1. Successfully Manage
Your Denials and
Become Mardi Gras
Royalty
MGMA of Missouri
May 06, 2013
Chastity D. Werner, RHIT, CMPE, NCP

2. Learning Objectives
What is your number
Remember when?
Today
Patient workflow
Prevention is key
Tracking results
Celebrate success

3. What Is Your Number?

4. What Is Your Number?
100 claims a day X 20 days a month
2000 claims
20% denial rate
33% of denials are never recovered
400 X 33% = 132
132 X $100.00 (average reimbursement) = $13,200
monthly
Source: The Physician Billing Process: 12 potholes to avoid in the road to getting paid, ed 2,
Walker-Keegan, Woodcock, Larch.13

5. What Is Your Number?
Source: The Physician Billing Process: 12 potholes to avoid in the road to getting paid, ed 2,
Walker-Keegan, Woodcock, Larch.13
$10.67 staff time
$1.50 supplied
$1.75 interest
$1.00 overhead_______________________

6. Source: GatewayEDI 2013

7. Source: GatewayEDI 2013

9. Scheduling
Visit
Printed &
Mailed Claim
Forms
Claim
Adjudication
Denials &
Patient
Collections
Claim Follow-Up
Via Telephone

10. Remember When?
Appointment Books
Dot Matrix Printers
Highlighters

11. Remember When?
Paper Charts
Misfiled Records
HMOs
• Copayments were only $10 - $20
• $250 Deductibles

18. Practice Management Software
Automated Eligibility & Benefits
• 270/271
Electronic Health Records

19. Charge Lag Time – 24 hours
Bill Lag Time – 48 hours
Electronic Claim Submission
• 837

20. Real Time Claim Adjudication
• 977, 276 & 277
Electronic Remittance Advices
(ERAs)
• Reason Codes- RARC &
CARC
• 835
• 2014 Reform

21. Electronic Fund
Transfers (EFTs)
Automated 2ndry Claim
Filing
Patient Portals

23. Scheduling
• Capturing information that
counts
• Now what?

24. Patient Workflow
Capturing the right
information at the
right time.

25. Patient Workflow
Prepare Patient for Visit
• Collect Previous Balances
• Review Financial
Expectations
• Price Estimations
• Directions
• Confirm Details

26. Patient Workflow
Pre-Visit Paperwork
• Electronic Forms
• Patient Portals
• Kiosks
• Patient Financial
Responsibility
• Does it fit
• Duplication

27. Patient Workflow
Financial Clearance
• System Automation
 Task to right person or group
• Eligibility/Benefits
 Task by plan and requirements

28. Patient Workflow
Check-In
• License
• Scan Insurance Card
• Confirm System Information
• Review Paperwork
• Collect Patient Financial
Responsibility
 Staff Scripts
 Continued Training
 Learned Responses

29. Patient Workflow
Check-Out
• Computer Assisted Coding
• Real Time Adjudication
• TOS
 Coinsurance
 Deductible
 Deposit

30. Patient Workflow
Billing
• Charge Lag Time
• Claim Scrubbing
• Bill Lag Time
• File Confirmation
• Automated Tasking

31. Patient Workflow
Account Follow-Up/Payment Posting
• 277 Files
• ERAs
• EFTs
• Reason Codes
• Posting Denials
• Filing Appeals

33. Patient Workflow
Source: Frank Cohen, www.frankcohen.com, 2010

34. Prevention is Key
GIGO = Leakage in Revenue
Denials
• 90% preventable
• 67% recoverable
Source: The Physician Billing Process: 12 potholes to avoid in the road to getting paid, ed 2,
Walker-Keegan, Woodcock, Larch.13

35. Prevention is Key
Denial Prevention
• Information captured at scheduling
• Financial clearance
• Identify balances owed
• Patient responsibility estimates
• TOS collections

36. Prevention is Key
The game has changed
• Practice management
system automation
• Batch eligibility & benefits
• Automated credit card
payments
• Reimbursement managers

37. Track Results
Post all denials
• Post by reason code
• Sort reports by reason codes
Dashboards
• Financial
• Quality of care
Payer fee schedules
• CPT Analysis

38. Track Results
Charge Lag = date charge entered – date of service
Bill Lag = date claim filed – date charge entered
Days in AR = total current receivables/average daily charges
Average Daily Charges = total gross charges/total days
Adjusted Collection Rate = payments/allowable charges
Allowable Charges = charges – contractual adjustments

39. Questions?

40. Celebrate Success
Days in AR
• Best – less than 35
• Average – 35 to 50
• Poor – greater than 50
Percentage of A/R greater than 120
• Best – less than 12%
• Average – between 12-25%
• Poor – greater than 25%
Net Collection Rate
• Best – higher than 99%
• Average – between 95-99%
• Poor – less than 95%
Source: Navicure 2012

41. Celebrate Success
Goals
Marathon not a sprint
Make it fun

42. Anders Health Care Services
Anders Health Care Services optimizes staff,
resources and revenue for hospitals and
physicians by offering solutions and direction
to complex practice management issues.
We provide an integrated approach from the
financial, operational, compliance and
strategic perspectives.

43. Contact Information
Chastity D. Werner, RHIT, CMPE, NCP
Health Care Consultant
Anders Health Care Services
314-655-5561 (direct)
314-920-7938 (cell)
Cwerner@anderscpa.com

44. Anders’ Practice Strategy Resources
DeAnna Cassat dcassat@anderscpa.com
Jessica Johnson jjohnson@anderscpa.com
Brian McCook bmccook@anderscpa.com
John McGuire jmcguire@anderscpa.com
Brian Meyers bmeyers@anderscpa.com
Jerrie Weith jweith@anderscpa.com
314-655-5500
www.andershealthcare.com