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Be Appealing Revenue Cycle Management Series


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Watch this Webinar to identify rejections, denials, and lost claims - Improve cash flow and your financial performance.

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Be Appealing Revenue Cycle Management Series

  1. 1. Official Disclaimer The information presented is for general information only and are not meant to substitute for legal advice. Always seek the advice of an attorney on legal matters. Legal Guidance Copy righted © material is subject to fine of $5000 per occurrence 03
  2. 2. 04 BILL PROMPTLY • 6% - 15% of revenue is lost to timely filing denials • Your #1 responsibility is to get your bills to the payer in a timely manner • Bill daily – it improvise cash flow, while making it easier to identify rejections, denials and lost claims • Get a receipt for your submissions – send X, receipt for X
  3. 3. 05 You have to press send
  4. 4. 06 In receipt of a bill a payer can only: Pay the claim In full or in part Reject the claim Deny the claim Ask for more information If you bill timely and are not paid within 30 days, verify on the payer website the payer’s receipt of your claim. Not there - resubmit In NYS & most states, a payer has 30 days to act on a received claim electronically. 45 days if submitted on paper
  5. 5. 07 Read & Understand Claim Receipts Read & Understand EOBs Paid Now that they have paid it – have they paid it in full? Have they paid it at the right rate? You need to review and audit the claim Rejected They said they could not process the claim – something is wrong They asked for additional information You need to understand what was “wrong” promptly correct and resubmit Denied They said NO You need to understand why the no, and what you can do about it
  6. 6. 08 No. 1 Reason for a Rejection of a claim An error in the patient name and/or address • 10%- 30% of all claims are rejected • 50% of all rejected claims are not re- submitted  Meaning the revenue from 5% - 15% of billing is lost Understand, Correct And Resubmit Rejected Claims
  7. 7. 09 Top 10 Reasons for Rejections 1. Incorrect or missing patient demographics 2. Incorrect or missing ICD-10 diagnoses 3. Incorrect of missing CPT modifiers 4. Incorrect or missing CPT procedure code 5. Physician Identification missing 6. Incorrect or missing place of service code 7. Missing or incorrect number of units of service 8. Claim submitted to the wrong address 9. Duplicate claim 10. Additional information needed – request for medical records
  8. 8. 10  Promptly correct and resubmit the claim.  Track as you would a new claim.  Remember: The clock is running against you – timely filing is based on the date of service – not the date of a resubmitted claim. Rejections Require Resubmission
  9. 9. 11 • 6%- 14% of claims are denied • 50% of denials are never appealed  Meaning the revenue from 3% - 7% of billing is lost • Never accept a denial without a challenge • A lost appeal is learning opportunity Denials – when they say NO
  10. 10. 12 Principal causes of denials Lack of permission • Requires Prior Authorization or Precertification • No Referral on File ▪ Set some policy ▪ Get some knowledge • If you have it -appeal Lack of Eligibility • Coverage terminated • Services Excluded or Non- covered ▪ Trust but verify ▪ A role for credit cards • An other insurer is primary • Understand the basics of COB Lack of eligibility means the patient is responsible – pursue the patient It does little good trying to appeal eligibility/non-covered issues
  11. 11. 13 10% 10% 17% 17% 19% 27% RecoveryOn Appeal Between 0% and 10% Between 10% and 20% Between 20% and 30% Between 30% and 40% Between 40% and 50% Between 50% and 60% Appeals recovery money
  12. 12. 14 • New physicians/providers • New Procedures • New technology Before learning by denial – know what your in for:
  13. 13. 15 You represent that this claim was denied for…. Attached please find documentation that such a determination was in error Simple – if you have the documentation to show they are wrong • Timely filing • Lack of referral • Lack of Authorization While Most Appeals Are Simple
  14. 14. 16 Denials for clinical reasons require more skill and these 4 sentences Sentence One & Two We request peer-to-peer conversation as sanctioned by most utilization review laws to facilitate a complete review of the denial. A clinical peer is defined by the Utilization Accreditation Commission (URAC) as a physician or other health professional who holds an unrestricted license in the same specialty as typically manages the medical condition, procedure or treatment under review. Physicians complain that “desk reviews” can never be as accurate and complete of a clinical picture as face-to-face interaction with a patient. Physicians should set aside time to pursue peer conversations with insurers. Such sessions are often effective in reaching a mutual agreement and, if not, the treating physician will still have initiated important dialogue with decision makers which could, in time, shape treatment options for patients.
  15. 15. 17 Sentence Three If peer-to-peer discussion is not promptly provided, please provide the following information which should have been properly disclosed with the initial denial: name of initial reviewer and description of applicable advanced training related to this type of care, a copy of the applicable clinical or coding guidelines used in the decision and the date of development, an outline of the specific records reviewed and a description of any additional records necessary for your review and recommendation regarding alternative care and/or coding which qualifies for benefits. This important sentence forces the carrier to disclose all details pertinent to the decision. Obtaining all the elements of this request will allow you to assess the quality of the review process and will help you determine if any other reimbursement is available or likely available for future treatment related to the patient’s condition.
  16. 16. 18 Sentence Four It is our position that failure to provide the requested information may violate (state name) and/or federal claim processing disclosure laws and, non disclosure reflects a poor-quality medical review process which discourages treatment provider input. Remember Health plans pay based on Coverage – not medical necessity The services must be medically necessary to be eligible for coverage, but coverage is based on the benefits that are purchased for the insurance premiums
  17. 17. 19 • Send appeal in within 30 days of the date of the denial • Send a NYS DOI/Regulatory Complaint at 60 days Appeal – Monitor - Get Help
  18. 18. 20 Those who refuse to learn from history are doomed to repeat it Learn from denials Do you have a higher than the norm level of denials? Is there a pattern?
  19. 19. 21 Never call a plan to ask the status of a claim or an appeal • Call centers are measured by the volume of calls they can “process” • He said/she said • And the she/he often times does not give a last name • The answers may be correct, but the question may be wrong • You suffer the consequences of their errors Think of the IRS – telephone inquires – answers wrong 14% of the time, at service centers, answered wrong 33% of the time, and emailed, answered wrong 35% of the time.