Stop the Denial Merry-Go-Round

Transcription

1 Stop the Denial Merry-Go-Round Lisa Waterfield, Enterprise Revenue Cycle Consultant 1

2 ZirMed is Now Waystar The combination of Navicure and ZirMed uniquely positions Waystar to simplify and unify the healthcare revenue cycle with innovative technology that allows clients to collect more with less cost and less stress, so they can focus on their goals, patients and communities. + = 2 2

3 Our Speaker Lisa Waterfield has more than 12 years of experience with healthcare revenue cycle management and compliance. Prior to joining ZirMed in 2013, Lisa worked with a large practice management system and a billing service. Lisa was responsible for best practice initiatives, change management to address implementation of new industry guidelines and corporate level training for their revenue cycle systems. She also managed audit of regional offices in system staging, process development and ongoing revenue cycle change. Lisa is an expert at process improvement. She brings a blend of business and technical expertise to her current role of enterprise revenue cycle consultant. 3 3

4 Agenda What key performance metrics should you monitor to manage denials? How can you prevent claim denials? What steps can you take to improve staff performance? How can you speed payer issue resolution to secure payment? 4 4

5 Measuring Performance Industry-wide 15-20% of gross charges are denied, shrinking net profit margins 3-5% 5

6 How do you rank today for these KPIs? Best Performers Average Performers Poor Performers Denial Rate Less than 5% Denial Rate Between 5 10% Denial Rate >10% Clean Claim Rate > 90% Denial Write-Offs < 3% 6 6

7 Identify Root Denial Causes Examine CARCs/RARCs Error Codes CARC RARC Non-Covered Charge Missing/Incorrect Required Info Duplicate Claim/Service Bundling/Not Seperately Payable Medicare is Secondary Payer Code to Highest Level of Specificity CO-96: Non-Covered Charge CO-16: Claim lacks information or has submission/billing errors CO-97: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. CO-B15: This service/procedure requires that a qualifying service/procedure be received and covered. CO-16:Claim lacks information or has submission/billing errors CO-16:Claim lacks information or has submission/billing errors N431: Not covered with this procedure N56: Procedure code is billed is not correct/valid for the services billed or the date of service N111: No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated. M80: Not covered when performed during the same session/date as previous procedures. MA04: Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible. M81: You are required to code to the highest level of specificity. 7 7

8 Prevent Claim Denials 90% of Denials are Preventable 8

9 Frequent Denials in Your Front Office Process break-downs lead to denials down the line: #1 Reason - Ineligible and uncovered services Incomplete or inaccurate patient demographic data Failure to obtain authorization or precertification Services covered by another plan or payer Lack of medical necessity 9 9

10 How to Stop Denials in Your Front Office Educate staff, measure performance, and provide technology: Verification of insurance eligibility in real-time to the line item level - three days before service, on the date of service, and before submitting the claim Validation of patient demographics on each visit Confirmation of patient s authorization or pre-certification before service Qualification for medical necessity Ask about secondary insurance and eligibility for government programs Educate staff about National and Local Coverage Determinations so they can explain coverage to patients 10 10

11 Frequent Denials in Your Back Office Errors adversely impact your cash flow: #2 Reason - Duplicate claim Already included in a bundled claim #3 Reason - Missing or invalid claim data Improper documentation or coding Failure to meet timely filing requirements 11 11

12 How to Stop Denials in Your Back Office Educate staff, measure performance, and provide technology: Improve payer claims acceptance by utilizing claims scrubbing software and clearinghouse auditing to prevent missing and invalid data Work with a clearinghouse that automatically provides documentation to prove timely filing requirements Monitor sources of denials, enforce process standardization and provide training and feedback on performance Custom Rules Written By Waystar Teams 10 s Of Millions Of Rules Derivations Embedded Claims Scrubber Prevents Denials Before Claims Are Sent To Payers 12 12

13 Improve Staff Performance 2 OUT of 3 DENIALS ARE RECOVERABLE 35% 65% OF DENIALS ARE NEVER WORKED 13

14 Provide for Staff Efficiency Automate Denial Identification to Reduce Write-Offs Providers spend $25 to manually audit and appeal denials Utilize claims status to check when an EOB or remit has not arrived in a typical payer turnaround Electronically convert paper EOBs to remittance advice and match each remit to the claim Automate review of CARCS and RARCS to route workable denials for action within payer timely filing requirements 14 14

15 Manage Staff Results 1 Identify and manage staff work by payer, bill type, CARC, RARC, service code combinations, and billed/allowed amounts 2 Track, work, and report non-standard payer behavior Drive Denial Resolution 3 Automatically route work to appropriate person or department that can take action 4 Escalate high priority denials to an expert or the SWAT team 5 Require management approval to write-off denials over a given dollar amount 15 15

16 Utilize Six Sigma and Technology for Process Improvement Define Measure Analyze Improve Control 16 16

17 Speed Payer Resolution 17

18 Reduce the Time to Work Denials Automation prevented 73% of denials with no recovery opportunity from wasting client FTE time. Clients had more time to pursue the 27% of denials with recoverable revenue within timely filing guidelines

19 Automate Reconsideration and Appeals 19 19

20 Results 201% Improvement In Denial Payment Recovery Highlights: $3.6M net payment recovery in the past 8 months resulting in a 201% improvement Reduced appeal time by 89% Five state, community-based behavioral health care provider serving more than 100,000 people annually by delivering care through more than 150 facilities and 220 schools. Zirmed has been one of easiest companies I have worked with. They actively assist us in finding ways to decrease our denials by providing new ways to work our denial management queues. Their system fills in the gaps that our billing system is unable to do

21 For more information about revenue cycle technology solutions to manage denials and expedite cash flow Visit: Or call Thank you. 21