Presented by: Yvonne Dailey, CPC, CPC-I, CPB ALL RIGHTS RESERVED

Transcription

1 Presented by: Yvonne Dailey, CPC, CPC-I, CPB ALL RIGHTS RESERVED

2 The materials are offered as tools to assist the participants in understanding their revenue cycle. No part of the presentation may be reproduced or transmitted in any form or by any means (graphically, electronically or mechanically, including photocopying, recording or taping) without the expressed written permission of Dailey Billing Services Inc. All Rights Reserved

3 Provider Practice as a BUSINESS Communication is Key Start of the Revenue Cycle Everyone has a Role and Responsibility Denial Management Timely Filing Guidelines and Corrected Claims Guidelines Getting the Patient involved Early Using New Technology Offer Multiple Payment Options Using the Internet for Skip Trace Techniques Written and Oral Communications Small Claims vs.. Collections Agency All Rights Reserved

4 The practice is a Business Start off on the right foot Financial Policy Stick to it, set the rule on getting paid Set up collection goals weekly, monthly, quarterly, annually Know your surroundings Get patients involved early Offer different methods for payments Know when to cut your losses Know who you are contracted with VERY important when scheduling

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6 The first step First contact with patient Cycle starts The MOST important step in process Most Ignored Determine if the provider is in network Inform patient prior to service of problems with insurance coverage New Patient vs. Established Patient No Time Loss of Revenue Identify if prior authorization/precertification and/or referral are needed ABN The Referring Provider What Questions to Ask?

7 Insurance verification Questions to ask: Does the patient have a deductible? Has it been met? Does the patient have co-insurance/what is the percentage? Does the patient have a Co-Pay/How much is it? Coverage start and end dates

8 Scenario: Practice has two patients, one named Rafael Lewis Gonzales and the other Rafael Luis Gonzales. Both born 8/4/1990. Rafael Luis Gonzales was seen today; however, no one noticed that the charge ticket the receptionist filled out was for Rafael Lewis Gonzales. Now the office billed for the wrong patient.

9 A GYN provider is often considered a PCP, not a specialist. If you collect the specialist fee, but a particular carrier views the GYN as PCP, you are placing your practice at risk because you have collected more than what you were entitled to.

10 INNER CIRCLE

11 Review intake form to ensure the information is accurate Did the patient sign the financial policy Make a copy of the insurance card front and back Make a copy of patient ID front and back Are ALL forms signed and dated Collect copay, deductible, and/or co-insurance Update intake forms annually Start and end dates for insurance carriers REQUIRE IT Review your returned mail Review at each visit review ID also for changes

12 Lack of patient signature on all proper documentation: ABN not signed financial policy not signed Physician missing, or wrong date of service Missing and/or not properly appended CPT /HCPCS Level II modifiers Clinical significance/medical necessity for lab orders Increased use of EMRs: Cloned documentation

13 The coder s responsibility is to review for accuracy Make sure not to leave money on the table Medical billing and coding is like a puzzle all pieces must link together accordingly Medical necessity Know your carrier guidelines and policies

14 Let s review the following examples: Provider documented : Flu shot The flu vaccine can be billed a number of ways: Medicare (depending on your Medicare Carrier) Q0236 Flu Vaccine ( your Q code depends on the ACTUAL vaccine administered to patient) G0008 Administration of Flu Vaccine To bill a commercial carrier: Flu Vaccine Administration of vaccine Changes if it was the FluMist This is a small sampling as there are multiple vaccines codes for the flu

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16 Enter all charges Review BEFORE submission Based on the provider s documentation Review for lost revenue (administration, supplies, etc) Samples of things to review : NPI, referring provider information, onset date, DOB, DOS Know payer policies for what is billed Know carrier timely filing guidelines Are any modifiers needed

17 Lost revenue Payment disputes (with patient and carriers) Audit risks Compliance risks

18 We often see money left on the table Missing charges for supplies Missing charges for services & procedures Missing charges for devices Not collecting payment at time of services (e.g., copays or self pays) Established patient vs. New patient

19 Let s review the sample charge ticket: How many billable charges are there? Is there anything missing? Will it require a modifier? Do you need a referring and/or ordering provider? Does it make a difference if this is a Medicare pt or a Commercial pt? Why or why not? Now let s look at the 1500 for this claim

20 Medicare Patient Procedure code on ticket Notes on ticket: Flu shot given Ear wax removed with tools both ears No name listed for referring provider Dx codes E11.9 I10 H61.20

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22 Review and document your claim submissions If your clearinghouse allows corrections on the site, be sure to correct on your end also Review your EDI reports daily Know what reports are needed for appeals and/or fighting your timely filing Know your claim submission file # (837, 835, 997, etc)

23 All payments must be posted EVEN your ZERO dollar EOBs, even if you are going to work the denial/rejection, post it Know your denial codes such as CO50, CO45, PR204, etc Use notes in your system important Document all communication with carriers date, time and person you spoke to

24 Name the following carriers: 1. W U NJX3HZN MEDBBDXE 5. MA A 7. YLM QFT

25 Let s review the following example: Allowed amount is $150, pt paid copay on date of service of $10.00 Par Dr. Amount Billed Paid at TOS Carrier payment Write off amount Amount to bill patient Difference $200 $10 $100 Non Par $200 $10 $100

26 Follow-up - Most important to manage the A/R Must be able to research and know where to search Insurance Aging Patient Aging Work weekly, monthly, quarterly, yearly Pick up the phone it still works Document your follow-up attempts, notes, letters, phone calls, etc.

27 In many cases practice denials represent internal errors Loss of revenue or delayed revenue Track denials Train staff on payer policies, coding, billing (your findings) Monitor Make staff members accountable

28 Know the difference between a denial and rejection Let s review denial code: CO50 PR27 Which is a rejection and which is a denial? Understand how to read your EOBs Just because the EOB states to write it off, doesn t always mean you write it off APPEAL APPEAL APPEAL

29 What s the difference between a rejected claim and a denied claim? What is a denied claim? A Denied claim is a claim that did not meet the coverage criteria: such as LCD denial, ICD9-CM to CPT /HCPCS code edits Denied claims are considered AFTER the coverage determination therefore they DO afford appeal rights. 29

30 What s the difference between a rejected claim and a denied claim? What is a rejected claim? A rejected claim is a claim that did not have the necessary information to determinate coverage such as billing errors (i.e. Data entry errors, not enough information, truncated ICD9-CM code, ) Rejected claims do not afford appeal rights nor can they be reopened 30

31 Rejections and Denial Codes You will notice that your Remittance Advice has a series of codes that indicate the nature of the rejection and/or denial RARC Remittance Advice Remark Code & CARC Claim Adjustment Reason Code Updated tri-annually (March, July, November) Can be downloaded from Washington Publishing Company (WPC) website 31

32 Clearinghouse Dashboards Gives complete summary (accepted /denials) Overview of your top rejections Use as training tool Share your findings with staff and providers Inform provider, not everything gets paid

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35 90 claims per day at $90 per claim = $8,100 If 10% denied = $810 in denial per day If only 1 in 10 denials are appealed it =$ per day 52 weeks x 5 days 20 day (vacations and holidays) = 240 working days, 240 days x $ = $174,960 lost per year

36 Practice Analysis Insurance Aging (90, 120, 151) Secondary Aging (medigap claims) Procedure Analysis Diagnosis Analysis Patient Aging Denial Report Surgery Report

37 Carrier United Health Care Oxford Aetna Cigna Cigna Great West Time Frame 90 Days from date of service 90 Days from Date of Service 180 Days from Date of Service 90 Days from Date of Service 15 months Medicare 12 months (Calendar ) This will differ if the provider is NON PAR. For example Cigna is 180 Days

38 Most carriers want your EDI reports to show claims accepted and acknowledged by Payer Some Carriers REQUIRE you use their forms to appeal It s not enough to have an acceptance from your clearinghouse. They want acknowledgement that THEY received it. If you mailed your claims, then you should have mailed certified with return receipt.

39 Carrier United Health Care Oxford Aetna Cigna Time Frame 60 Days from date of remit 60 Days from date of remit 12 Months from date of remit 180 Days from date of remit Some may require that you use THEIR forms, other may allow you to simply write a request. Forms may vary depending on State where provider is located. Should ALWAYS BE SENT CERTIFIED WITH RETURN RECEIPT. Keep a file and/or log so you can track

40 Job loss reduced income Emergency situations Loss of insurance coverage Hardship Not understanding insurance plans Wasn t aware they owed

41 Kill it with kindness Keep it simple, keep it professional, be assertive Offer multiple payment options

42 Financial Policy Funds Were Paid To Patient Past Due Notices (30, 60, 90) Offering Different Payment Methods No Payment Received By Carriers Pre-existing Clause Insurance Verification Letter Financial Hardship

43 Copay Amount Cash/Check At time of service Credit card payment in office $20.00 $0 ($20.00) $.96 ($19.04) Billing the patient $3.00 ($17.00) Billing the patient TWICE $6.00 ($14.00) Patient has been billed three times and NEVER Pays - $29.00

44 Debit Cards Credit Cards Online AUTOMATIC withdrawals from checking or savings Check Cash Via your website PayPal

45 Merchant account now offer ways to pay by credit card via the internet where the patient feels comfortable putting in their own information We use Netdeposit Set up direct payment out of their checking, savings account and/or credit card Taken out automatically on a monthly or bimonthly (check payment online)

46 Automatic debit from any account type Recurring payment schedules View payment history View future payments Archived payment receipts Receipts ed to both patient and practice Payment scheduled is also ed to patient and practice

47 Month Checks Chk Amt Credit Cards Credit Amt Total Rev Feb $ $ $ Mar $ $ $ Apr $ $ $ May $ $0.00 $ Jun $ $0.00 $ Jul $ $0.00 $0.00 Aug $ $0.00 $0.00 Sep $ $0.00 $0.00 Oct $ $0.00 $0.00 Nov $ $0.00 $0.00 Dec $ $0.00 $0.00 Jan $ $0.00 $0.00 Feb $ $0.00 $0.00 Totals: 5 $ $ $

48 What is Skip-trace? Skip trace identifiers: Patient s EXACT full name Date of birth or age Social security numbers Previous address last known Driver s license number Insurance policy numbers

49 Use your Postal Service Ancillary service endorsements Return service requested Temp -return service requested Address service requested Change service requested NCOA-link services

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52 Many different websites to assist you Other people search sites The costs vary from $1.00 to $350.00

53 PEOPLE SEARCH RESULTS We found 8 people that match Yvonne D Dailey in the United States. Click on the View Details or Get a Detailed Report link for more info. = Available Search Again >> See Details on All 8 People! Name Age Previous Cities DOB Phone Address Avg. Income Avg. Home Value Relatives 1 Yvonne D Dailey 38 Bradenton, FL Oneco, FL Randall T Dailey (40) Connie Y Dailey (70) Thomas M Dailey (70) Constance Y Dailey (70) William F Dailey (36) 2 Yvonne D Dailey 41 Long Branch, NJ Albuquerque, NM Toms River, NJ Delroy A Dailey (40) Bill Dailey Mr. Dailey 3 Yvonne D Dailey 52 Austin, TX Claremore, OK Spicewood, TX Camille Yvonne Dailey (52) Jon Dailey

54 Use the collection letters Call the patient if over 60 days Offer a payment plan and stick to it Never complete your collection conversation without collecting a least a third of your outstanding balance if you can t collect the full balance and be sure to have a payment plan in place

55 Know when to cut your losses and at what price Regardless of route you used, you will need to prove your collection efforts Small claims will cost you the cost of court plus the attorney fee Patients fear court Collection Agency negotiate your fees (28 to 45% of collections)

56 CEU # Thank you for attending. How to contact us: info@daileybilling.com Yvonne Dailey, CPC,CPC-I :ydailey@daileybilling.com Website:

57 United States Postal Service Netdeposit Online Merchant Vendor Useful websites: Example letters: Yvonne Dailey-Dailey Billing Services