1. KEEPING AR
SQUEAKY CLEAN
AAPC Des Plaines Local Chapter 10/19/16
Vanessa Moldovan, CPC, CPPM
Chapter President

3. Increase reimbursement
Identify areas of improvement

4. So who says it’s a mess anyway?
MA (Medical Group Management Assoc.)

5. AR Benchmarks
0-30 days 31-60 days 61-90 days 91-120 days over 120 days
60% 13% 7% 4% 16%
KPIs (Key Performance Indicators)
 Days in AR between 30-45 days
The average number of days to collect payment on services that have been
rendered.
Total current AR/average daily charges
 % of AR over 90 days between 10-12%
Usually measured by entry date
 % of collections (payments/charges-adjustments)
 Financial trending

6. In order to clean up
the mess, you must
know what’s all
mixed up in it.

7. Why is it important for
everyone involved in
the Revenue Cycle be
knowledgeable of all
the working parts?

8. Credentialing/Contracting
Appointment
Type of insurance
Authorizations
Visit/Encounter
Medical Note
Surgical Note
Checkout/patient payment

9. Charge
Entry/Coding
Manual
Electronic
Front System Edits
Claims Submission
Paper
Electronic

11. Patient AR Follow-up
Statements
Phone calls
Insurance AR Follow-up
Denials
Lack of response

12. Along with
Revenue Cycle…..
Payer Mix
Workflow

13. The Big Picture
Identify the AR
 Aging reports by aging date
Plan
 Prioritize (date, balance, payer)
 Don’t ignore credits
 Set realistic benchmarks and timelines
Manage
 Distribute the work (reports or work
queues)
 By payer, client, specialty, etc.
Monitor (productivity, effectiveness,
quality)
Prevent
 Clog the holes that are causing the leaks.

14. Tools, tips and resources to make
clean up more effective and
efficient

15. ANSI Reason Codes/Remark Codes
www.wpc-edi.com
CO, PR, OA, PI
Categorized:
coding, eligibility, registration, billing, credentialing, plan
limitations,
preventable, non-preventable
patient, provider or billing responsibility
Medicaid uses different codes

16. List of important practice/provider info
PTAN
NPI
TIN
Contact info
Effective dates with payers
W-9s

17. List of payer info
Phone and fax numbers
Provider portal
Appeals address
Appeals form
Timely filing (initial, appeal, OON and IN)
Specific guidelines

18. Clearinghouse and/or payer
responses
Original EOBs and/or
charges
Medical Records
Online claim status and
eligibility and appeals

19. Explanation of benefits
Electronic corrected claim
Electronic 2ndary claim

20. Policies/Processes
Client/provider requests
Escalations
Credentialing issues
Patient responsibility
Changes to coding
Know who does what (coding, registration,
authorizations, etc.)

21. Time to dive
into all of that
AR

22. No response received
(sometimes referred to as ‘pending AR’)

23. Claim was rejected at the clearinghouse and the error was not corrected.
The charge(s) are in an edit queue within the PM system.
The member is ineligible.
The Subscriber ID and/or name is incorrect.
The claim is being sent to the incorrect payer, examples:
Claims address: UHC, PHCS, UMR, etc.
Blue Cross IPA
Medicare (Railroad or Jurisdiction)
Managed care plans
The payer’s mailing address and/or electronic ID are incorrect.
The provider is not credentialed/contracted with the payer.

24. Other reasons for no response:
Claim not on file
Set payers up on electronic
submission
Send paper claims through
clearinghouse
Payment sent, but not posted.
May have been posted incorrectly
Set payers up on EFT and ERA

25. Denials
(often there are entire departments assigned to this)

26. Confirm charge entry
Charges
Diagnoses
Providers
Place of service
Verify registration
Demographics
Insurance

27. Know the payer guidelines for corrections:
Corrected claim, reconsideration, redetermination,
appeal (keep a copy until resolved)
Submission guidelines:
payer form or letter template
mail, fax, online
Timely limits

28. AAPC Coder
Fee Schedules
MUE
Global Days
CMS 1500 Real Time Scrubber
Survival Guides

29. Practical Application
Let’s review some top denials

30. Third Party Liability (TPL)
Workman’s Compensation:
Submit claims with notes, claim number, DOI
Slow payer
If in litigation in Illinois, check status Illinois Work Comp website
www.iwcc.il.gov.
Personal Injury and Auto Accident
These are often in litigation for many years and the patient’s personal injury
policies are quickly exhausted.
Obtain your client’s policy on whether they want to be notified of PI cases
so that they can file a lien.

31. Account/Claim Notes
Purpose
For those who follow behind you
For your future follow-up
Legality
Content
What is the problem?
What research was done?
What steps were taken?

32. Identify the AR
 Aging reports by aging date
Plan
 Prioritize (date, balance, payer)
 Don’t ignore credits
 Set realistic benchmarks and timelines
Manage
 Distribute the work (reports or work
queues)
 By payer, client, specialty, etc.
Monitor (productivity, effectiveness,
quality)
Prevent
 Clog the holes that are causing the leaks.