PAGE 1 KAREO | CONFIDENTIAL
Denial Management:
Tested Techniques the Get Claims Paid
Starting Now…
PAGE 2 KAREO | CONFIDENTIAL
How to Participate Today…
Follow us on Twitter
@GoKareo
We’ll be tweeting live using
the hasht...
PAGE 3 KAREO | CONFIDENTIAL
Our Schedule for Today…
1 Introduction & Welcome Elizabeth
2 Denial Management: Tested Techniq...
PAGE 4 KAREO | CONFIDENTIAL
Elizabeth Woodcock, MBA, FACMPE, CPC
 Professional Speaker, Trainer, & Author
 Specializing ...
PAGE 5 KAREO | CONFIDENTIAL
Our Schedule for Today…
1 Introduction & Welcome Elizabeth
2 Denial Management: Tested Techniq...
PAGE 6 KAREO | CONFIDENTIAL
Agenda
•Denials
•Action
•Appeal
•Prevent
©2013
PAGE 7 KAREO | CONFIDENTIAL
Denials
•Why?
•Reason code [Claim Adjustment
Reason Code (CARC)]: why a claim
or service line ...
PAGE 8 KAREO | CONFIDENTIAL
Denials
6 – The procedure
code is inconsistent
with the patient's
age.
2 – Coinsurance
Amount
...
PAGE 9 KAREO | CONFIDENTIAL
Denial Workflow
•Establish protocols to take action on denials based
on the reason
Transfer to...
PAGE 10 KAREO | CONFIDENTIAL
Denial Workflow
1. Review copy of card (both sides)
[Front office scans both sides]
2. Search...
PAGE 11 KAREO | CONFIDENTIAL
Denial Workflow
Supporting Documents
 EOB
 Office notes, operative reports, etc.
 Proof of...
PAGE 12 KAREO | CONFIDENTIAL
Denial Workflow
Source (image): Smarta.com
50 to 70 Accounts per Day per
Employee
©2013
PAGE 13 KAREO | CONFIDENTIAL
Denial Workflow
Payer
$ Amt
Reason
Volume
©2013
PAGE 14 KAREO | CONFIDENTIAL
Denial Workflow
“Reminder” “To Do”
“Tickler” “Task”Electronic Option:
©2013
PAGE 15 KAREO | CONFIDENTIAL
Denial Workflow
• Specific timeframe to
appeal the decision
of non-payment
• Information beco...
PAGE 16 KAREO | CONFIDENTIAL
Write-Offs
Taking an
Adjustment
(A.K.A. Writing Off
the Due Amount)
Source (image): safetyfir...
PAGE 17 KAREO | CONFIDENTIAL
Write-Offs
•Protocols for Write-offs
– >$0 - Approval by Supervisor
– >$500 – Approval by Man...
PAGE 18 KAREO | CONFIDENTIAL
Action
UnitedHealthcare Single Claim Reconsideration Request Form
This form is to be complete...
PAGE 19 KAREO | CONFIDENTIAL
Action
Following the
Payers’ Process
Helps to Avoid
Creating another
Denial for a
Duplicate C...
PAGE 20 KAREO | CONFIDENTIAL
Put it in writing
– Research process required by
payer
– Be professional
– Identify the claim...
PAGE 21 KAREO | CONFIDENTIAL
 Authoritative sources
• Medical literature
• Specialty society
• Medicare: National and
loc...
PAGE 22 KAREO | CONFIDENTIAL
Request
• Review by expert in your specialty
Appeal
“peer review”
©2013
PAGE 23 KAREO | CONFIDENTIAL
Carbon copy
– State insurance commissioner
– Medical director
Appeal
List of insurance
commis...
PAGE 24 KAREO | CONFIDENTIAL
• Return denials to origin (e.g., registration
errors to front office), ideally automatically...
PAGE 25 KAREO | CONFIDENTIAL
Conclusion
•Measure
•Monitor
•Prevent
•Work
©2013
PAGE 26 KAREO | CONFIDENTIAL
Our Schedule for Today…
1 Introduction & Welcome Elizabeth
2 Denial Management: Tested Techni...
PAGE 27 KAREO | CONFIDENTIAL
Discover Kareo’s Role
“…Make Your Practice a Best Practice!”
PAGE 28 KAREO | CONFIDENTIAL
Discover Kareo’s Role
• Cloud-based
• Medical Billing
• Patient Payment Services
• Insurance ...
PAGE 29 KAREO | CONFIDENTIAL
Discover Kareo’s Role
•Eligibility
Verification
• Coverage
• Copay
• Co-insurance
• Deductible
PAGE 30 KAREO | CONFIDENTIAL
Discover Kareo’s Role
•Eligibility
Verification
•Dashboard
• Status of Claims
• Ready to send...
PAGE 31 KAREO | CONFIDENTIAL
Discover Kareo’s Role
•Eligibility
Verification
•Dashboard
•Edit Claims
• Remarks
• Reasons
PAGE 32 KAREO | CONFIDENTIAL
Discover Kareo’s Role
•Eligibility
Verification
•Dashboard
•Edit Claims
•Top Denial
Reasons
PAGE 33 KAREO | CONFIDENTIAL
Discover Kareo’s Role
PAGE 34 KAREO | CONFIDENTIAL
Denial Management:
Tested Techniques the Get Claims Paid
Thank You!
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Kareo - Denial Management: Tested Techniques That Get Claims Paid

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Tested Techniques That Get Claims Paid

Is this your practice? Denied claims languish for days–even weeks–before a staff member finally resubmits. Then they come back: denied again. You don’t need a complex claims denial-management system, but this work process does require your time and attention. With the cost of reworking a claim approximately $15, and perhaps more, you simply can’t afford stay on the denial merry-go-round.

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  • Make sure you are not unintentionally documenting things you did not address.
  • Compare your E&M percentages against the CMS “norms” Betsy discussed on her slides.
  • Kareo - Denial Management: Tested Techniques That Get Claims Paid

    1. 1. PAGE 1 KAREO | CONFIDENTIAL Denial Management: Tested Techniques the Get Claims Paid Starting Now…
    2. 2. PAGE 2 KAREO | CONFIDENTIAL How to Participate Today… Follow us on Twitter @GoKareo We’ll be tweeting live using the hashtag #KareoTip Join our other social media channels for constant updates!
    3. 3. PAGE 3 KAREO | CONFIDENTIAL Our Schedule for Today… 1 Introduction & Welcome Elizabeth 2 Denial Management: Tested Techniques to Get Claims Paid 3 Discover Kareo’s Role 4 Answer Questions
    4. 4. PAGE 4 KAREO | CONFIDENTIAL Elizabeth Woodcock, MBA, FACMPE, CPC  Professional Speaker, Trainer, & Author  Specializing in Medical Practice Management  Author of 12 Best-Selling Practice Management Books  Fellow in the American College of Medical Practice Executives  Certified Professional Coder  MBA in Healthcare Management from The Wharton School of Business  BA from Duke University Elizabeth W. Woodcock, MBA, FACMPE, CPC Woodcock & Associates Speaker, Trainer, Author Atlanta, Georgia 404.373.6195 elizabeth@elizabethwoodcock.com www.elizabethwoodcock.com
    5. 5. PAGE 5 KAREO | CONFIDENTIAL Our Schedule for Today… 1 Introduction & Welcome Elizabeth 2 Denial Management: Tested Techniques to Get Claims Paid 3 Discover Kareo’s Role 4 Answer Questions
    6. 6. PAGE 6 KAREO | CONFIDENTIAL Agenda •Denials •Action •Appeal •Prevent ©2013
    7. 7. PAGE 7 KAREO | CONFIDENTIAL Denials •Why? •Reason code [Claim Adjustment Reason Code (CARC)]: why a claim or service line was paid differently than it was billed •Remark code: used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a CARC List of standard codes: www.wpc-edi.com/content/view/695/1 ©2013
    8. 8. PAGE 8 KAREO | CONFIDENTIAL Denials 6 – The procedure code is inconsistent with the patient's age. 2 – Coinsurance Amount “Soft” Denial “Hard” Denial Example: 99392 coded for child (established) with DOB 9/12/2000 99394 ©2013
    9. 9. PAGE 9 KAREO | CONFIDENTIAL Denial Workflow •Establish protocols to take action on denials based on the reason Transfer to next financially responsible party (e.g., patient/guarantor; secondary payer) Soft Denial If mistake, correct and resend If action needed, investigate… Hard Denial ©2013
    10. 10. PAGE 10 KAREO | CONFIDENTIAL Denial Workflow 1. Review copy of card (both sides) [Front office scans both sides] 2. Search in alternate sources? (Hospital, Nursing Home, etc.) 3. Check payers’ member database (Medicaid) [Easy access, including passwords, to sources] 4. Contact patient [Correct phone number; template letter] 31 – Patient cannot be identified as our insured ©2013
    11. 11. PAGE 11 KAREO | CONFIDENTIAL Denial Workflow Supporting Documents  EOB  Office notes, operative reports, etc.  Proof of filing date(s)  Specialty society  American Medical Association’s CPT® Manual  Others? ©2013
    12. 12. PAGE 12 KAREO | CONFIDENTIAL Denial Workflow Source (image): Smarta.com 50 to 70 Accounts per Day per Employee ©2013
    13. 13. PAGE 13 KAREO | CONFIDENTIAL Denial Workflow Payer $ Amt Reason Volume ©2013
    14. 14. PAGE 14 KAREO | CONFIDENTIAL Denial Workflow “Reminder” “To Do” “Tickler” “Task”Electronic Option: ©2013
    15. 15. PAGE 15 KAREO | CONFIDENTIAL Denial Workflow • Specific timeframe to appeal the decision of non-payment • Information becomes more difficult to retrieve ©2013
    16. 16. PAGE 16 KAREO | CONFIDENTIAL Write-Offs Taking an Adjustment (A.K.A. Writing Off the Due Amount) Source (image): safetyfirststands.blog.com ©2013
    17. 17. PAGE 17 KAREO | CONFIDENTIAL Write-Offs •Protocols for Write-offs – >$0 - Approval by Supervisor – >$500 – Approval by Manager – >$1,000 – Approval by Physician Establish these and put them in writing as policy Each month (minimum): 100% Adjustment Report ©2013
    18. 18. PAGE 18 KAREO | CONFIDENTIAL Action UnitedHealthcare Single Claim Reconsideration Request Form This form is to be completed by physicians, hospitals or other healthcare professionals to request a claim reconsideration for members enrolled in benefit plans administered by UnitedHealthcare. NOTE: Please submit a separate claim reconsideration request form for each claim reconsideration request No new claims should be submitted with this form. Do not use this form for formal appeals or disputes. Continue to use your standard appeals process for formal appeals or disputes. https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en- US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Claims%20&%20Payments/UnitedHealthcare%20Re quest%20for%20Reconsideration%20Form/ClaimReconsiderationRequestForm.pdf ~75% of all denials can be resolved without an appeal ©2013
    19. 19. PAGE 19 KAREO | CONFIDENTIAL Action Following the Payers’ Process Helps to Avoid Creating another Denial for a Duplicate Claim ©2013
    20. 20. PAGE 20 KAREO | CONFIDENTIAL Put it in writing – Research process required by payer – Be professional – Identify the claim, patient and all details re: service – State the facts – Gather input from the provider Appeal Best Practice: Maintain a “library” of appeal letters on your computer’s shared drive so you don’t have to recreate the wheel. ©2013
    21. 21. PAGE 21 KAREO | CONFIDENTIAL  Authoritative sources • Medical literature • Specialty society • Medicare: National and local coverage determinations Appeal • CPT: AMA’s CPT® Manual, CPT® Assistant, CPT® Changes: An Insider’s View, etc. • Payer’s website; policy manual ©2013
    22. 22. PAGE 22 KAREO | CONFIDENTIAL Request • Review by expert in your specialty Appeal “peer review” ©2013
    23. 23. PAGE 23 KAREO | CONFIDENTIAL Carbon copy – State insurance commissioner – Medical director Appeal List of insurance commissioners: www.naic.org/state_web_ map.htm ©2013
    24. 24. PAGE 24 KAREO | CONFIDENTIAL • Return denials to origin (e.g., registration errors to front office), ideally automatically • Implement feedback loop with providers by listing top denials ($/#) at provider meetings; attaching EOBs as examples Prevent ©2013
    25. 25. PAGE 25 KAREO | CONFIDENTIAL Conclusion •Measure •Monitor •Prevent •Work ©2013
    26. 26. PAGE 26 KAREO | CONFIDENTIAL Our Schedule for Today… 1 Introduction & Welcome Elizabeth 2 Denial Management: Tested Techniques to Get Claims Paid 3 Discover Kareo’s Role 4 Answer Questions
    27. 27. PAGE 27 KAREO | CONFIDENTIAL Discover Kareo’s Role “…Make Your Practice a Best Practice!”
    28. 28. PAGE 28 KAREO | CONFIDENTIAL Discover Kareo’s Role • Cloud-based • Medical Billing • Patient Payment Services • Insurance Billing & Remittance • Scheduling & Practice Management • Electronic Health Records • Medical Billing Services 20,000 Providers Nationwide
    29. 29. PAGE 29 KAREO | CONFIDENTIAL Discover Kareo’s Role •Eligibility Verification • Coverage • Copay • Co-insurance • Deductible
    30. 30. PAGE 30 KAREO | CONFIDENTIAL Discover Kareo’s Role •Eligibility Verification •Dashboard • Status of Claims • Ready to send • Denials • No response • ERA with denials
    31. 31. PAGE 31 KAREO | CONFIDENTIAL Discover Kareo’s Role •Eligibility Verification •Dashboard •Edit Claims • Remarks • Reasons
    32. 32. PAGE 32 KAREO | CONFIDENTIAL Discover Kareo’s Role •Eligibility Verification •Dashboard •Edit Claims •Top Denial Reasons
    33. 33. PAGE 33 KAREO | CONFIDENTIAL Discover Kareo’s Role
    34. 34. PAGE 34 KAREO | CONFIDENTIAL Denial Management: Tested Techniques the Get Claims Paid Thank You!
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