www.claimremedi.com
Revenue Cycle Maximization
Revenue Cycle
Maximization
Presented by:
Peter Bowhall CEO
Andrea Neace
ClaimRemedi, Inc.
Santa Rosa, CA
FQHC Revenue Cycle
At its core is the Claim Revenue Cycle
•
Maximizing claim revenue
•
Accelerating claim revenue
•
Managing the process
Claim Revenue Cycle
The complete Claim Revenue Cycle process involves:
• Staff– clinical, front desk, billing office
• EMR/PM systems
• Clearinghouse/EDI Services
Survey- Question
Survey Question:
Do you know what percentage of
your claims are denied?
Survey- Response
Do you know what % of your claims are denied?
Survey said:
• 24% = 1%-10% denial rate
• 28% = 11%-30% denial rate
• 6% = 30%-50% denial rate
• 42% = don’t know
Rejection/Denial Statistics
• 20%-30% of claims are rejected or denied on
first submission
• 33% of denials are not recovered
(The Physician Billing Process)
• Initial claim cost = $5-$7 versus $25-$30 to
rework a rejected/denied claim
Payment Statistics
• Payers report the incorrect contracted payment
rate on 12%-21% of claims
• 20% of claims are underpaid
• Underpayment equates to 7% of net revenue
What’s Ahead
• 5010 (January 2012)
• ICD10 (October 2013)
• Physician Quality Reporting Initiative—PQRI (2015)
Claim Lifecycle Management
• Eligibility
• Claim Submission
• Claim Scrubbing & On-line
Editing
• Claim Tracking Management by Exception
• ERA Processing
• Analytics—Denial
Management,
Benchmarking, Dashboards
Eligibility Verification
• One of two ways to reduce first pass rejections
• Eligibility is one of the most common causes for
claim rejections
• Study—8% of total claims submitted rejected
due to eligibility issues
Eligibility Verification
• Is the patient covered?
• Does the patient have other insurance?
• Do we have the correct registration info?
• What are the maximum allowable visits?
• What is the patient’s share of cost?
The first step in the claim revenue life cycle.
Eligibility Statistics
79% of practices check patient eligibility. 24%
check patient eligibility every visit (MGMA-Larson
Allen LLP). Best performers check eligibility:
• For all patients
• Every patient visit
• Using EDI technology
Best Performers
Lower A/R days and shorter collection cycle.
Other things they have in common:
• They do more analysis than others
• They have more support staff per provider
• They utilize more technology services
Claims Scrubbing
• The second way to reduce first pass rejections
• Identify & correct errors before claims are sent
to payers
• “Reverse engineer” ERAs to identify payer
specific edits
Scrubber Rules Engine
Why “reverse engineer” ERAs to identify payer
specific edits?
• Edits vary significantly by payer
• Many payers do not use industry wide standards
• Many payers use undisclosed proprietary edits
• “We do not release what we do and do not edit.”
Claim Management
Track and monitor the status of all claims
after they have been forwarded to payers.
Manage by exception those claims that are:
• Rejected, pended or denied—claims requiring
rework or follow-up
• Missing in action—payer “lost” or never
received claim
Claim Management
Claim Management
Claim Management
Proof of timely filing:
• Claims that never make it into adjudication
• Payers want to see the acknowledgment
they sent you– not your record of when you
sent claims
Revenue Cycle Management
You can’t manage what you don’t measure.
Claim Revenue Cycle Management consists of:
• Managing denials
• Comparing payer reimbursements with contracted amounts
Analytics
• If you are getting 835s (ERAs) & 277s, you have all
the data you need.
• “Data is not information. You have to torture it
before it becomes useful.” (MGMA conference)
• Analytics tools are often underused.
• Enables you to manage the claim process instead
of letting the claim process manage you.
Denial Management
Managing denials with technology instead of manual
processes can significantly lower your A/R days –
no matter how good your manual processes are.
• Identify reasons for denials
• Implement staff training at the source
• Reduce denials
• Fix process instead of fixing individual claims
• Measure effectiveness of denial management
Denial Management
Denial Management
Denial Management
Track denials by payer, procedure,
provider, location and user.
• Identify who or what is causing denials– front
desk, back office, etc.
• Identify problem payers & their requirements
• Drill down to claim detail
Payment Monitoring
Track actual allowed amounts by
procedure, modifier & payer:
• Ensure payments are in line with your contracts
• Identify underpayments
Those who monitor allowed amounts will find
incorrect payments from payers.
Payment Monitoring
Underpayments
How do payers underpay:
• Payer errors
• Partially paid claims
• Downcoding
Payment Monitoring
Payer Comparisons
Compare payers by:
• Reimbursement—allowed amounts
by procedure & modifier
• Denials
• Days to pay
Days to Pay
Days to Pay
Payment Monitoring
How Do You Compare
How do you compare with other provider
organizations? How do you stack up?
• By specialty, zip code, state & payer
• Allowed amounts by procedure, modifier & payer
• Denials
• What percentile do you fall into?
How Do You Compare
Questions?
Questions?