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Kareo - Denial Management: Tested Techniques That Get Claims Paid

Date post: 07-May-2015
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Tested Techniques That Get Claims Paid Is this your practice? Denied claims languish for days–even weeks–before a staff member finally resubmits. Then they come back: denied again. You don’t need a complex claims denial-management system, but this work process does require your time and attention. With the cost of reworking a claim approximately $15, and perhaps more, you simply can’t afford stay on the denial merry-go-round.
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PAGE 1 KAREO | CONFIDENTIAL Denial Management: Tested Techniques the Get Claims Paid Starting Now…
Transcript
Page 1: Kareo - Denial Management: Tested Techniques That Get Claims Paid

PAGE 1 KAREO | CONFIDENTIAL

Denial Management:Tested Techniques the Get Claims Paid

Starting Now…

Page 3: Kareo - Denial Management: Tested Techniques That Get Claims Paid

PAGE 3 KAREO | CONFIDENTIAL

Our Schedule for Today…

1 Introduction & Welcome Elizabeth

2 Denial Management: Tested Techniques to Get Claims Paid

3 Discover Kareo’s Role

4 Answer Questions

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PAGE 4 KAREO | CONFIDENTIAL

Elizabeth Woodcock, MBA, FACMPE, CPC

Professional Speaker, Trainer, & Author

Specializing in Medical Practice Management

Author of 12 Best-Selling Practice Management Books

Fellow in the American College of Medical Practice Executives

Certified Professional Coder

MBA in Healthcare Management from The Wharton School of Business

BA from Duke University

Elizabeth W. Woodcock, MBA, FACMPE, CPCWoodcock & AssociatesSpeaker, Trainer, Author

Atlanta, Georgia404.373.6195

[email protected]

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PAGE 5 KAREO | CONFIDENTIAL

Our Schedule for Today…

1 Introduction & Welcome Elizabeth

2 Denial Management: Tested Techniques to Get Claims Paid

3 Discover Kareo’s Role

4 Answer Questions

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PAGE 6 KAREO | CONFIDENTIAL

Agenda

•Denials

•Action

•Appeal

•Prevent

©2013

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Denials

•Why?•Reason code [Claim Adjustment Reason Code (CARC)]: why a claim or service line was paid differently than it was billed•Remark code: used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a CARC

List of standard codes:www.wpc-edi.com/content/view/695/1

©2013

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PAGE 8 KAREO | CONFIDENTIAL

Denials

6 – The procedure

code is inconsistent with the patient's

age. 

2 – Coinsurance Amount

“Soft” Denial “Hard” Denial

Example: 99392 coded for child (established) with DOB 9/12/2000

99394

©2013

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Denial Workflow

•Establish protocols to take action on denials based on the reason

Transfer to next financially responsible party (e.g., patient/guarantor; secondary payer)

Soft DenialIf mistake, correct and resend

If action needed, investigate…

Hard Denial

©2013

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Denial Workflow

1. Review copy of card (both sides)[Front office scans both sides]2. Search in alternate sources? (Hospital, Nursing Home, etc.)3. Check payers’ member database (Medicaid)[Easy access, including passwords, to sources]4. Contact patient[Correct phone number; template letter]

31 – Patient cannot be identified as our insured

©2013

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PAGE 11 KAREO | CONFIDENTIAL

Denial Workflow

Supporting Documents EOB Office notes, operative reports, etc. Proof of filing date(s) Specialty society American Medical Association’s

CPT® Manual Others?

©2013

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PAGE 12 KAREO | CONFIDENTIAL

Denial Workflow

Source (image): Smarta.com

50 to 70 Accounts per Day per Employee

©2013

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Denial Workflow

Payer

$ Amt

Reason

Volume

©2013

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Denial Workflow

“Reminder” “To Do”“Tickler” “Task”Electronic Option:

©2013

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Denial Workflow

• Specific timeframe to

appeal the decision of non-payment

• Information becomes more difficult to retrieve

©2013

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Write-Offs

Taking an Adjustment

(A.K.A. Writing Off the Due Amount)

Source (image): safetyfirststands.blog.com

©2013

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PAGE 17 KAREO | CONFIDENTIAL

Write-Offs

•Protocols for Write-offs– >$0 - Approval by Supervisor

– >$500 – Approval by Manager

– >$1,000 – Approval by Physician

Establish these and

put them in writing as

policy

Each month (minimum): 100%

Adjustment Report

©2013

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PAGE 18 KAREO | CONFIDENTIAL

Action

UnitedHealthcare Single Claim Reconsideration Request Form This form is to be completed by physicians, hospitals or other healthcare professionals to request a claim reconsideration for members enrolled in benefit plans administered by UnitedHealthcare. NOTE: Please submit a separate claim reconsideration request form for each claim reconsideration request No new claims should be submitted with this form. Do not use this form for formal appeals or disputes. Continue to use your standard appeals process for formal appeals or disputes.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Claims%20&%20Payments/UnitedHealthcare%20Request%20for

%20Reconsideration%20Form/ClaimReconsiderationRequestForm.pdf

~75% of all denials can be resolved without an appeal

©2013

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PAGE 19 KAREO | CONFIDENTIAL

Action

Following the Payers’ Process Helps to Avoid

Creating another Denial for a

Duplicate Claim

©2013

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PAGE 20 KAREO | CONFIDENTIAL

Put it in writing– Research process required by

payer

– Be professional

– Identify the claim, patient and all details re: service

– State the facts

– Gather input from the provider

Appeal

Best Practice: Maintain a “library” of appeal letters on your computer’s shared drive so you don’t have to recreate the wheel.

©2013

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PAGE 21 KAREO | CONFIDENTIAL

Authoritative sources

• Medical literature• Specialty society• Medicare: National and

local coverage determinations

Appeal

• CPT: AMA’s CPT® Manual, CPT® Assistant, CPT® Changes: An Insider’s View, etc.

• Payer’s website; policy manual

©2013

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Request

• Review by expert in your specialty

Appeal

“peer review”©2013

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PAGE 23 KAREO | CONFIDENTIAL

Carbon copy –State insurance commissioner

–Medical director

Appeal

List of insurance commissioners:www.naic.org/

state_web_map.htm

©2013

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PAGE 24 KAREO | CONFIDENTIAL

• Return denials to origin (e.g., registration errors to front office), ideally automatically

• Implement feedback loop with providers by listing top denials ($/#) at provider meetings; attaching EOBs as examples

Prevent

©2013

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PAGE 25 KAREO | CONFIDENTIAL

Conclusion

•Measure

•Monitor

•Prevent

•Work

©2013

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PAGE 26 KAREO | CONFIDENTIAL

Our Schedule for Today…

1 Introduction & Welcome Elizabeth

2 Denial Management: Tested Techniques to Get Claims Paid

3 Discover Kareo’s Role

4 Answer Questions

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PAGE 27 KAREO | CONFIDENTIAL

Discover Kareo’s Role

“…Make Your Practice a Best Practice!”

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PAGE 28 KAREO | CONFIDENTIAL

Discover Kareo’s Role

• Cloud-based

• Medical Billing

• Patient Payment Services

• Insurance Billing & Remittance

• Scheduling & Practice Management

• Electronic Health Records

• Medical Billing Services

20,000 Providers Nationwide

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Discover Kareo’s Role

•Eligibility Verification• Coverage

• Copay

• Co-insurance

• Deductible

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PAGE 30 KAREO | CONFIDENTIAL

Discover Kareo’s Role

•Eligibility Verification

•Dashboard• Status of Claims

• Ready to send• Denials• No response• ERA with denials

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PAGE 31 KAREO | CONFIDENTIAL

Discover Kareo’s Role

•Eligibility Verification

•Dashboard

•Edit Claims• Remarks

• Reasons

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PAGE 32 KAREO | CONFIDENTIAL

Discover Kareo’s Role

•Eligibility Verification

•Dashboard

•Edit Claims

•Top Denial Reasons

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PAGE 33 KAREO | CONFIDENTIAL

Discover Kareo’s Role

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Denial Management:Tested Techniques the Get Claims Paid

Thank You!


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