keeping ar squeaky clean aapc 10.19.16
TRANSCRIPT
KEEPING AR SQUEAKY CLEAN
AAPC Des Plaines Local Chapter 10/19/16Vanessa Moldovan, CPC, CPPM
Chapter President
Increase
reimbursement
Identify areas of
improvement
So who says it’s a mess anyway? MA (Medical Group Management Assoc.)
AR Benchmarks0-30 days 31-60 days 61-90 days 91-120 days over 120 days60% 13% 7% 4% 16%KPIs (Key Performance Indicators)
Days in AR between 30-45 daysThe average number of days to collect payment on services that have been rendered.Total current AR/average daily charges
% of AR over 90 days between 10-12%Usually measured by entry date
% of collections (payments/charges-adjustments) Financial trending
In order to clean up the mess, you
must know what’s all mixed
up in it.
Why is it important for
everyone involved in the
Revenue Cycle be knowledgeable of
all the working parts?
Credentialing/Contracting
AppointmentType of insuranceAuthorizations
Visit/EncounterMedical NoteSurgical Note
Checkout/patient payment
Charge Entry/CodingManualElectronic
Front System EditsClaims Submission
PaperElectronic
Back Edits
Payer Rejections (sometimes included in AR)
Clearinghouse rejections (sometimes included in AR)
System Edits
Payment posting
Manual
Electronic
Patient AR Follow-upStatementsPhone calls
Insurance AR Follow-upDenialsLack of response
Along with Revenue Cycle…..
Payer Mix
Workflow
The Big PictureIdentify the AR
Aging reports by aging datePlan
Prioritize (date, balance, payer)
Don’t ignore credits Set realistic benchmarks and
timelines
Manage Distribute the work (reports or
work queues) By payer, client, specialty, etc.
Monitor (productivity, effectiveness, quality)
Prevent Clog the holes that are causing the
leaks.
Tools, tips and resources to make clean up more effective
and efficient
ANSI Reason Codes/Remark Codeswww.wpc-edi.com
CO, PR, OA, PICategorized:
coding, eligibility, registration, billing, credentialing, plan limitations,
preventable, non-preventablepatient, provider or billing responsibility
Medicaid uses different codes
List of important practice/provider info
PTANNPITINContact infoEffective dates with payersW-9s
List of payer infoPhone and fax numbersProvider portalAppeals addressAppeals formTimely filing (initial, appeal, OON and IN)Specific guidelines
Clearinghouse and/or payer responses
Original EOBs and/or charges
Medical RecordsOnline claim status and eligibility and appeals
Explanation of benefitsElectronic corrected claimElectronic 2ndary claim
Policies/ProcessesClient/provider requestsEscalationsCredentialing issuesPatient responsibilityChanges to codingKnow who does what (coding,
registration, authorizations, etc.)
Time to dive into all of that AR
No response received
(sometimes referred to as ‘pending
AR’)
Claim was rejected at the clearinghouse and the error was not corrected.
The charge(s) are in an edit queue within the PM system.The member is ineligible.The Subscriber ID and/or name is incorrect.The claim is being sent to the incorrect payer, examples:
Claims address: UHC, PHCS, UMR, etc.Blue Cross IPAMedicare (Railroad or Jurisdiction)Managed care plans
The payer’s mailing address and/or electronic ID are incorrect.
The provider is not credentialed/contracted with the payer.
Other reasons for no response:Claim not on file
Set payers up on electronic submission
Send paper claims through clearinghouse
Payment sent, but not posted.May have been posted
incorrectlySet payers up on EFT and ERA
Denials
(often there are entire departments assigned to this)
Confirm charge entryChargesDiagnosesProvidersPlace of service
Verify registrationDemographicsInsurance
Know the payer guidelines for corrections:Corrected claim, reconsideration, redetermination, appeal (keep a copy until resolved)
Submission guidelines: payer form or letter templatemail, fax, online
Timely limits
AAPC Coder
Fee SchedulesMUEGlobal DaysCMS 1500 Real Time ScrubberSurvival Guides
Practical Application
Let’s review some top denials
Third Party Liability (TPL)Workman’s Compensation:
Submit claims with notes, claim number, DOISlow payerIf in litigation in Illinois, check status Illinois Work Comp
website www.iwcc.il.gov. Personal Injury and Auto Accident
These are often in litigation for many years and the patient’s personal injury policies are quickly exhausted.
Obtain your client’s policy on whether they want to be notified of PI cases so that they can file a lien.
Account/Claim Notes
PurposeFor those who follow behind youFor your future follow-upLegality
ContentWhat is the problem?What research was done?What steps were taken?
Identify the AR Aging reports by aging date
Plan Prioritize (date, balance,
payer) Don’t ignore credits Set realistic benchmarks and
timelines
Manage Distribute the work (reports or
work queues) By payer, client, specialty, etc.
Monitor (productivity, effectiveness, quality)
Prevent Clog the holes that are causing the
leaks.