Revenue Cycle Management: Understanding and Implementing Best Practices for Efficient and Accurate Reimbursement

Transcription

1 Revenue Cycle Management: Understanding and Implementing Best Practices for Efficient and Accurate Reimbursement Presented by Scott Spradling Objectives Understand Contracting/Credentialing Process & Payor Mix Obtaining Efficient and Accurate Payer Benefits/Authorizations Principals of Coding Rules Understanding Your Accounts Receivable (AR) Revenue Cycle 1

2 Payer Mix Understanding your payor mix reimbursement trends: health of your practice; other offered services Payer Mix Credentialing 2

3 Credentialing Making the credentialing process as efficient as possible: Keep up-to-date credentialing files on hand for each provider and update yearly (Regular online re-attestation and document updates) Follow up on credentialing applications on a regular basis Be timely in terminating providers from contracts when leaving practice Value What are you worth? What do you want to be paid? Reimbursement What are others paying you? Who is your best Payer? Expenses What is the cost of doing business? 3

4 Value What are you worth? What do you want to be paid? vs. Reimbursement What are others paying you? Who is your best Payer? 4

5 Reimbursement What are others paying you? Who is your best Payer? Reimbursement What are others paying you? Who is your best Payer? (3units) w/ 50% MPPR and 2% Sequestration w/ No MPPR and 2% Sequestration 5

6 Payer Reimbursements Expenses What is the cost of doing business? Expenses What is the cost of doing business? *mid sized practice w/ 60 min visits 6

7 Expenses What is the cost of doing business? *Medicare with MPPR and Sequestration Expenses What is the cost of doing business? How to decide??? things to look at allowed amounts of top payers average reimbursement cost per visit 7

8 Managing fee schedules Check with payers on a yearly basis for updated fee schedules Audit insurance contracts Quarterly audits Periodically review Explanation of Benefits (EOB) to ensure accurate reimbursement Revenue Cycle Scheduling provider availability / variety timely eligibility & benefit verification timely authorization of care Documentation & Compliance timely completion of visit documentation notes & POC s to referring providers PQRS & FLR ICD-10 Billing timely charge entry/edits CCI edits transmit or file with clearinghouse & payers 8

9 Coding 8-Minute Rule CCI Edits Proper ICD-10 Coding 8-Minute Rule Insurance/Payer billing rules for therapy services are often specified within their payer contracts. These billing rules for therapy services may differ from payer to payer. There are payers that state in their contracts that they follow the Medicare 8-minute rule, others that state that they follow the CPT Guideline rule and others that do not specify either of those rules, in which case you may opt to specify the Flat 15-Minute rule. Based on the choice made under unit calculation the minutes documented for each timed code procedure or modality will be billed according to the choice made under unit calculation. Medicare 8-Minute: The sum of all timed code minutes within a single treatment session must reach a minimum of 8 minutes to bill one timed code unit. A total time factor (or the sum of all timed code minutes) determines the number of units that may be billed. The basic Medicare 8-Minute calculation is as follows: 9

10 CPT Guideline (a.k.a. Mid-Point Rule) A unit of time is attained when the midpoint is passed. The CPT Guideline is based on a 15-minute window and requires the mid-point to be passed (i.e., 8 minutes) for each unit of that specific timed code to be billed. In contrast to Medicare 8-Minute, the CPT Guideline does not apply a total time factor (or the sum of all timed code minutes) to determine the number of units that may be billed. Combining minutes from different timed code services to bill units is not permitted. The basic CPT Guideline calculation is as follows: Flat 15-Minute Each timed procedure code is billable at the 1st minute of a 15-minute window. Like CPT Guideline, the Flat 15-Minute, does not apply a total time factor (or the sum of all timed code minutes) to determine the number of units that may be billed. Likewise, combining minutes from different timed codes to bill units is not permitted. The basic Flat 15-Minute calculation is as follows: Coding CCI Edits Most common is 59 used for edit pairs used for re-eval Other Medicare Modifiers GA This modifier indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare. Use of this modifier ensures that upon denial, Medicare will automatically assign the beneficiary liability. GX Report this modifier only to indicate that a voluntary ABN was issued for services that are not covered. Medicare will automatically reject claims that have the GX modifier applied to any covered charges. 10

11 Coding CCI Edits Other Medicare Modifiers GY Notice of Liability Not Issued, Not Required Under Payer Policy. This modifier is used to obtain a denial on a noncovered service. Use this modifier to notify Medicare that you know this service is excluded. GZ Item or Service Expected to Be Denied as Not Reasonable and Necessary. This modifier should be applied when an ABN may be required, but was not obtained. Coding Proper ICD-10 Coding M codes vs S codes S codes use of the 7th digit A vs D vs S S codes including external causations management nt solutions 11

12 Revenue Cycle Payment Posting Insurance ERA / EFT downloaded from clearing house directly to billing system direct deposit into bank account requires extra measure of cross checking Insurance EOB / Checks Receive Explanation of Benefits (EOB) via mail Checks come with (can be separate as well i.e.: L&I) manual data entry posting 12

13 Payment Posting Patient Payments at time of service co-pays, self-pay, account balances 30 day statement cycle co-insurance, deductibles out of network / out of benefit A/R Management Accounts Receivable (AR) = Money owed to Practice Aged AR shows who owes what and for how long Multiple ways to view it (by Payer, Patient, Provider) A/R Management management nt solutions ons 13

14 A/R Management Denial Management: Common reasons for denials Zero explanation of benefits CPT codes and modifier usage Lack of medical necessity Errors due to patient demographic data Patient no longer covered by policy Begin denial management within 24 hours of receipt of denial 1. learn why the denial occurred and if there is a unique appeals form/process 2. put an appeal letter together; Include: Dates of service that are denied Insured accurate name and date of birth Policy number(s) Any additional forms the payor needs Include the medical records that support your letter A/R Management Helpful Elements Know: Days in AR This is a measure of the rate of A/R turnover. It represents the average time it takes to get a claim paid. 14

15 A/R Management Helpful Elements Know: Days in AR in AR A/R Management Helpful Elements Know: Days in AR <35 days is a good benchmark can obscure aged columns or poor/slow payers if DAR is 40 but Medicare DAR is 55 = problem A/R Management Helpful Elements Know: Collection Rate: Helps to project future cash flow 15

16 A/R Management Helpful Elements Know: Collection Rate: Helps to project future cash flow A/R Management Totals Majority should be in Current or 30Day The farther to the right >90 & >120 = the harder to collect A/R Management Patient Notices: 30-60: Friendly Reminder Call (or at next visit) >60: First Letter >90: Second Letter >120: Final Letter, 15 days, punt to Collections *third party collections typically take 30% to 35%, weigh the value **Payment Plans as Alternative 16

17 Thank You!!! Scott Spradling