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www.pearcebevill.com
REVENUE CYCLE MANAGEMENT
KAREN LAKE
PEARCE, BEVILL, LEESBURG, MOORE, P.C.
Medical Billing/Revenue Cycle Management is a lot more than just filing claims.
• Scheduling
• Insurance Verification
• Time of Service Collections
• Coding
• Denials and Rejections
• Payment Posting
• Statements
• Credit Balances
REVENUE CYCLE MANAGEMENT—SEEING THE BIG PICTURE
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PATIENT SCHEDULES AN APPOINTMENT
• Name
• Date of Birth (DOB)
• Address
• Phone Number
• Primary Insurance
• Subscriber Information (including DOB)
Necessary data elements to capture when scheduling an appointment:
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INSURANCE VERIFICATION
Best Practice is to verify Insurance 2‐3 days prior to the appointment.
Things to look out for:
• Address Change
• Terminated Coverage
• PreAuth/Referral Requirements
• Patient Financial Responsibility
• Complete Demographic Forms
• Sign Consents
• Receive/Sign HIPAA Notice
• Front and Back copies of Ins Cards
PATIENT CHECK-IN
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THE DOCTOR WILL SEE YOU NOW…The provider uses codes to communicate what services were performed and why. Those codes are used to bill the insurance company.
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CPT CODES
CPT Code – Current Procedural Terminology (CPT) is a medical code set that is used to report medical, surgical, and diagnostic procedures and services. It explains what was done.
E/M – Evaluation and Management coding (to bill the actual visit). This code represents:
• Chief Complaint – Patient complains of…
• History of Present Illness (HPI) – This is a description of the Chief Complaint
• Review of Symptoms (ROS) – Inventory taken from the patient though questions for recognizing symptoms the patient currently has or has had.
• Past, Family, Social History
• Examination
• Medical Decision Making
OTHER CPT CODES• Surgery
• Radiology
• Lab
• HCPC
• Ambulance Services
• Prosthetic Devices • Drugs• infusion additives • ancillary surgical supplies
• ETC
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International Classification of Diseases, Tenth Revision, Clinic Modification is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded.
ICD-10 CODES
• Patient healthcare costs –including both deductibles and out‐of‐pocket maximum payments – have increased by 30% since 2015
• The average deductible is $1820 and the average out‐of‐pocket is $4,400
• 68% of patients failed to fully pay off medical bill balances in 2016, up from 53% in 2015, and 49 percent in 2014. This number is expected to climb to 95% by 2020
PAIN COLLECTIONS
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Now that the patient has seen the provider, the provider has documented the charges, those charges should be reviewed for
• Accident date
• Modifiers
• Correct ranking
Once the charges have been reviewed, they are then submitted to the insurance companies. Remember, the sooner you file, the sooner you get paid.
TIME TO SUBMIT CHARGES!
I’VE FILED THE CLAIM…NOW WHAT?
Once the charges are submitted, you should receive an audit trail from the clearing house.
Definitions:
Clearinghouse – an intermediary that forwards claim and payment information back and forth between the insurance companies and the providers billing software.
Audit Trail – record and reporting of each claim submitted through the insurance company
Acceptance report – the claims accepted by the insurance company
Rejections – A rejected claim has been rejected because of errors. An insurance company might reject a claim because patient or insurance information was incorrect. Once a medical billing specialist amends the errors on a rejected claim they can resubmit it for processing with an insurance company.
You should balance to the claims submitted from your billing system to the clearing house. Rejected claims should be worked immediately – they have not made it to the payor.
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SHOW ME THE MONEY!
PaymentsPayments can come in several different forms
EFT – Electronic Funds TransferMoney is deposited electronically. Most payors prefer or require you to accept this as payment. Is a benefit to the practice because you typically receive the money faster and is generally easier to post via an ERA (Electronic Remittance Advice)
Credit Cards Not only do patients pay via credit cards, but some insurance companies do as well.
ChecksThese can be handled through the practice or a lockbox
A fee schedule is a complete listing of fees used by Insurance Companies to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee‐for‐service basis.
FEE SCHEDULES
# Amounts apply when services performed in a facility setting
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INSURANCE PAYMENTS…
Payments received from an insurance company should always come with an Explanation of Benefits –EOB. This information provides to who and how the money and contractual adjustments should be applied.
Denials are also communicated via the EOB.
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WORKING DENIED CLAIMS• A denied claim is one that has been
determined by an insurance company to be unpayable. Typically, insurance companies explain the reasons in the Explanation of Benefits (EOBs) attached to the claim.
• Claims are often denied because of common billing errors or missing information, but can also be denied based on patient coverage. Denied claims can be appealed and reprocessed in some cases.
• Top Denial Codes
• Prior Authorization/Precertification Required
• No Referral on File
• Services Excluded or Non‐Covered
• Bundled (NCCI edits)
• Not medically necessary
• Request for medical records
• Coordination of Benefits
• Other ins primary
• Missing EOB
• Member has not updated insurer with other ins info
• Bill Liability Carrier
• Timely Filing
REPORTSTotal Charges and Payments – It’s important to review a trend of charges and payments. This helps you to identify potential increase/decrease in cash flow, trends from month to month.
Payor Mix – This is important to monitor because it helps you determine reimbursement, appropriate days in AR
First Pass Rate – this demonstrates how healthy your claim scrubbing/review process is. The goal is to be 95% or above. The longer the claim is delayed getting to the insurance company, the longer it takes you to get paid.
Gross Collections
Date of Service to Date Billed – This is how long it takes the claim to get out the door. This is important to monitor to avoid timely filing denials, delay in payments, etc.
Accounts Receivable Aging
• Run by payor
• Identify problems with Insurance Companies
• Patient Collections
• Credentialing issues
• Lack of follow‐up/working denials/rejections
Days in AR – How long on average it takes you to get paid. What is recommended is determined by your payor mix
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Questions……
Karen LakePearce, Bevill, Leesburg, Moore, P.C.
(205)313‐[email protected]
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