KEEPING AR SQUEAKY CLEAN

AAPC Des Plaines Local Chapter 10/19/16Vanessa Moldovan, CPC, CPPM

Chapter President

Increase

reimbursement

Identify areas of

improvement

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

AR Benchmarks0-30 days 31-60 days 61-90 days 91-120 days over 120 days60% 13% 7% 4% 16%KPIs (Key Performance Indicators)

Days in AR between 30-45 daysThe 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

In order to clean up the mess, you

must know what’s all mixed

up in it.

Why is it important for

everyone involved in the

Revenue Cycle be knowledgeable of

all the working parts?

Credentialing/Contracting

AppointmentType of insuranceAuthorizations

Visit/EncounterMedical NoteSurgical Note

Checkout/patient payment

Charge Entry/CodingManualElectronic

Front System EditsClaims Submission

PaperElectronic

Back Edits

Payer Rejections (sometimes included in AR)

Clearinghouse rejections (sometimes included in AR)

System Edits

Payment posting

Manual

Electronic

Patient AR Follow-upStatementsPhone calls

Insurance AR Follow-upDenialsLack of response

Along with Revenue Cycle…..

Payer Mix

Workflow

The Big PictureIdentify the AR

Aging reports by aging datePlan

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.

Tools, tips and resources to make clean up more effective

and efficient

ANSI Reason Codes/Remark Codeswww.wpc-edi.com

CO, PR, OA, PICategorized:

coding, eligibility, registration, billing, credentialing, plan limitations,

preventable, non-preventablepatient, provider or billing responsibility

Medicaid uses different codes

List of important practice/provider info

PTANNPITINContact infoEffective dates with payersW-9s

List of payer infoPhone and fax numbersProvider portalAppeals addressAppeals formTimely filing (initial, appeal, OON and IN)Specific guidelines

Clearinghouse and/or payer responses

Original EOBs and/or charges

Medical RecordsOnline claim status and eligibility and appeals

Explanation of benefitsElectronic corrected claimElectronic 2ndary claim

Policies/ProcessesClient/provider requestsEscalationsCredentialing issuesPatient responsibilityChanges to codingKnow who does what (coding,

registration, authorizations, etc.)

Time to dive into all of that AR

No response received

(sometimes referred to as ‘pending

AR’)

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 IPAMedicare (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.

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

incorrectlySet payers up on EFT and ERA

Denials

(often there are entire departments assigned to this)

Confirm charge entryChargesDiagnosesProvidersPlace of service

Verify registrationDemographicsInsurance

Know the payer guidelines for corrections:Corrected claim, reconsideration, redetermination, appeal (keep a copy until resolved)

Submission guidelines: payer form or letter templatemail, fax, online

Timely limits

AAPC Coder

Fee SchedulesMUEGlobal DaysCMS 1500 Real Time ScrubberSurvival Guides

Practical Application

Let’s review some top denials

Third Party Liability (TPL)Workman’s Compensation:

Submit claims with notes, claim number, DOISlow payerIf 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.

Account/Claim Notes

PurposeFor those who follow behind youFor your future follow-upLegality

ContentWhat is the problem?What research was done?What steps were taken?

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.