managed care billing submission.pdfaverage costs of electronic transactions . page 3 . electronic...

Managed Care Billing The Claim Submission And Adjudication Process How does it impact you?

Bonadio Receivable Solutions, LLC has been a division of The Bonadio Group

since 2008

The Bonadio Group is the only independent accounting firm with a division that specializes in

accounts receivable management

Average Costs of Electronic Transactions

Electronic Transaction Savings Opportunities for Physician Practices, Milliman USA

HIPAA Standard Transactions

Paper Claim Electronic Claim

Claims * $6.63 $2.90

Eligibility Verification $3.70 $0.74

Preauthorization $10.78 $2.07

Payment Posting $2.96 $1.48

Claim Status $3.70 $0.37

*Includes the cost of administrative overhead to produce, submit and process, as well as a 12-month amortization of electronic set-up costs

HIPAA Standard Transactions

HIPAA Standard Transactions ASC X 12 Identifier Transaction

270 / 271 Eligibility Inquiry / Response

276 / 277 Claim status inquiry / Response

835 Payment and Remittance Advice

837 P and I Claim (P = professional, I = institutional)

1. Receive claim in administrative system

2. Determine patients’ eligibility/benefit level and validate provider data

3. Review for prior authorization

4. Apply claim edits

5. Apply pricing claim edits

6. Complete adjudication

7. Generate EOB/RA

8. Send payment

Typical Payer Workflow

1. Receive claim in administrative system Electronic claims – Data extraction/verification occurs, accept/”receive”

claim and send acknowledgement report

Paper claims – date stamp and scans into document management system that assigns a claim routing number. May then route to specific claims processor who manually enters it into the administrative system. Data extraction/verification then occurs.

Many payers now use software that combines scanning, image processing and recognition technologies (data capture workflow) which reads/interprets the claims data and analyzes, corrects and validates the data which reduces the need for manual error corrections.


• Paper

• Electronic claims via a direct connection between billing system and payer

• Electronic claims via a clearinghouse

• Payer offers a direct data entry (DDE) methodology Medicare – FISS (OmniPro)

Medicaid – ePACES

Wellcare – DDE Portal

Others?

Claims Submission Methodologies

• Vendor that serves as a middleman between facility and payers for claims submission

• Rather than facility sending electronic claims to each payer as a separate transmission the clearinghouse is a central portal to submit transmissions to multiple payers

• Clearinghouse forwards each claim to the appropriate payer

• Often provides other valuable billing-related services

What Is a Clearinghouse?

• Payers require test claim transmissions before they issue you a submitter number – clearinghouse handles this

• Claims submission software (may be the facility depending on billing system) must stay up to date and adjust when a payer changes rules – clearinghouse handles this

• If a payer doesn’t accept electronic claims a clearinghouse converts the electronic file to paper claims and forwards them

• Should run claim edits to verify that all fields are completed – helps ensure a “clean claim” 10-digit NPI, valid ICD-9, valid CPT, valid date formats, etc.

• Quickly generates report of errors for timely resubmission

Benefits Of A Clearinghouse

• Electronic eligibility verification

• Claim status checks

• Secondary payer billing services

• Patient statement printing and mailing

• Patient payment portal

Benefits Of A Clearinghouse (continued)

• Cost versus benefit analysis

• Evaluate clearinghouse to ensure that it supports the majority of the payers you bill

• Can it accommodate the output from your billing system?

• Can it submit claims in the required format – professional, institutional, proprietary modifications?

• If you have an old system that can’t create a HIPAA 837 (electronic claim) the clearinghouse must be able to accept a print image (electronic flat file format) Requires billing system to generate a claims submission batch

file and transmit the print image of its claims - This is inefficient – get a new system

Selecting a Clearinghouse

2. Determine patients’ eligibility/benefit level and valid provider data Determines if patient is a “match” in

their administrative system

Determines if patient is eligible to receive benefits for the date of service

- If eligible, determines whether services are covered services according to the patient’s benefit plan

Verify NPI, tax ID, participating provider, etc.


• MLTC for dual eligible if in mandatory county & CB-LTC for >120 days

• Current recipients of Medicaid CB-LTC Services (Personal Care, CHHA, Adult Day Care, Private Nursing, Lombardi) Transition to MLTC through mandatory enrollment process

• Receive series of notices

- Announcement letter

• 60-day choice letter (NY Medicaid CHOICE aka Maximus) and Managed Care Guide

Choose or be auto enrolled

• Enroll with MLTC or Medicaid Advantage Plus or PACE

- If Medicaid Advantage Plus or PACE – must enroll directly with plan

• New applicants to CB-LTC Services If no Medicaid, apply at local DSS and when approved enroll in MLTC

Enrollment – CB-LTC

• There are no Medicaid pending services in MLTC CHHA – possible if they are willing

• Can be dis-enrolled if sabotage care, not cooperate, not pay spend-down, other reasons

• Note about delivery of care: 90-day Transition Period – ALL care must remain the same (not apply

when switch plans) • After Transition Period – MLTC will sent client new Plan of Care, effective

no earlier than day 91

• Client may appeal by requesting an Internal Appeal with the MLTC

• State Fair Hearing option only when lose Internal Appeal

Enrollment – CB-LTC (continued)

• Pending Federal Approval (postponed once already) Seniors and People with Disabilities who have Medicare have to enroll

in a MLTC to get nursing home care

Those with Medicaid only with no Medicare have to enroll in a “mainstream” Medicaid Managed Care plan to get nursing home care

June 2014 – NYC, Long Island, Westchester

December 2014 – Rest of state

• ALL adult Medicaid recipients age 21+ who become permanent NH residents (after June/December 2014) required to enroll in Managed Care Plan MLTC for dual eligible

Mainstream Medicaid Managed Care for those w/o Medicare

Enrollment – Nursing Home

• New Admission w/o MLTC or Mainstream Medicaid Managed Care Plan Apply for institutional Medicaid, after approved, choose MLTC within 60 days

If not select, will be assigned in a plan nursing home contracts with

NY Medicaid CHOICE assists with education, selection and enrollment

• New Admission with Mainstream Medicaid Managed Care Plan Must enter a nursing home that participates in plan

• New temporary Admission with MLTC – can go to anywhere, plan can’t restrict Probably will be under Medicare coverage and plan will pay coinsurance if no

Medigap coverage

• Current resident with Medicaid – grandfathered but will have eventual voluntary enrollment in MLTC

Enrollment – Nursing Home (continued)

• NY Medicaid CHOICE assists with education, selection and enrollment for MLTC plans

• NY Medicaid CHOICE does NOT assist with Medicaid Advantage Plan or PACE enrollment

• 2 transactions: 1st Medicare Advantage and then a connected Medicaid plan

• Client can switch MLTC plans at any time in the month Change effective date: 1st of next month or the following month

Enrollment

• How will you track initial enrollment?

• How will you track dis-enrollments and changes? Who?

Schedule?

Develop P&P

Failure to track will result in the in-ability to bill correct payer

Enrollment (continued)

• Medicare, Medicare Advantage Plan, Medicare Part D, Supplemental Plans, Medigap, Commercial Plans, Medicaid, Medicaid Managed Care, Medicaid Long Term Care

Example Scenarios: • Dual Eligible with original Medicare, Medicare Part D, Medigap and

MLTC will have 5 insurance cards Medicare, Medicare Part D, Medigap, Medicaid and MLTC

• Dual Eligible with Medicare Advantage and MLTC will have 3 cards Medicare Advantage, Medicaid, MLTC

• Dual eligible with Medicaid Advantage Plus will have one card

Eligibility/Insurance Verification

• ePACES Carefully look at eligibility codes (institutional Medicaid, spend down, etc.)

Follow up as needed

• Medicare Common Working File Need to check for each patient – not just Medicare admissions

CWF isn’t always correct – follow up on inconsistencies

• Clearinghouse

• Contact/verify each insurance

• Document every call/contact in your billing system

• Verification completed before admission

Eligibility/Insurance Verification (cont’d)

• Contracts will likely require credentialing MMCP will credential NH but will “minimize additional NH

requirements”

Is CAQH UPD (Council for Affordable Quality Healthcare Universal Provider Datasource) utilized by payer?

What types of providers will have to be credentialed? • MD, NP/PA, CNM, LCSW, LMHC, LMFT, PT/OT/SP, AuD

Will billing office complete forms and monitor credentialing progress?

• Time consuming

• Already overworked billing staff

Participating Providers

Credentialing

Payer and Plan Credentialing (on-line Provider Manuals April 2014)

Fidelis Care (All Plans) CAQH + other required documents MD/DO, NP, PA, PT, OT, CNM

WellCare CAQH not indicated MD/DO, Allied Health Professionals (AHP), home health agencies, SNF, other ancillary facilities/health care delivery organizations. AHP includes but not limited to (NP, PA, CNM, LCSW, LMHC, LMFT, PT, OT, SP, Audiologist)

VNSNY CHOICE (All Plans) CAQH not indicated MD/DO and all other health professionals and facilities who are permitted to practice independently under State law

3. Review for prior authorization Was prior authorization required?

Is prior authorization number on claim?

Validate prior authorization number


Prior-Authorization • Can be very time consuming

• ALWAYS verify if an authorization is needed and for what services

• Payer requirements change and payers often require prior-auths for some plans but not others

• Fax, phone, on-line portal, specific form?

• Document contact and telephone numbers for future authorization extensions

• Document every call/contact

• Coordinate between billing and prior auth staff When/how/does billing get authorization number?

• Don’t just write off claims denied for no authorization Attempt to obtain a retroactive authorization

Prior Authorization (continued)

Payer and Plan Prior Authorization (on-line Provider Manuals April 2014)

Fidelis Care Pre-authorization obtained by Quality Health Care Management (QHCM) Department. Request should be sent at least 5 days before DOS.

Fidelis Care at Home (FCAH) All non-emergency services must be authorized by Nurse Care Manager

Fidelis Medicare Advantage (4 plans offered)

No prior-authorization. Out of network services have higher out of pocket cost.

Fidelis Medicare Advantage – Dual Advantage Plans

No prior-authorization. All care (excluding emergent/urgent) must be in-network.

Fidelis Medicaid Advantage Plus All services must be coordinated by Nurse Care Manager

WellCare Required for elective and non-urgent services

Prior Authorization (continued)

Payer and Plan Prior Authorization (on-line Provider Manuals April 2014)

VNSNY CHOICE Medicare Advantage All elective admissions, outpatient surgery outpatient treatment/testing if done out of network. Specific list for in-network.

VNSNY CHOICE SelectHealth Specific list available

VNSNY CHOICE MLTC

Adult Day Services, Audiology, Chore and Housekeeping, Home Care, Home Delivered Meals, Home Safety Modification, Med/Surg Supplies/Equip, Nursing Home Care, Nutritional Supplements, OP Rehab, PERS, Podiatry (if non-Medicare covered), Transportation

• Ongoing Authorizations When updated?

What forms are used?

What triggers a reassessment?

Is there a portal or other electronic method used?

What department oversees the authorizations?

Does/when/how billing department get/need/use the authorization?

Ongoing Authorization Considerations

4. Apply claim edits Determines whether specific codes and combinations of codes

are eligible for payment


4. Apply claim edits (continued) Payers use CPT, NCCI (National Correct Coding Initiative) and CMS

payment rules

Other common proprietary claim edits • Correct claim format – UB04 or 1500

• Billed contracted rate

• Specific revenue codes and modifiers used

• Missing condition/value/occurrence/CPT

• Itemized or room/board line

• Non-covered services

• Timely filing

• Duplicate claim

• Missing NPI, member ID

• Incorrect payer


• Common claim edits (CPT, NCCI, CMS, etc.) Medicare Billing Error Rate: 11% = $34.3 Billion

• Use editing software

• Build into your billing system

• Possible to achieve denial rates less than 1% (benchmark = 3%)

Claims editing software • Substantially lowers administrative costs associated with billing

• Improved compliance with reimbursement guidelines

• Improved revenue cycle from a reduction in inaccurate claims and submissions

• Reduced audit risks

• Rapid return on investment

Claim Edits

• Common claim edits (CPT, NCCI, CMS, etc.) (cont’d) Clearinghouse editing

Claim Edits

• Timely Filing Considerations Know timely filing requirements

Easiest way to file timely - Bill Monthly! • Claims should be sent by the 15th of the

following month

Keep claims alive through follow up • Document every submission, mailing, phone call, letter, etc.

in the billing system

• Make sure claim is received – fax, registered mail, deliver in person, clearinghouse acknowledgement reports

• Appeal before write off if claim denied for timely filing and claim has been kept alive

Timely Filing

Timely Filing (continued)

Payer and Plan Timely Filing (on-line Provider Manuals April 2014)

Fidelis Care at Home (FCAH) 90 days

Fidelis Medicare Advantage (4 plans offered plus 2 Fidelis Dual Advantage plans)

Not indicated

Fidelis Medicaid Advantage Plus 90 days

WellCare 180 days, 90 days after primary payment when WellCare is secondary payer

VNSNY CHOICE Per contract

VNSNY CHOICE MLTC – Nursing Home 90 days after end of month services rendered

VNSNY CHOICE MLTC – Transportation

Not indicated

5. Apply pricing claim edits Paper claims:

• Claims processor manually enters each line into its administrative system and in some cases the claims processor manually reviews the line items during data entry to make the non-fee determinations (covered services, down-coded, bundled)

Electronic claims: • System adjudicates using complex series of claim edits that

determines fee schedule, allowed amount, contracted rate and then adjusts rate to reflect additional adjustments


Payment Accuracy

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Aetna Anthem Cigna HCSC Humana Regence UHC Medicare

96.69%

91.64%

97.46%

92.60%

97.92%

85.21%

98.13% 99.68%

Contracted Fee Schedule Match Rate 2013 National Health Insurer Report Card (NHIRC)

Payment Accuracy (continued) • Underpayment concerns 2.5% error rate on $3M =

$75,000

Know what you should be paid

Establish process to ensure payments are correct • Store rate in billing system and

perform automatic cross checks

• Review payment exception reports and follow up on underpaid claims

• Review how each staff handles - w/o as contractual?

6. Complete adjudication Determines the level at which the claim will be paid

Issue denial

Issue payment


How To Handle Denials • Know each payer’s appeal process Time limits

Specific forms

• Internal Process Who gathers necessary documents?

Who submits?

Who monitors progress?

Report final decision to interested parties?

• What can be learned from denials?

Claim Appeals

Payer and Plan Appeals/Disputes/Reconsiderations (on-line Provide Manuals April 2014)

Fidelis Care Medical necessity appeal - Submit within 60 days Administrative denial reconsideration (timely filing, co-insurance, eligibility, lacking pre-auth, other errors on claim, underpayments) – Submit within 60 days Timely filing – penalty of up to 25% may be imposed

WellCare Timely filing, incidental procedures, bundling, unlisted procedure codes, non-covered, etc. – Submit within 6 years of the date of denial

VNSNY CHOICE – MCare and MCaid Advantage Plans

Disputes resulting from claim adjustments or denials: Standard reconsideration request - denial of payment or medical necessity – per contract

VNSNY CHOICE – Medicaid MLTC

Disputes resulting from claim adjustments or denials: Standard reconsideration request – denial of payment or medical necessity - per contract Request for denial of payment due to claim coding – Submit within 90 days Request for denial of payment due to no authorization – Submit within 90 days

Typical Payer Workflow 6. Complete adjudication (continued) Approves payment

• Queued into a payment register or “to pay” system

• Places claim in the cycle for the next check run

• During check run payer cuts check and mails or processes EFT

• With electronic remittances: processes the 835 EOB/RA and sends it to facility or clearinghouse

• Paper or electronic EOB/RA may or may not accompany paper check or EFT

7. Generate EOB/RA (explanation of benefits/remittance advice) Sends a paper or an electronic 835 to you and the patient that

details the allowed amount, contracted adjustment amount, the paid amount and the patient responsibility


• Use the information to process and post payments and adjustments to billing system Make sure to reconcile against payment

• Evaluate EOB/RA for accuracy to detect processing errors (inappropriate CPT changes, inaccurate reimbursement rates, quantity of services not recognized, etc.)

• Standard remittance advice remark codes? Know how to handle each code

Review EOB/RA

8. Send Payment Payment transmission or EFT

• Review payment and the remittance information for consistency with the information on the EOB/RA as well as the information from the original claim submitted

• EOB/RA should show reasons (remark codes) for partial payments

• Denied claims will appear as a zero remittance EOB/RA


• Communication Tips Training provided?

• Billing, Prior Authorization, etc.

Online access to provider and billing manuals? • Billing department needs contract, provider

and billing manuals that are easily accessible

• Develop a summary page of key points for each contract and keep updated

Ask questions • Don’t assume you know the answers

• Don’t assume payer always knows the right answer either - Follow up on inconsistencies

Communication With Payer

• Communication Tips (continued) Provider representatives:

• Make sure you are assigned a provider representative

• Develop a partnership with each payer via their representative

• Request and hold regular meetings with representatives

• Realize that representatives would much rather help up front than deal with you when you are frustrated

Communication With Payer

• Fidelis Medicare/Medicaid/FHP/CHP/MLTC (numerous versions/dates)

• Section 22A – Fidelis Medicare Advantage (V11-1/1/11)

• Section 22B – Fidelis Care At Home (V13.0-12/9/13)

• Section 22c – Medicaid Advantage Plus (V13.0-12/9/13)

• WellCare (June 17, 2013)

• VNSNY Choice (12/27/13)

Many sections broken into sub-sections for • VNSNY CHOICE Medicare Advantage Plans

• VNSNY CHOICE Select Health

• VNSNY CHOICE Managed Long Term Care Plan

Provider Manuals

Andrea Hagen, Manager Bonadio Receivable Solutions, LLC 171 Sully’s Trail Pittsford, NY 14534 Office (585) 249-2814 Cell (585) 967-3716 [email protected] www.bonadio.com

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