today’s(discussion((( denial(management denial...
TRANSCRIPT
10/14/14
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Denial Management
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Today’s Discussion
• Iden*fying Denials • Trends & Tips • Strategies for Preven*on
• U*lizing Some Tools
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Denial Management
Delivery of Healthcare must be viewed as a business these
days. ü If you are not profitable you can’t keep
doors opened for care. ü A strong denial management workflow and
structure will help keep them opened. 3
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Denial Management The only thing worse than a denial, is a denial that you don’t know you have..
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Denial Management
• Constantly changing informa*on -‐ Pa*ent & Payers
• Recovery & cost -‐ 90% of denials are preventable / avoidable -‐ 67% of those are recoverable -‐ That leaves 33% never recovered -‐ Average cost to re-‐work a claim-‐ $15.00-‐$25.00 per
claim Source-‐ HFMA (Health Financial Management Assoc.)
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Denial Management • Preventable / Avoidable
q Timeliness q Expired Creden*aling or Provider Enrollment q Registra*on inaccuracies q Charge “Bundling” q Incorrect Modifiers
• Unavoidable q Medical Necessity (some) q Addi*onal informa*on requested
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Everyone's GOAL
Get the claim paid and out the door
once !!!!
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Denial Management
What is the average denial rate for a “beder” performing prac*ce?
Less than 5%
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Denial Management
• Average to normal office: 8% -‐ 15%
• Big issues: Over 15% plus
*determining factors can affect these percentages
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Annual Prac*ce Review
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Iden=fying
• What are your most common denials? • How do you track denials? • Upfront or backend errors? • Does staff understand denials?
WHO, WHAT, WHERE, WHEN & WHY
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Iden=fying • The source of denials allows you to educate and/or add resources where needed
q Registra*on inaccuracies q Eligibility q Referrals / pre-‐auths missing q Charge entry errors q Coding and Modifiers q Creden*aling q Interfaces q PMS set-‐up errors q Timeliness q What is root cause?
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Trends & Strategy • Weekly, monthly, yearly
q By category / provider q By payer q By dollar amount q By user
• Measuring (start with) q Payment pos*ng process q Insurance A/R Specialist q Your PMS (Prac*ce Management System) q Outside tools and programs q Clearinghouse-‐ EOB codes, reports, codes through ERA/835’s q Graph out trends/results for everyone-‐ visual impact q Contracts loaded and updated
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Trends & Strategy
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$5,000
$1,000
$2,200
$300
$50
$-‐
$20,000
$1,800 $500
$1,500
$2,000
$800
$-‐
$5,000
$10,000
$15,000
$20,000
$25,000
Jan-‐14 Feb-‐14 Mar-‐14
Pt Not Found
Bundled code
No doctor on file
Invalid DX
AMA Report Card • The next slides are results from the Na*onal Health
Insurer Report Card (NHIRC) years 2008-‐2013 that address denials. www.ama-‐assn.org/go/reportcard
• Metric 11 -‐ Percentage of claim lines denied Descrip*on: What percentage of claim lines submided are denied by the payer for reasons other than a claim edit? A denial is defined as: allowed amount equal to the billed charge and the payment equals $0.
• Metric 2-‐ First remiAance response Cme (median days) Descrip*on: What is the median *me period in days between the date the physician claim was received by the payer and the date the payer produced the first ERA? If a payer did not provide the Payer Claim Received Date, the most current date of service that was reported on the claim was used to perform the calcula*on.
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Know your numbers from
reports,
It all *es together 18
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Total A/R by Class
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$1,217,393.00
$808,843.00
$392,299.00
$518,971.00
$451,736.00
Commercial
Medicare
Self Pay
BCBS
Medicaid
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0
10
20
30
40
50
60
Aetna
Blues
Cigna
Medicare
UHC
Medicaid
Self Pay
Comm
ercial
38.4
19.2
45.1
31
23.8
51.2
59
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Days in A/R by Financial Class
Days in A/R
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Total claims and Errors by payer
Payer Name Total Claims Total Charges Claim Errors Error Charges
ACCESS MEDICAID 3759 $1,106,804.00 56 $19,759.00 ADVANTRA 124 $51,368.25 0 $0.00 ADVANTRA 8052 34 $20,827.00 0 $0.00 AETNA 981106 531 $133,411.33 0 $0.00 AETNA 981107 161 $52,479.67 0 $0.00 ALLIANCE BCBS 14882 622 $330,920.00 31 $9,376.00 ANTHEM BLUE CROSS BLUE SHIELD 417 $100,876.00 0 $0.00 ANTHEM FED EMP PROGRAM 2 $342.00 0 $0.00 BCBS IL 805107 1408 $313,887.94 26 $3,168.88 BLUE CROSS NORTH CAROLINA 35 2899 $955,163.00 10 $3,689.00 BLUE CROSS OF GEORGIA 1542 $52,211.00 0 $0.00 BLUE CROSS OF MO 110 $20,100.00 0 $0.00
11609 $ 3,138,390.19 123 $ 35,992.88
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Payer Name Message Errors Charges
ACCESS MEDICAID 00750 ICD 9 Diagnosis 2 Code must be valid. 2300.HI*02-‐2 1 $179.00
AETNA 14079 60054
Medicare en*tlement informa*on is required to determine primary coverage Pending/Pa*ent Requested Informa*on 2 $836.00
AETNA 14079 60054
Dependent : En*ty not eligible Acknowledgement/Returned as unprocessable claim 1 $179.00
AETNA 14079 60054
Subscriber and subscriber id mismatched Acknowledgement/Returned as unprocessable claim 1 $462.00
BLUE CROSS NORTH CAROLINA 05536 Member ID must be valid. 26 $8,175.00
BLUE MDCR HMO 56152 INVALID SUBSCRIBER 4 $1,680.00
CIGNA 62308
Pa*ent : Pa*ent eligibility not found with en*ty Acknowledgement/Rejected for Invalid Informa*on 7 $2,016.00
MEDCOST BENEFIT 25307 56162 Group Number required on claims 11 $2,679.00
NC MEDICARE PART B 11502
Insured or Subscriber : En*ty's contract/member number Acknowledgement/Rejected for Invalid Informa*on 1 $393.00
TRICARE FOR LIFE TDDIR INVALID SUBSCRIBER 1 $393.00
55 $ 16,992.00
Denials by Payer
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1 2 1 1
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4
7
11
1 1
BCBS NC -‐ Member ID Must be valid
Medcost-‐ Group Number required on claim
Cigna-‐ PaCent eligibility not found
MDCR HMO-‐ Invalid Subscriber informaCon
Denial Management Effec*ve Denial Management Programs/Systems Includes:
§ Distribu*on of sta*s*cs across payers, departments, providers, registra*on points, CPT codes, ICD9 (I10)
§ Age of denials in rela*on to claim expira*on, refilling deadlines
§ Analy*cs of comparing periods, current status, pending ac*ons, etc.
§ Can ID under and over payments § Route work automa*cally to users in customizable tasks § Dashboard, can set reminders § Reimbursement analy*cs compared by payers § Appeal system
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Healthcare Financial Management Association (HFMA) Recommended Key Performance Indicators (KPI)
• Measure: Denial Rate – Zero Pay
• Purpose: Trending indicator of % claims not paid
• Value: Indicates provider’s ability to comply with payer requirements and payer’s ability to accurately pay the claim
• EquaCon: N: Number of zero paid claims denied D: Number of total claims remided
• Measure: Denial Rate – ParCal Pay
• Purpose: Trending indicator of % claims par*ally paid
• Value: Indicates provider’s ability to comply with payer requirements and payer’s ability to accurately pay the claim
• EquaCon: N: Number of par*ally paid claims denied D: Number of total claims remided
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Healthcare Financial Management Association (HFMA) Recommended Key Performance Indicators (KPI)
• Measure: Denials Overturned by Appeal
• Purpose: Trending indicator of hospital’s success in managing the appeal process
• Value: Indicates opportuni*es for payer and provider process improvement and improves cash flow
• EquaCon: N: Number of appealed claims paid D: Total number of claims appealed and finalized or close
• Measure: Aged A/R as a Percent of Billed A/R by Payer Group
• Purpose: Trending indicator of receivable collectability by payer group
• Value: Indicates revenue cycle’s ability to liquidate A/R by payer group
• EquaCon: N: Billed payer group by aging (0-‐30, >30, >60, >90, >120 days) D: Total billed A/R by payer group
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Trends & Strategy • Weekly / Bi-‐ weekly mee*ngs with the right
people (a commidee) q Billing manager q Registra*on manager q Coding Manager q Client Rep (billing services)
• Goals need to be set q Clean claim-‐paid rates q Resolu*on of exis*ng denied accounts q Minimizing write-‐offs due to uncollected denials
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Trends & Strategy • Wriden Policy and Procedure
q Work electronic and paper denials q Develop appeal leder templates for most common
denial reasons-‐ Pre-‐populated q If you can assign different types of appeals to different
staff and cross train i.e. Urgent/level 1/level 2 q Know details and contacts to escalate denials if
necessary-‐ *State Insurance Commissioner/Adorney General
q Use your denial data to compare payer by payer for your benefit
q Registra*on steps and requirements
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Trends & Strategy • Appeals
q Talk with team and get top appeals done and work on pre-‐populated leders to save *me. q Procedure code is being bundled & it is not suppose to be
bundled per the CCI edits q When insurance is requiring more documenta*on Lev I and then
have a Lev II q Materials not covered q Modifiers q Procedure being incidental to the related procedure
ü Refer to guidelines from coding rules, government regula*ons, court cases pertaining to your appeal. Build your case.
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Collabora=on Each office should be collabora*ng with
insurance companies.
q The rules are constantly updated and change
q Review contracts at a minimum yearly q Review for underpayments and meet with
them q Discuss denial rates and issues q Make sure you keep a good updated
contact on file 30
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Collabora=on The Right Team in Place
q Highly experienced team in correct roles q Cer*fied coders and billers in your
specialty / special*es q Audi*ng team or ability to audit q Staff that is fluent in top carriers q Outside consultants q Training needs
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Tips to think on
• Full understanding of what payer really wants
• Understanding and knowing root cause • Do you have a senior denial team? • Training of staff, pa*ents, physicians • Understand if denial can be corrected and resubmided or does it require an appeal?
• Updates shared with staff • Audits of staff and process
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Tips to think on
• Goals set / best prac*ces • Wriden policies for handling denial management
• Follow-‐up • Capturing all remidance informa*on • Obtain access to other systems (hospital to pull in needed informa*on
• Iden*fying and managing underpayments • Review payer contracts
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Tips to think on • Details of what can be wrote off • Know payer guidelines • Automate what you can-‐ directly to the next step in workflow without requiring review
• Create report cards and do something with them
• Consider having a 3rd party consultant in to review your process
• Talk with peers 34
People
Process
Tools 35
Summary
• Iden*fying and managing denials-‐ measuring, tracking, training, follow-‐up
• Understanding and sharing trends and root cause-‐ Collabora*on!!
• Minimizing denials to maximize reimbursements
• U*lizing tools, technology, peers and others • Be Proac*ve!!
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Commit and invest to denial
management to opCmize what you
deserve.
Thank you Shelly Bangert
314-821-8055 x5205
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