Terry's 4th of July Sparkling Spectacular of Tools and Techniques for Managing and Preventing Denials

When a claim is denied, it is important to understand the denial reasoning in order to effectively manage current claims and prevent future denials. It is crucial to proactively identify the root causes of your denials to prevent labor intensive analysis, research and resubmission.

Start by asking yourself these four questions:

1. What is causing our claim denials?
2. When do these mistakes occur in our practice?
3. Where is our practice most at risk?
4. How can we prevent claim denials from happening in our practice and manage them when they emerge?

Here are some of the most common reasons for claim denials and ways to avoid them:

1. Invalid insurance form - Prior to each patient appointment, verify insurance eligibility to be sure the patient is actually enrolled in the plan at the time of service. Upon check-in, obtain a photocopy of the patient's insurance card and accurately enter the information into the practice management system.

2. Invalid patient demographic information - Register patient prior to the visit and ensure that all demographic information is completed by the patient of or patient representative and correctly entered into the practice management system.
   

3. Provider information incorrect/invalid - It is essential that the provider's credentialing department confirms that all providers within the organization are credentialed and enrolled as a participating provider with the payer.
   

4. Invalid diagnosis/CPT code - Keep your charge tickets current with the latest updates of ICD-9/CPT codes.
   

   
   
   • Review medical records to verify the validity of diagnosis/procedure code.
   
   
   • Use current ICD-9/CPT references and resources.
   
   
   • Utilize the latest updates of automated coding software and/or a coding editor.
   
   

   
   
5. Referring physician information invalid/missing - Certain services, such as diagnostic or clinical laboratory test, require the submission of the ordering or referring physician's name and NPI number in items 17 and 17b of the 1500 HCFA claim form.
   

6. Referral/Authorization required - Strive to maintain up to date information on all policies and procedures related to referrals and authorizations for each payer.
   

   
   
   • Follow payer guidelines when submitting referrals/authorizations (via telephone, fax, submit attachment online, attach to paper claim or electronic data transaction) and enter the acquired information into the practice management system.

   
   
7. Duplicates - If you are signed up for automatic crossover for secondary claims, do not submit the claim manually or electronically since these claims are automatically sent to the secondary payer from the primary payer.
   

   
   
   • Research the claim to determine the details of the denial (true duplicate, maximum frequency, missing modifier, etc.).
   
   
   • Review the practice management system to verify duplicate entries of a service/procedure.
   
   
   • Pull data entry batches and examine encounter sheets to verify if an error was made by marking the service/procedure multiple times.
   
   
   • Review medical record, and if appropriate, add valid modifier to CPT code.
   
   
   • Use automated coding software and/or a coding editor to test for duplicate entries.

   
   
8. Documentation missing/needed - Required data is missing on the claim form.
   

   
   
   • Verify what data is needed by reviewing the remarks code on the explanation of benefits (EOB).
   
   
   • Correct, attach and resubmit claim electronically as a new claim.
   
   
   • Communicate to the appropriate staff and establish claim edits in your practice management system to ensure that corrections of these errors occur prior to claim submission.

   
   
9. Coordination of benefits - Verify insurance eligibility for both payers and determine primary/secondary sequence. Under certain circumstances you may need to use the active employment, birthday rule for dependents or dependent methodologies to determine insurance sequence.
   

10. Late filing/Filing time limit - Verify and understand payer's filing deadline.
    

    
    
    • Enter charges into the practice management system in a timely manner.
    
    
    • Follow up on claims with no payer response within 7-14 days of submission to make sure claim has been received by the payer.

    
    

These are just a few common reasons for denials. Denials for your practice may vary, but should be tracked to determine what types of denials your practice is experiencing.

Happy 4th of July!

Terry Fragoso
Vice President of Operations
http://www.thinkfirst.us/lower.php?url=terry-fragoso

Monica's Summer Cleaning Tips

The benefits of using a claims scrubbing software can tremendously reduce denial rates, shorten AR cycles and improve cash flow. With some tweaks, adjustments and updates you can maximize the effectiveness of your claims scrubbing software.


Here are my Top 10 Tips to Maximize Your Claims Scrubbing Software:

1. Stay current with the latest version of your claims scrubbing software - you may be missing out on many new enhancements!
   
2. If applicable, perform routine Local or National Coverage Determination (LCD/NCD) updates. Verify with your claims scrubbing vendor how often medical necessity policies are published for your state.


3. Implement routine CPT, ICD-9 and Correct Coding Initiatives (CCI) updates, ensuring CPT/ICD-9 validity.


4. Research if your claims scrubbing vendor publishes reports, training materials, newsletters and/or bulletins relating to application issues and updates.


5. It is crucial to inquire about and apply recommended database maintenance procedures (i.e. purges, size, speed, error messages, etc.) with your claims scrubbing software.


6. Discuss customization capabilities - it is important to create parameters (edits, payer specific rules, etc.) around unusual insurance specifications.


7. Generate and utilize standard and custom system reports regularly to assess and analyze how claims are being processed. These reports can be used to assist in training, education and tracking trends.


8. Consistently review your denials and appeals so that your claims process can become more streamlined. These findings will contribute to improved business decisions and help in modifying your claims scrubbing software.


9. Attend educational sessions offered by other organizations and users of the claims scrubbing software (user groups, conferences, seminars, webinars, etc.).


10. Finally -- never underestimate the power of tapping into your internal knowledge base! Create an internal team to make your claims editing software more efficient and valuable.

End Result = Clean Claims = Priceless!

Monica Stovall, Senior Consultant, Think First
http://www.thinkfirst.us/lower.php?url=monica-stovall

If You Are Serious...

If you are serious, get serious.

Serious analysis requires serious tools. The process has to be programmatic, reproducible without guesswork, and have the ability to be validated. Many meetings I have participated in the last few weeks have centered on our clients desire to achieve a level of intelligence that will help improve company profitability. Various stakeholders question the credibility of the data being provided, the frequency in which it is provided, how it is being provided, and the what the information is telling them.

Many organizations are great at tracking lagging indicators. Wikipedia defines a lagging indicator as an economic indicator that summarizes past events rather than explicitly predicting future events. For example, in an academic medical group, Work RVU's is a lagging indicator that reflect physician productivity.

Most organizations struggle with developing leading indicators. Wikipedia states that leading indicators are generally used to predict a new phase of the business cycle. A leading indicator is one that changes before your economy does; a lagging indicator is one that changes after the economy has changed. An example of a leading indicator could be the number of new patients see during clinic activity, which will often improve or worsen before a similar change in the economy.

Too many times we ask ourselves, "What happened?" We all spend time and money on tools that help us to analyze lagging indicators and past performance. I would love to hear from anyone out there who have created leading indicators. This seems to be a concept we have yet to actualize.

Chris George, CEO, Think First
http://www.thinkfirst.us

Think Before I Do

"Think First... Well - that's good advice," observed the main greeter at a hospital in central Maine as he read my business card. This comment stuck with me as I proceeded to meet with the executives of this very rural hospital system.

More often than not in our daily busy lives, the majority of us spend days staying ahead of the things we know we need to get done in both our work and personal lives. I typically measure my day by the difference between the tasks I had on my list at the start of the day compared to what remains there when the day is through. Again and again, it seems that my list has grown larger at the end of every day.

When I reflect on the day, I find myself spending a lot of time "doing" and not necessarily "thinking" about how to be more effiecient in my everyday life. These could be such things as making a list of priorities for the day, outlining my priorities for the week, etc...

In this day of information overload, there are many resources available that can help us make informed decisions about almost every aspect of our lives. There are websites striclty dedicated to the quality of data at hospitals, where our governments spends its money and even the most popular iPhone applications. However we all seem so busy that we very rarely take advantage of the data available that could drive better decision making. We typically make decisions about not waht is available statistically, but rather who referred us in the first place.

I frequently recall my conversation in Maine and now strive everyday to take the time to think before I do. After all, the data is usually available and I do work at a company named Think First.

Chris George, CEO, Think First
http://www.thinkfirst.us

Rubik's Cube

"I find a lot of humor and frustration in how much management needs reports, yet they have no idea what they want to see or how to make sense out of what they are looking at. Each report generates a need for a new report and the focus seems to get lost in the details."

This was an observation from an individual who inquired about employment opportunities at our firm. We are a firm that is markedly focused on producing bottom line results for our customers. We achieve this through a keen focus on turning data into useful information that can be utilized in problem solving.

Much like a Rubik's Cube, there are several ways to solve the puzzle. It does not matter how you solve the puzzle - it matters that you actually solve it. However, in order to get there you need to know where you are going.

I have been in many healthcare organizations that have built countless reports and dashboards with many slices and dices of information. This information requires much interpretation and many years of experience to uncover where potential opportunity lies to improve performance. Once these opportunities are identified, it takes much rigor to actually turn them into bottom line results.

While there may be many ways to get there, the real question is, "Where is there?"

Chris George, CEO, Think First
http://www.thinkfirst.us/

Two Ears

I was speaking with a Chairman of Surgery today and we were discussing the continual need for information in all facets of his department. He kept saying that his monthly financials were not right - they couldn't be.

He thought for sure that the charge volumes and work RVU's for many of his providers were inaccurate.

After more discussion, I finally understood where he was coming from. It was not that the reports were technically incorrect - it was that the business processes and supporting analytics were not designed in a way that delivered the information needed to make decisions. Not all of the charges were being reconciled and entered and some of the procedures had unlisted procedure codes that had no RVUs. While seemingly easy to resolve, these particular issues take time to work through and arrive at a point where the information being provided to key stakeholders is trusted.

How many times have you heard that someone does not believe in the data being provided? Typically, this is financial information. Imagine moving to a world of clinical information where all healthcare providers are benchmarked according to industry standards. How many of us are really going to believe these numbers?

The reality is that sites are already emerging with this information. Sites such as hospitalcompare.hhs.gov, patientsfirstma.org and healthgrades.com. How credible is this information? Is this all self reported data?

The real challenge for healthcare quality will be how we get to unbiased and reliable data we can all trust and believe in. Consumer Reports is the goto source for comparing many products. They have a rigorous process for evaluating and rating competing products. Don't we also need this for healthcare providers? It would be nice to know from an unbiased third party what the strengths and weaknesses are of the healthcare providers in your area. I wonder where our Consumer Reports for healthcare will come from?

Chris George, CEO, Think First
http://www.thinkfirst.us/

Relentless Repeatability

The key to any successful sustainable business is the concept of relentless repeatability. Doing the same thing, the same way, every time to achieve a consistent outcome. This concept is well document in Ray Croc's book about McDonald's. A Big Mac in New York taste exactly the same as one in Toyko. This is because the process by which they build the Big Mac is exactly the same across the world. All McDonalds employees' are educated the same way in the art of creating a Big Mac. We can learn a lot from this success story.

When working with healthcare provider organizations I often see how one simple workflow has the potential to create organizational chaos. Take for example, the patient regstration process. Every insurance company needs the same registration information in order to process a claim, yet when I go from client to client and clinic to clinic - the forms are different, the data elements are different and sometimes the systems are different. Employees have been trained by a number of different methods. Some by their Managers. Some by Corporate Trainers. Some not at all.

This leads to inaccurate registrations which delays claims, ultimately delaying revenue. Getting to a relentless repeatable process is imperative for resolving some of your chronic issues around the revenue cycle. Read Ray's book and transform your organization into the next McDonalds.

Chris George