Ann Silvia, BS, CPC, CPB, CPC-I, CPMA, CPPM, CANPC, CEMC, CFPC

Transcription

1 Ann Silvia, BS, CPC, CPB, CPC-I, CPMA, CPPM, CANPC, CEMC, CFPC

2 This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information, the ultimate responsibility for the correct submission of claims lies with the provider of services. I make no guarantee that this information is error free and bear no liability or responsibility for any results or consequences resulting from the use of this information. Medical providers are responsible for the day to day implementation and compliance with applicable state and federal laws and regulations.

3 Appointment Scheduled Follow to $0 Balance Check In Billing Charge Capture

4 Demographic information Insurance Patient is asked to come in a little early or fill out the required information on line Appointment is given

5 Time Information is put in the system incorrectly Another patient account is created in the Electronic Practice Management system when an account for that patient already exists

6 The office can verify coverage prior to the patient s arrival Co-payment, deductibles and coinsurance information can be obtained prior to the visit Point of service collection of these fees

7 This is the most important position in the revenue cycle Verifies information the patient has provided Copies or scans the patient insurance card and picture identification Notice of Privacy Practice and Financial Policy

8 Collects the co-pay, deductible, and any old balances Patient may be flagged to speak to the manager or financial counselor in the office

9 Wrong insurance is entered Wrong policy number Medicare Secondary Payer questions not completed Too timid to ask for money NO SHOWS

10 This is the beginning of the revenue cycle The front office is the face of your practice Errors here cost the practice money

11 Who is responsible for capturing the charges? -EHR system? -Provider? -Nurse or MA? -Check out person? -Biller? -Coder?

12 The electronic health record is only as good as the information entered Poor or incomplete code descriptions Tests ordered that do not comply with medical necessity standards Records not completed or signed off in a timely manner

13 Do not know how to code -records not reviewed before signing -codes in the wrong order -charges not submitted to billing -tests ordered for rule out diagnosis

14 Do not submit charges to billing Miss administration for the injection given Forgot to submit the venipuncture Did not get an ABN or similar form for a possible non-covered service

15 Responsible for entering charges but has no training No time to check for accuracy or missed charges Billing unsigned or unfinished documentation

16 Coding tells the story of the medical visit -depends on the documentation -depends on the clinical staff accurately capturing the other services (injection administration etc) -depends on that ABN if necessary

17 Changes Payers are not uniform in their billing rules Compliance with each of the contracts Inconsistencies or non-compliance result denials and repayments

18 Charges should be entered daily or as soon as possible from the date of service Insurance and demographic information has to be correct and in the system

19 Claims that are billed and processed without being touched again Claims that need worked = money lost Practice management systems have edits set Clearinghouse level also has edits

20 The billing process includes the claim being cleared through the editing process at the billing clearinghouse A rejection report is generated here that identifies problem claims that need some kind of fix to send on This report shows claims sent and claims accepted by the payer

21 The correct provider is attached to the charge Correct date of service Correct place that services are rendered Billing should not take place until the record has been signed by the provider of service

22 Referring providers name and or NPI number Provider NPI Group NPI Other missing information from the claim

23 The challenges are: - charges written off that should not be - Electronic posts are not always accurate - $0 pays are not posted timely - Payments by contract not always right - Helps identify fee schedules set too low

24 Why is it denied? There are timely filing rules with payers for re-filing and corrections Not all denials are because something you did was wrong Denial codes are not always the real reason a claim is denied

25 Re-submitting claims without doing anything is not appropriate What is the action required? Phone call to insurance Back to the coder Patient information error Patient involvement Physician or NPP

26 Some complex issues involve getting others involved like Region 5 for Medicare issues Use the Insurance Commissioners office Request a review from the payer with a physician of the same specialty Get the patient involved for ERISA plans

27 Credits should be worked monthly Medicare has very strict guidance for how much time the practice has to refund Bad Debt should be written off when it is turned over to collections

28 Watching the revenue cycle from beginning to end is critical for a successfully run practice Challenges can be overcome with good training and best policies and practices

29 Questions? Contact Information: Physician Auditing, Consulting and Education 311 E. School St Centerville, IN (317)