Managed Care Readiness Training Series: Revenue Cycle Management 3 rd Learning Community Claim Submission and Payer follow-up

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1 Managed Care Readiness Training Series: Revenue Cycle Management 3 rd Learning Community Claim Submission and Payer follow-up

2 Claim Submission and Payer follow-up Presenter: David Wawrzynek MS, MBA

3 Managed Care Technical Assistance Center (MCTAC) Overview What is MCTAC? MCTAC is a training, consultation, and educational resource center that offers resources to all mental health and substance use disorder providers in New York State. MCTAC s Goal Provide training and intensive support on quality improvement strategies including business, organizational and clinical practices, to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care. 3

4 Managed Care Contracting requirements For two years Medicaid Managed Care Plans will be required to contract with providers that serve five or more of their enrolled individuals. MCOs will be required to pay the Medicaid fee for service rate for all authorized procedures delivered to individuals enrolled in managed care plans and HARPs. HCBS rates are listed on the HCBS fee schedule 4

5 Revenue Cycle Defined All administrative and clinical functions that contribute to the capture, management, and collection of client service revenue. This describes the life cycle of a client account from creation to payment collection and resolution. The client account cycle is supported by a number of additional activities necessary to assure that all encounters are billable, meet regulatory requirements and revenue collection is maximized. 5

6 What is the impact? Yearly Revenue Example: $2,000,000 Denial/Void/Non billed or Under billed services % 12% $240,000 10% $200,000 8% $160,000 6% $120,000 4% $80,000 2% $40,000 Amount of Revenue left uncollected 6

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8 Phases of the Revenue Cycle Prior to Service Pre-registration including eligibility verification and authorization Scheduling During Services New client registration Eligibility verification Collection of fees Charge capture and coding Following Services Claims submission Payer follow-up Remittance processing and posting Ongoing Analysis Process improvement 8

9 Claims submission Claim Submission - Definition Submission of billable fees to the insurance company via the required universal claim form. 9

10 Errors in claims submission results in revenue loss or additional expense Each claim that is rejected or denied due to improper formatting or missing data elements must be touched and resubmitted Cash necessary to support Agency operations will be delayed Finding, fixing, and resubmitting claims is redundant work and unnecessarily diverts resources from other more important tasks 10

11 Claims Electronic claims will be submitted using the 837i (institutional) claim form. Providers will enter the rate code in the header of the claim as a value code. Plans will have a complete listing of all existing providers and rate codes as well as rate amounts by MMIS provider ID and locator code and/or NPI and zip+4 These will be posted by OMH and OASAS 11

12 Claims (continued) Every claim will require: Use of the 837i Rate code Procedure code(s) Modifiers (as needed), and Units of service 12

13 Claims Coding Crosswalks OMH and OASAS has provided crosswalks to: Provide a link between existing FFS rate code billing and the unique rate code/procedure code/modifier code combination that will be required. Procedure and modifier code combinations have been created in such a way that even if the rate code does not exist the plan could differentiate between the various services and pay at the correct amount. 13

14 Claims Submission Claim data can be submitted directly or through a clearinghouse Processes must be in place to scrub claims to assure that they are clean. Some common tests should be: Was the claim formatted correctly and are all required data elements present Was the service of the required duration for the code Was the documentation completed properly: Progress note was completed Service was on the treatment plan Treatment plan was up to date Claims should be submitted as soon as feasible 14

15 Claims Submission (continued) Clearinghouses can do a good job at scrubbing claims with technical errors but only an EMR with a billing component can evaluate claims for compliance with documentation requirements. An EMR can suspend claims and alert staff to errors that renders the claim unbillable and support quality improvement efforts and regulatory compliance. If there is no EMR scrubbing of claims it is essential that there is an active Quality Assurance process that identifies improper claims and voids them when necessary. 15

16 Payer follow-up Once payments are received identify variances between billed amounts and paid amounts. Claims may be denied out right or paid at a different amount than billed Attempt to determine the reason for each claim variance 16

17 Payer follow-up - Denials Review each denied claim and determine the cause Some common denials are: Claim was submitted after the allowable time period Visit was not authorized Client was not eligible Provider was not credentialed Claim had incorrect client or provider data Provider technical error Payer technical error Adjudicate claims, correct errors and resubmit promptly 17

18 Payer follow-up - Denials When necessary work directly with the plan but: Be organized Have the data you need in front of you Clearly make your case Know what you are talking about Ask for technical support from the plan if you do not understand their requirements 18

19 Payer follow-up - Denials Continue to work denied and under paid claims until resolved Track denials by payer and by reason to identify: Internal processing and workflow problems Billing system set-up issues Payer problems Fix internal issues as soon as possible, repeating mistakes are very costly 19

20 Payer follow-up Client Fees Outstanding client fee collection is difficult and labor intensive You must be able to demonstrate reasonable due diligence in attempting to collect all fees owed to you Some considerations: Will you send outstanding client fees to collection after a reasonable effort to collect them What do you consider a reasonable effort to collect What will you do when terminated clients with an outstanding balance return to treatment. 20

21 Resources As part of the state qualification process plans are required to develop and implement a comprehensive provider training and support program for network providers to gain appropriate knowledge, skills, and expertise and receive technical assistance to comply with the requirements under managed care. Training and technical assistance shall be provided to BH network providers on billing, coding, data interface, documentation requirements, and UM requirements. New providers should have a submission testing environment to work in prior to submitting live claims. 21

22 Resources Resources (continued) 22

23 Resources (continued) New York State HARP Mainstream BH Billing and Coding Manual provides billing mechanics for all the Medicaid fee-for-service government rate services (including OMH licensed and OASAS certified services). This should be reviewed in conjunction with the coding taxonomy, HCBS Fee Schedule, and the rate table. The second section of the manual gives detailed information on OASAS services. There are numerous links in this document, provided for your convenience. 23

24 Resources (continued) Coding Taxonomy This file provides the required coding construct for billing the OMH government rates services. Government rates must be used for the first 24 months of the behavioral health carve-in. Plans will need to program their payment systems to accept these coding combinations and then look through the Rate Table to ascertain the correct payment amount for the various unique coding combinations (specified using procedure codes, modifier codes, and units of service - all cross-walking to rate code) and the specific provider and BH service (based on MMIS provider ID or NPI and rate code). 24

25 Resources (continued) HCBS Fee Schedule This file shows the required coding combinations for providers to bill the Plan for the provision of these services. The rate codes that the Plans will use to receive reimbursement from emedny will be provided in the near future and are subject to CMS and NYS DOB approval. 25

26 Resources (continued) Rate Table This will have to be built into the Plan s payment system. It shows the rate amount for each MMIS provider ID and rate code combination. 26

27 Upcoming Learning Communities The four content areas for the RCM Series are: #1 Scheduling & Pre-registration and Point-ofservice registration & collection #2 Charge capture & coding #3 Claim Submission and Payer follow-up #4 Remittance processing and Appeals, collections, and analysis 27

28 RCM Learning Community-NYC & Rest of the State May Monday Tuesday Wednesday Thursday Friday 4/27-5/1 5/4-5/8 5/11-5/15 5/18-5/22 #2 Webinar General Overview (NYC providers) 5/25-5/29 MEMORIAL DAY #1 Webinar General Overview (NYC providers) Office Hours #1 Office Hours #2 #3 Webinar General Overview (NYC providers) Office Hours #3 *All Webinars and Office Hours will be held from 12pm-1pm 28

29 RCM Learning Community-NYC & Rest of the State 6/1-6/5 7/13-7/17 7/20-7/24 7/27-7/31 8/3-8/7 June Monday Tuesday Wednesday Thursday Friday #4 Webinar General Overview (NYC providers) July Office Hours #4 #1 Webinar General Overview (Rest of the State) Office Hours #1 #2 Webinar General Overview (Rest of the State) Office Hours #2 #3 Webinar General Overview (Rest of the State) Office Hours #3 August #4 Webinar General Overview (Rest of the State) Office Hours #4 *All Webinars and Office Hours will be held from 12pm-1pm 29

30 For further discussion, questions and answers, please join us during Office Hours on Thursday from Please submit your questions ahead of time to with the subject line RCM Learning Community Questions 30

31 Thank you for participating! Please visit and to sign up for additional offerings and trainings. 31