detail and reconciliation. Staff should be trained on how to read the explanation of benefits (EOB) and remittance advice for any payments not in full.
  • Despite manual or automated payment posting, clinics must assure payments match the expected amount to be collected. Whether the amount is equal to the clinic’s fee schedule or the contract agreed amount. According to a 2017 MGMA poll, only 20% of respondents compared reimbursement to contracted rates on a daily basis. Almost 30% were unsure or were unclear on if they compared incoming payments to contracted rates. Administrators and managers should perform due diligence to guarantee they are being paid in full for their services.
  • Review adjustment reasons and prepare for denial management and appeals. Administrators should train staff to not accept incoming payments or denials as is without assuring all avenues for full collection have been sought. Best practice is for adjustments to be made during the payment posting process, not before.
  • Allocate payments by line item incoming from payers. This helps with tracking, reconciliation, and
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Topics: revenue cycle management, Medical Practice Improvement, Medical Coding Services, payment posting

Optimizing The Revenue Cycle 8 of 12: Claims Submission

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 30, 2019 7:52:00 AM

A claim is an invoice that the clinic submits to a payer to get paid for the services (charges) performed. Most payers require that the invoices (claims) be submitted to them be in a certain format. Some require that if the invoice contains a specific service (charge) that additional documentation should be submitted. Administrators must have someone on their staff who is aware of these requirements. In addition to these requirements, individual states have their own rules regarding these claims. Knowledge and the preparation taken in the steps prior to this are the only ways to optimize this step in the revenue cycle. 

 

To receive payment from a payer in a prompt manner, clinics must submit a claim free of mistakes and errors. This is usually termed submitting a “clean claim.” 42 CFR 447.45 defines a clean claim as one that needs no additional documentation from the service provider or third party. Below is a list of links to state’s insurance codes regarding claims. Almost all states now have some sort of “prompt payment” regulation. Some of these regulations have definitions regarding clean claims that are to be submitted to insurance companies. Those marked below do not have a specific definition.

 

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Topics: revenue cycle management, Medical Practice Improvement, claims submission, Medical Coding Services

Optimizing The Revenue Cycle 6 of 12: Medical Coding

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 16, 2019 7:46:00 AM

Unlike other service industries, healthcare has a complicated medical coding system for the services provided. For example, in accounting one hour of service is a specific cost. A simple tax return is another specific cost. In healthcare, it is rare that we can easily quote that a service will be a specific cost. This is due to the way that we are required to code the services we provide and then bill for them. The rules are dictated by outside agencies on how providers document patient encounters in a specific way, code the encounter a certain way, and then the payers may contradict that. Just another fun day in the world of healthcare coding and billing!

 

To optimize the coding step of the revenue cycle, medical practice administrators must

  • determine who will be responsible for knowing the documentation requirements for the medical codes being used,
  • assure that the documentation meets these requirements and
  • that the code combinations also meet insurance regulations.

Once responsibility is assigned, how each of these steps will be accomplished must be determined.

 

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Topics: revenue cycle management, Medical Practice Improvement, Medical Coding Services, Outsourced Medical Coding, Supplemental Medical Coding, medical coding

Avoid OIG Medical Coding Audits

Posted by David Blanchard on Dec 18, 2018 4:03:00 PM

Whether you are dealing with a commercial payer, Medicare, or Medicaid, there are certain types of improper claims that should be avoided if you want to reduce your risk of a medical coding audit. That bit of wisdom comes from an entity that ought to know: the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG).

The OIG has released a roadmap to help new physicians avoid medical billing fraud and abuse in the Medicare and Medicaid programs. But this advice also broadly applies to how you approach reimbursement from commercial payers, and can also serve as a helpful reminder for physicians with years of experience in practice.

The agency warns, sternly, about consequences, noting in bold type that “when the federal government covers items or services rendered to Medicare and Medicaid beneficiaries, the federal fraud and abuse laws apply.”

When it comes to medical coding errors, the broad categories of “fraud” and “abuse” have distinct meanings. Fraud involves intentional misrepresentation. Abuse means “the falsification was an innocent mistake, but nonetheless representative,” according to the AMA’s Principles of CPT® Coding, ninth edition.

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Topics: medical coding, Medical Coding Compliance, ICD-10, Medical Coding Services, medical audits, HCC Coding

Why You Need Internal Coding Audits

Posted by Jared Petersen on Oct 19, 2018 9:53:00 AM

Fraud. Scary word, right? Well it happens a lot, and if you are not careful it might be happening at your practice right now. “Get a free scooter!” You may remember those words uttered on a commercial that ran continuously a few years back. In August of 2014, the Washington Post broke a story on how the government paid billions of dollars for Medicare recipients to get a free motorized wheelchair. The perpetrators of this scam were intentionally defrauding the government by using loopholes to make huge profits on markups for these chairs.

The wheelchair scam example is an outlier, but it is what most people think about when the topic of fraud is brought to the forefront, but that is just one high profile case. There are many instances of unintentional errors that can occur due to lack of understanding of the many regulations and nuances of medical billing. Consider auditing your providers for compliance and finding opportunities for improvement.

Here are 4 reasons why:

 

 

1. Billing Mistakes: still the provider's problem

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Topics: medical coding, Medical Coding Compliance, ICD-10, Medical Coding Services, medical audits, HCC Coding

6 Key Best Practices to Avoid a CMS Compliance Audit

Posted by David Blanchard on Sep 27, 2018 8:54:00 AM

Medicare and Medicaid audits are an extremely popular topic. Imagining the possibility of having your practice or hospital audited for its billing practices is a daunting thought. How simple it can be for a practice to overlook a coding change to IDC-10 or suddenly fall behind the latest PHI requirements.

Failure to stay on top of the changing landscape can lead to major financial problems down the road and the need to pay back unallowable funds. Daily we hear of OIG audits that are the results of missing a coding change or improper practice policies that can be catastrophic to the financial well being of a healthcare organization. 

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Topics: medical coding, Medical Coding Compliance, ICD-10, Medical Coding Services, medical audits

2019 Proposed Fee Schedule Changes - Input From Peers

Posted by David Blanchard on Sep 17, 2018 3:35:10 PM

A few weeks ago The AAFP released its initial summary(2 page PDF) of the proposed 2019 Medicare physician fee schedule which, for the first time, also includes recommended changes that would affect CMS' Quality Payment Program in 2019.  Is this good or bad for you? Let me share some quotes from the AAFP website that can be found here: https://www.aafp.org/news/government-medicine/20180724mpfssumm.html

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Topics: medical coding, Medical Coding Compliance, ICD-10, Medical Coding Services, medical audits, payment posting

"SMART" Year End Revenue Cycle Goals

Posted by Ben Castleberry on Aug 3, 2018 10:06:00 AM

2018 is more than halfway over. "Finishing Strong" will start to be a common message through out organizations all over the country. Goals will be set, measured, and some will be met, some will be exceeded and most will fail. What makes a good goal. What goals should you be setting for your revenue cycle and your medical coding? 

2018 is more than halfway over. "Finish Strong" will start to be a common message throughout organizations all over the country. Goals will be set, measured, and some will be met, some will be exceeded...Most will fail. What makes a good goal? What goals should you be setting for your revenue cycle? 

Before we get into specific goals, lets quickly what sets apart the structure of a good goal versus the structure of a poorly set goal. We call them "SMART" Goals. Specific, Measurable, Attainable, Relevant, and Time-Bound. 

Specific - In terms of revenue cycle and medical coding, you should choose the particular metric you want to improve, like coding related denials, Days in AR, or Overall Medical Coding reimbursement revenue. You should also identify the team members working towards the goal, the resources they’ll have, and their plan of action.

Measurable - If you want to gauge your team’s progress, you need to quantify your goals, like achieving an X percentage increase in Denials, AR, or Reimbursement.

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Topics: medical coding, Medical Coding Compliance, ICD-10, Medical Coding Services, medical audits, payment posting

Changes to Medicare Payments

Posted by David Blanchard on Jul 31, 2018 2:01:42 PM

This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2019 to implement changes arising from our continuing experience with these systems. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this proposed rule would update and refine the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. The proposed rule also includes requests for information on promoting interoperability and electronic health care information exchange, improving beneficiary access to provider and supplier charge information, and leveraging the authority for the Competitive Acquisition Program (CAP) for Part B drugs and biologicals for a potential CMS Innovation Center model. In addition, we are proposing to modify the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure under the Hospital Inpatient Quality Reporting (IQR) Program by removing the Communication about Pain questions.

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Topics: medical coding, Medical Coding Compliance, ICD-10, Medical Coding Services, medical audits, payment posting

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