Generating Cleaner Healthcare Claims


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A brief look at the challenges Healthcare providers face in generating claims as well as some best practice guidelines to ensure cleaner claims.

Published in: Health & Medicine

Generating Cleaner Healthcare Claims

  1. 1. Claims Processing : Ensuring Cleaner Claims Dr Kunalsen Sawant
  2. 2. Agenda <ul><li>Introduction to the Concept </li></ul><ul><ul><li>What is a ‘Clean Claim’ </li></ul></ul><ul><ul><li>Common Industry Challenges handling claims </li></ul></ul><ul><ul><li>How big is the problem </li></ul></ul><ul><li>Claims Lifecycle Analysis </li></ul><ul><ul><li>Important systemic validations </li></ul></ul><ul><li>Other Important guidelines </li></ul><ul><ul><li>Recommended best practices </li></ul></ul><ul><ul><li>CAQH role </li></ul></ul>
  3. 3. What is a Clean Claim? <ul><li>A Clean Claim shouldn’t have </li></ul><ul><ul><li>any defects </li></ul></ul><ul><ul><li>any impropriety </li></ul></ul><ul><ul><li>any incomplete information leading to delay in payment </li></ul></ul><ul><ul><li>Source: As defined in Act 68 -Prompt Payment Provision </li></ul></ul><ul><li>The Clean claims legislation </li></ul><ul><ul><li>Mandates payer response for clean claims in 45 days </li></ul></ul><ul><ul><li>If deemed ‘clean’ Payer has to pay 85 % of the claim amount in 45 days </li></ul></ul><ul><ul><li>Imposes penalties for non-compliance by payers (1.5%) </li></ul></ul>
  4. 4. Why Clean Claim? That’s in an ideal world…….
  5. 5. Providers Payers <ul><li>EDI penetration across various segments of providers is varied (many practices & institutions still follow paper-based submission </li></ul><ul><li>Early adopters are facing aging IT systems with increased collection risks and related costs resulting in inefficient claims processing </li></ul><ul><li>Contracts could have multiple variables pertaining to (Payor  plan  employer) with changes in billable groups of services  stay limits, etc. </li></ul><ul><li>Payers are creating more complex plans under the guise of providing patients with multiple choices and thereby complicating claims calculations </li></ul><ul><li>Fraudulent claims submission by providers involves implementing stringent checking and adjudication mechanisms thereby increasing the complexity of claims processing solutions </li></ul>Why is claims handling still difficult?
  6. 6. How big is the problem? <ul><li>Top Five reasons for Claims rejections </li></ul><ul><ul><li>Duplicate Claims </li></ul></ul><ul><ul><li>Provider Number Issues </li></ul></ul><ul><ul><li>Insured Number Issues </li></ul></ul><ul><ul><li>Paper Claims </li></ul></ul><ul><ul><li>Incomplete claims </li></ul></ul><ul><li>A denied claim triples the cost due to delay in cash & staff intervention </li></ul><ul><li>5 billion claims are processed every year in the USA out of which 30% are rejected </li></ul><ul><li>An average of $25-$30 per claim is spent on reworking claims and managing denials. </li></ul><ul><li>One out of every five claims are delayed or denied, and almost 96 percent of claims are submitted more than once. </li></ul><ul><li>Source: PNC Bank Study 2007 </li></ul>Higher %age of claims getting processed faster by making claims ‘Clean’ Source: America’s Health Insurance Plans (AHIP)
  7. 7. What is the key issue? Healthcare is the only industry where the seller (provider), at the time of service delivery, may not know how much services a buyer (patient) would consume totally, what would be the payor obligation to reimburse, how much should they collect from the patient and by when…………… Providers must manage a disjointed and protracted receivables path, as a result they are actively seeking systems which integrate diverse data sources to present an aggregate view-point in managing claims and receivables…………… <ul><li>Multiple Collection points at multiple times for a single healthcare event </li></ul><ul><ul><li>Co-pay (time of admission), Payor remittance (45days +), COB, Balance collection from patient </li></ul></ul><ul><li>Multiple data inputs in calculating final claims from diverse/ independent systems </li></ul><ul><ul><li>Charge master, payor-contract mngmt, E&M, Codes DB, DRG grouper, Clinical systems (lab, clinical documentation, CPOE, pharmacy, etc.), Billing, Payer-interface </li></ul></ul>
  8. 8. <ul><li>ABN/ Medical Necessity </li></ul><ul><li>Referral Authorization </li></ul><ul><li>Benefit Authorization </li></ul>Admission Care Delivery Charge Capture Claim Submission Pre-admission <ul><li>Eligibility Verification (plan/ member validity) </li></ul><ul><li>Admission Diagnosis capture (IPPS) </li></ul><ul><li>Ensure Co-pay, deductible & Co-insurance calculated </li></ul><ul><li>E & M Guidelines based clinically necessary documentation </li></ul><ul><li>POS Charge Capture </li></ul><ul><li>Check for Non-Covered services </li></ul><ul><li>ER and Inpatient charges separate </li></ul><ul><li>Verify Code assignments </li></ul><ul><li>Correct charge capture </li></ul><ul><li>Verify with Updated contract/ plan </li></ul><ul><li>Services-diagnosis validity checking </li></ul><ul><li>- Field Edits </li></ul><ul><li>COB checking </li></ul><ul><li>Consolidate non-covered charges </li></ul><ul><li>Duplicate service billing </li></ul>Claims Lifecycle overview Claims Lifecycle
  9. 9. Industry Best practices for Cleaner Claims Financial Health Information management Ensure that your processes mandate….. <ul><li>Pre- registration and prior verification. </li></ul><ul><li>Collection of payer specific Insurance information. </li></ul><ul><li>Collection of finance and legal documents prior to delivery of services. </li></ul><ul><li>Collection of copay amounts at time of pre-registration. </li></ul><ul><li>Records of discharged/departed patient are available to HIS in 24 hours. </li></ul><ul><li>Documentation issues are trended and addressed concurrently. </li></ul><ul><li>Timely and accurate documentation of procedures and diagnosis in patient medical records. </li></ul><ul><li>Clinical reports are electronically available to coders. </li></ul>
  10. 10. Daily Weekly Monthly Best practices for Claims handling Ensure that you track….. <ul><li>Transmit claims files. </li></ul><ul><li>Check claim totals against claims created in your practice management system, </li></ul><ul><li>Work on all rejections. </li></ul><ul><li>Resubmit the rejected claims from practice management system, once corrected. </li></ul><ul><li>For the previous week, confirm that all rejected claims have been resubmitted. </li></ul><ul><li>Determine the highest volume errors by depart/payer and correct yours system. </li></ul><ul><li>Be sure all claims have been cleared through payer. </li></ul><ul><li>Get the snapshot of how your office is doing and where you might save time and money. </li></ul><ul><li>Update system with payer information provided on banner pages and newsletters. </li></ul><ul><li>Work on report of electronic claims dropping to paper. </li></ul>
  11. 11. Newer initiatives- CAQH guidelines <ul><li>CAQH : Non-Profit alliance of leading health plans, networks & trade associations </li></ul><ul><li>Providers will send an online inquiry and know: </li></ul><ul><ul><li>Whether the health plan covers the patient * </li></ul></ul><ul><ul><li>Whether the service to be rendered is a covered benefit (including copays, coinsurance levels and base deductible levels as defined in member contract) </li></ul></ul><ul><ul><li>What amount the patient owes for the service** </li></ul></ul><ul><ul><li>What amount the health plan will pay for authorized services** </li></ul></ul><ul><ul><li>(in **Phase 2) </li></ul></ul><ul><li>Recommend a CORE certification which guarantees </li></ul><ul><ul><li>Acknowledgements Rule: Always and only one ACK </li></ul></ul><ul><ul><li>Response Time Rule: Real Time – 20 Sec Round trip , Batch ( 7am next day for receipt by 9 pm today) </li></ul></ul><ul><ul><li>System Availability: Minimum 86% </li></ul></ul><ul><ul><li>Connectivity Rule: HTTP/HTTPS 1.1 </li></ul></ul><ul><ul><li>Companion Documents Rule: Core Companion Document Format for all 270/271 Transactions </li></ul></ul>Give Providers Access to Information Before or at the Time of Service...
  12. 12. Thank You….
  13. 13. Appendix….
  14. 14. Process Cost Source: AHIP
  15. 15. Reasons for Pended/Delayed Claims Source: AHIP
  16. 16. How quickly Providers submit Claims? Source: AHIP Source: AHIP
  17. 17. Claims Statistics Source: Humana
  18. 18. Claims Aging Source: AHIP