Mastering Clean Claims and EDI Reports for Increased Revenue Office Management Solution, Inc. John Peake, President Who are we? Office Management Solutions, Inc. 4917 Ehrlich Road, Suite 204 Tampa, Florida 33624 813-963-5582 Don’t worry about your computer, thats our job! Visit us on the web: www.oms-online.com Office Management Solutions • OMS has been providing support to the medical community for 20 years! • We act as the first line of defense for your practice: PM, EMR, EDI, as well as, many other products and services • A majority of support call involve EDI claim errors, rejections and denials. Mastering Clean Claims and EDI Reports for Increased Revenue • YOU – The Masters of Revenue Cycle Management (RCM) • • • • • • • • Entering Patient Services Generate, Review, and Submit Claims Follow-up and Tracking of Unpaid Claims Receiving and Posting Payments Auditing Explaination of Benefits (EOBs) Appealing Incorrect Payments and Denials Billing Secondary Health Insurers Billing Patients for Their Portion Mastering Clean Claims and EDI Reports for Increased Revenue How Do you Do it While Managing: - The Patients - The Doctor - The Practice RCM Mastering Clean Claims and EDI Reports for Increased Revenue • Review of most common practice – – – – – Post charges in Practice Management System (PM) Send claims to Payer / Clearinghouse Wait for rejection report Correct rejections in PM Repeat process until paid • Results of the common practice – Wasted valuable processing time • You should have a claim status in 2 day and payment in 14 – Tons of useless printed paper – Mentality of ‘I’ve always done it this way’ Mastering Clean Claims and EDI Reports for Increased Revenue • Before we get started… – Your Practice Must be a Group – Stop Sending Paper Claims – Take advantage of the internet • Information equals money • CPT, ICD, LCD Specialty Websites • Social Media Group Discussions – Develop and Review your Process – Do it Right the First Time – Choosing the Right Clearinghouse Mastering Clean Claims and EDI Reports for Increased Revenue • Why are you still sending paper? • • • • I always send paper to … plan I always print my secondaries claims … I have to send documentation Too much work to send electronic – They always get rejected Practices save big money by receiving and processing electronic transactions Mastering Clean Claims and EDI Reports for Increased Revenue The Internet is More Than Just Social Media • Join social groups / discussions – Many Medical Billing and Coding Groups/Discussions – AMA: Administrative Simplification LinkedIn Group – Medical Group Management Association (MGMA) – PAHCOM: Medical Practice Management, Education, Help – Healthcare Billing and Management Association (HBMA) – CHANGE.GOV Mastering Clean Claims and EDI Reports for Increased Revenue Do it right the first time! According to a report by the Center for Information Technology Leadership (a non-profit health technology research group) commenting on the issue of claims denial management: the current state of affairs ‘’is costing medical providers and health insurers around $20 billion-about $10 billion on each side- in unnecessary administrative expenses ’’ This is where having the right clearinghouse proves it’s value to you and your practice. Mastering Clean Claims and EDI Reports for Increased Revenue Develop and Review Your Process OFTEN - How often do you check your CPT / ICD codes and update relevant superbills? How about LCD? Do you review payer specific fee schedules and contracts annually? How does your practice review the most common billing errors? If you always do what you have always done, you will always get what you have always gotten . Nike FALSE Choosing the Right Clearinghouse • Relationships (with payers) – Availity, Emdeon, Thin, Gateway EDI, Realmed, etc. – The Practice Insight Difference • Claim Editing and Reporting – Robust, Versatile, Informative • Data Formatting Flexibility – Takes what you can send – Sends what you Need! So Let’s Dig In Mastering Clean Claims and EDI Reports for Increased Revenue Start with Eligibility Verification Every Time Do your doctors know that they are working for free? Effective Eligibility Matters • Cost cannot be a factor. Just do it! – Not getting paid costs you more. • Managing logins at every insurance website – Changing passwords every 90 days? – What is free costing you? • Getting the right type of eligibility request – Not just « Type 30 - Health Benefit Plan Coverage» – Be Specialty and Procedure Specific Eligibility! Not just for patients • Who manages your enrollments with plans • Many payers de-enroll provider for inactivity • Translation: • 09/10/2014: A8:496 Acknowledgement / Rejected for relational field in error.:Submitter not approved for electronic claim submissions on behalf of this entity. Note: This code requires use of an Entity Code.: Entity Billing Provider (A8:496:85) (A8:496:85) Mastering Clean Claims and EDI Reports for Increased Revenue Top 5 medical claim denials Article by Kevin Fuller, Producer at Healthcare Finance News – July 2013 • • • • • 1. 2. 3. 4. 5. Duplicate Claim Claim Lacks Information Eligibility Expired Claim Not Covered By Insurer Time Limit Expired / Timely Filing http://www.healthcarefinancenews.com/news/top-5-medical-claim-denials Mastering Clean Claims and EDI Reports for Increased Revenue Analysis of our own data Claims for 16 unaffiliated practices managed by a billing service 74654 Claims billed over the last year. 2418 Rejected (3.2%) • • • • • • 1. 2. 3. 4. 5. 6. – – Missing or incomplete data Patient not eligible for service Use of Entity Code required Submitter not approved Duplicate service charges Other Miscellaneous Invalid billing combination. See STC12 for details. “Rejected” 165 – 35k 114 – 53k 1486 – 337k 741 – 189k 581 – 171k 370 – 100k 205 – 58k 712 – 215k Missing / Invalid Information Other Rejections: Eligibility Other Rejections: Vague Managing Rejections How are you doing it? Send Clean Claims First How do you know your claims are Valid? Fix Your Invalid Claims Before You Send Them Taking VALID to the Next Level Example of Clinical Claim Scrubber How They Do That And by they, I mean you Mastering Clean Claims and EDI Reports for Increased Revenue I have sent my claims, so now what? Acknowledged Accepted / Rejected Paid / Denied Typical health insurer administrative system workflow • Step 1 Receive Claims • Step 2 Determine Patient’s Eligibility • Step 3 Apply Pricing Claim Edits • Step 4 Apply Health Insurer Proprietary Edits • Step 5 Complete Adjudication • Step 6 Generate EOB / ERA • Step 7 Send Payment / EFT Steps 3/4: Pricing Claim Edits • Pricing Rules – – – – Contract Use of/Req. Modifiers Multiple Procedure Reduction Procedure in date rules • Claim Edit Rules – AMA CPT coding guidlines – CMS Payment Rules – NCCI • Health Insurer Proprietary Rules • “Lesser of” vs. Fee Schedule • PPO Affiliated Lowest Fee NHXS Survey Results • Effect of $0.01 adjustment For Every $1.00 Billed $0.43 Fee Sched. Adjustment/Rules $0.01 CPT, NCCI, CMS and Proprietary Rules $0.10 Paid By Patient $0.45 to be paid by health insurer For every $50,000 billed, $1,000 is lost to proprietary edits. National Health Exchange Service (NHXS) 2007 Survey of 1.7 Million claims over 90 days submitted to 14 commercial payers and several medicares. Mastering Clean Claims and EDI Reports for Increased Revenue “Typically you will spend between $14 and $25 For each claim that you audit and appeal” Mastering Clean Claims and EDI Reports for Increased Revenue • Trading Partner First Responses – ACK – ACK-997 – ACK-999 • Other Response Types – Acknowledged by Clearinghouse – Acknowledged by Third Party Mastering Clean Claims and EDI Reports for Increased Revenue What You Should See What You Should Do Next Mastering Clean Claims and EDI Reports for Increased Revenue Working your Rejected Claims Managing Your Practice Rejections Mastering Clean Claims and EDI Reports for Increased Revenue - Trading Partner Next Response - Claim Paid - Denied Claims - Not Denied but Not Paid Either Mastering Clean Claims and EDI Reports for Increased Revenue DENIED! Mastering Clean Claims and EDI Reports for Increased Revenue No Exactly Denied, but… Managing Your Practice Denials What to know when calling EDI Help Desk Who is looking at your claims? First Level Support - What you Send vs. What they see Mastering Clean Claims and EDI Reports for Increased Revenue Know your Loops and Segments - Loop 2300 Claim Information - Loop 2310A Referring Provider Name - Loop 2310B Rendering Provider Name - Loop 2310C Service Facility - Loop 2330A/B Other Payer Subscriber - Loop 2400 Service Lines Segments different sections of the specific loops with fields seperated by ‘*’ Mastering Clean Claims and EDI Reports for Increased Revenue - Example of an outbound claim by segment Mastering Clean Claims and EDI Reports for Increased Revenue - Maintain the Continuity of a Claim - Fix Claim at the Clearinghouse and Resubmit - Always update the PM with claim Changes - Never Rebill a Claim in the PM - Don’t forget to mark claim as ‘Replacement ’ Mastering Clean Claims and EDI Reports for Increased Revenue Mark Claim as Replacement Mastering Clean Claims and EDI Reports for Increased Revenue Maintaining the Continuity of a Claim Other Valuable Tools - ERA / EOB Manager Denial Management Duplicate Claim Finder Paper EOB to ERA Statement tools Just like Claims Lockbox Services Questions and Answers Thank you for your time Office Management Solutions, Inc. 4917 Ehrlich Road, Suite 204 - Tampa, Florida 33624 813-963-5582 Don’t worry about your computer, thats our job! www.oms-online.com
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