10/14/14
Denial Management
Today’s Discussion
Denial Management
• Iden*fying Denials • Trends & Tips • Strategies for Preven*on • U*lizing Some Tools
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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. 2
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Denial Management
The only thing worse than a denial, is a denial that you don’t know you have..
Denial Management
Denial Management
• Preventable / Avoidable q Timeliness q Expired Creden*aling or Provider Enrollment q Registra*on inaccuracies q Charge “Bundling” q Incorrect Modifiers
• 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
• Unavoidable q Medical Necessity (some) q Addi*onal informa*on requested
Source-‐ HFMA (Health Financial Management Assoc.) 4
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Everyone's GOAL
Denial Management
Get the claim paid and out the door once !!!! 7
Denial Management
What is the average denial rate for a “beder” performing prac*ce? Less than 5%
• 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
Iden=fying
Iden=fying
• The source of denials allows you to educate and/or add resources where needed
• 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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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? 12
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Trends & Strategy • Weekly, monthly, yearly
$25,000
By category / provider By payer By dollar amount By user
0,0 00
$20,000
Pt Not Found Bundled code
$15,000
• Measuring (start with)
No doctor on file
Payment pos*ng process Insurance A/R Specialist Your PMS (Prac*ce Management System) Outside tools and programs Clearinghouse-‐ EOB codes, reports, codes through ERA/835’s Graph out trends/results for everyone-‐ visual impact Contracts loaded and updated
Invalid DX
$10,000
0
$2
,00
,00
• Metric 2-‐ First remiAance response Cme (median days)
$-‐
00
00
$5
$8
0
Feb-‐14
0
$5
00 Jan-‐14
,20
0
$3
0
0
,80
,50
,00
$1
$1
$1
$-‐
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$2
0
$5,000
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. 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.
$5
q q q q q q q
• 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
$2
q q q q
AMA Report Card
Trends & Strategy
Mar-‐14
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Know your numbers from reports, It all *es together
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Medicaid
BCBS
Self Pay
Total A/R by Class $451,736.00 $518,971.00
Total claims and Errors by payer ACCESS MEDICAID 3759 $1,106,804.00 56 $19,759.00
Days in A/R by Financial Class 59
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Payer Name
ADVANTRA ADVANTRA 8052 AETNA 981106
51.2
50
40
30
$392,299.00
20
38.4
46
45.1 31 23.8
19.2
Days in A/R
$808,843.00
19
e
UH C
s Bl ue
ed ica id Se lf Pa y Co m m er cia l
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Claim Errors
Error Charges
0
$0.00
34 $20,827.00
0
$0.00
531 $133,411.33
0
$0.00
AETNA 981107
161 $52,479.67
0
$0.00
ALLIANCE BCBS 14882 ANTHEM BLUE CROSS BLUE SHIELD
622 $330,920.00
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$9,376.00
417 $100,876.00
0
$0.00
$342.00
0
$0.00
BCBS IL 805107 BLUE CROSS NORTH CAROLINA 35
1408 $313,887.94
26
$3,168.88
2899 $955,163.00
10
$3,689.00
BLUE CROSS OF GEORGIA
1542 $52,211.00
0
$0.00
110 $20,100.00
0
$0.00
BLUE CROSS OF MO
M
$1,217,393.00
M ed ica r
Commercial
Ci gn a
0
Ae tn a
Medicare
Total Charges
124 $51,368.25
ANTHEM FED EMP PROGRAM
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Total Claims
2
11609 $ 3,138,390.19
123 $ 35,992.88
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Payer Name
ACCESS MEDICAID 00750 l
AETNA 14079 60054 AETNA 14079 60054 AETNA 14079 60054 BLUE CROSS NORTH CAROLINA 05536 BLUE MDCR HMO 56152 CIGNA 62308
Message
ICD 9 Diagnosis 2 Code must be valid. 2300.HI*02-‐2
Errors
Charges
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$179.00
Medicare en*tlement informa*on is required to determine primary coverage Pending/Pa*ent Requested Informa*on 2 Dependent : En*ty not eligible Acknowledgement/Returned as unprocessable claim 1 Subscriber and subscriber id mismatched Acknowledgement/Returned as unprocessable claim 1 Member ID must be valid.
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INVALID SUBSCRIBER 4 Pa*ent : Pa*ent eligibility not found with en*ty Acknowledgement/Rejected for Invalid Informa*on 7
MEDCOST BENEFIT 25307 56162 Group Number required on claims
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$836.00 $179.00 $462.00 $8,175.00 $1,680.00 $2,016.00
Denials by Payer
Medcost-‐ Group Number required on claim
Cigna-‐ PaCent eligibility not found
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Denial Management Effec*ve Denial Management Programs/Systems Includes:
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§ 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
BCBS NC -‐ Member ID Must be valid
7 26 4
MDCR HMO-‐ Invalid Subscriber informaCon
$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
$393.00
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$ 16,992.00 22
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Healthcare Financial Management Association (HFMA) Recommended Key Performance Indicators (KPI)
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: 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: 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
• 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 q q q
Billing manager Registra*on manager Coding Manager 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 26
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Trends & Strategy
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 28
Collabora=on
• 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
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ü Refer to guidelines from coding rules, government regula*ons, court cases pertaining to your appeal. Build your case. 29
Each office should be collabora*ng with insurance companies. The rules are constantly updated and change Review contracts at a minimum yearly Review for underpayments and meet with them Discuss denial rates and issues Make sure you keep a good updated contact on file 30
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Tips to think on
Collabora=on q q q q q q
The Right Team in Place Highly experienced team in correct roles Cer*fied coders and billers in your specialty / special*es Audi*ng team or ability to audit Staff that is fluent in top carriers Outside consultants Training needs 31
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 32
• 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 33
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Tips to think on
Summary
People
• 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
• 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!!
Process Tools 34
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10/14/14
Thank you
Shelly Bangert
[email protected]
Commit and invest to denial management to opCmize what you deserve.
314-821-8055
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x5205
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