Claims Rejection Trends—
And Preventing Their Recurrence
Marianne Swank, EDI Reimbursement Manager, Walgreens Infusion and Respiratory Services, Buffalo Grove, IL
Top 4 Things to Know for CE
1. Make sure your BADGE IS SCANNED each time you enter a session to
record your attendance.
2. Carry your Evaluation Packet with you to EVERY session.
3. Pharmacists, Pharmacy Technicians and Nurses need to track their hours
on the Statement of Continuing Education Form as they go (the 2-page
triplicate form, so press firmly!).
4. FOR CE: At your last session, total the hours and sign both pages of your
Statement of Continuing Education Form.
 Keep the PINK copy for your records and place the YELLOW and
WHITE copies in your CE Envelope.
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you attended (extra forms are available at the registration desk if you
forgot to pick one up).
 Write your name and unique ID number (six digit number at the bottom
of your name badge) in the designated area on the outside of the
envelope, seal it, and place it in the drop box located near the
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registration area.
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• Marianne Swank declares no conflicts of
interest or financial interest in any service
or product mentioned in this program.
• Clinical trials and off-label/investigational
uses will not be discussed during this
presentation.
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Putting the Puzzle Pieces Together
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•
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What are our rejections?
Where do we find them?
How to fix/resolve them?
Moving forward – how to prevent them?
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Where did I find my rejections???
• Front End Rejections
– Claims never making it to the intended payer
• Back End Rejections
– Reports
– EOBs
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Where Did We Get Our Data?
• We provided HCPC codes and “infusion specific” information to the following companies:
– Remit Data
– ZirMed
– Emdeon
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Findings from Remit Data
• They gave us data from all of their infusion clients
• The data shown here is from the last quarter of 2011 (October, November, December)
• 5010 Rejections do not factor in to their results
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Remit Data
• Medicare Most Common Denial Codes
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Remit Data
• Medicaid Most Common Denial Codes
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Remit Data
• Commercial Most Common Denial Codes
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Findings from ZirMed
• Data is from 2012 (1/1/2012 to 2/27/2012)
• They were given the most common HCPCs used by the infusion industry
• It includes some of the 5010 rejections that all of us have struggled to correct
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ZirMed’s Top Rejections
• A8:306 – Acknowledgement/rejected for relational field in error. Detailed description.
• A3:54 – Acknowledgement/Returned as unprocessable claim – Duplicate claim.
• 5X No medical coverage effective for date of service.
• Service date: invalid, must be less than or equal to transaction set creation.
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Emdeon Findings
• They were provided a list of the most common HCPCs used in the infusion industry
• They compared infusion specific claims to all claims submitted through their system, for an entire year
• They also compared the infusion industry’s rejection numbers to all other provider types
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Emdeon’s Comparison
Emdeon Summary Information
Emdeon Reject Rate
Payer Reject Rate
NHIA Provider Summary Information
Quarter of Year
Payer Model(Claims)
Q1 2011
BLUE CROSS/BLUE SHIELD
1.4%
2.7%
Total Reject Rate
4.1%
Emdeon Reject Rate Payer Reject Rate
2.9%
4.3%
Total Reject Rate
7.2%
Q1 2011
CHAMPUS
1.2%
2.0%
3.2%
12.3%
14.6%
26.9%
Q1 2011
COMMERCIAL
1.1%
3.1%
4.2%
2.6%
5.2%
7.8%
Q1 2011
MEDICAID
2.6%
2.0%
4.6%
5.8%
2.7%
8.5%
Q1 2011
MEDICARE
2.3%
2.0%
4.4%
3.0%
6.5%
9.6%
Q1 2011
WORKERS COMPENSATION
1.0%
5.6%
6.6%
0.0%
100.0%
100.0%
Q2 2011
BLUE CROSS/BLUE SHIELD
1.6%
2.7%
4.3%
2.5%
4.9%
7.4%
Q2 2011
CHAMPUS
1.5%
2.2%
3.8%
11.7%
9.7%
21.4%
Q2 2011
COMMERCIAL
1.1%
2.7%
3.8%
3.1%
4.4%
7.5%
Q2 2011
MEDICAID
2.4%
2.1%
4.5%
5.4%
3.2%
8.6%
Q2 2011
MEDICARE
2.2%
2.7%
4.9%
2.1%
6.5%
8.6%
Q2 2011
WORKERS COMPENSATION
1.0%
7.5%
8.5%
0.0%
100.0%
100.0%
Q3 2011
BLUE CROSS/BLUE SHIELD
1.6%
2.7%
4.3%
3.4%
4.5%
7.9%
21.9%
Q3 2011
CHAMPUS
2.1%
2.5%
4.6%
12.3%
9.6%
Q3 2011
COMMERCIAL
1.1%
2.5%
3.7%
3.3%
3.7%
7.0%
Q3 2011
MEDICAID
2.7%
2.5%
5.2%
5.3%
3.9%
9.2%
Q3 2011
MEDICARE
2.0%
3.0%
5.0%
3.0%
7.3%
10.3%
Q3 2011
WORKERS COMPENSATION
1.1%
8.3%
9.4%
0.0%
100.0%
100.0%
Q4 2011
Q4 2011
BLUE CROSS/BLUE SHIELD
CHAMPUS
1.6%
2.0%
3.7%
3.4%
5.3%
5.4%
3.1%
10.0%
5.1%
8.1%
8.2%
18.1%
Q4 2011
COMMERCIAL
1.4%
2.9%
4.4%
4.3%
4.2%
8.5%
Q4 2011
MEDICAID
2.6%
3.0%
5.6%
8.1%
5.4%
13.5%
Q4 2011
MEDICARE
2.3%
5.8%
8.1%
1.8%
5.7%
7.5%
Q4 2011
WORKERS COMPENSATION
0.8%
7.1%
7.9%
5.5%
88.4%
93.9%
Total 2011
Total All
1.5%
2.8%
4.2%
3.8%
4.9%
8.7%
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Top Emdeon Front End Rejections
• Service Date: Invalid; Must be less than Claim Date
• Service Date: Invalid; Must be less than or equal to Transaction Set Creation Date
• Destination Payer Primary Identifier: Invalid; Must be a Payer ID from the Emdeon Payer List
• Payer Secondary Identifier: Invalid; Must be a valid Claim Office Number for Payer
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Emdeon Top Payer Rejections
• Service Line Procedure Code and/or Modifier: Invalid
• Member Primary Identifier: Invalid; Must be valid and on file with Payer
• Destination Payer Primary Identifier: Invalid; claim submitted to incorrect Payer
• Member Primary Identifier Invalid: Social Security Number/Employee Number not found for Payer
• Diagnosis Code Invalid
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Possible Intake Rejections For Discussion
• Member IDs.
• Primary Payer – or payer id invalid – how do we get the claim to the correct payer?
• Incorrect Diagnosis code – what will happen with ICD‐10 implementation????
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Possible Missing/Invalid Data Rejections for Discussion
• HCPC and Modifier combinations
• Claim/service lacks information which is needed for adjudication
– At least one Remark Code must be provided 4/8/2012
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Possible Technology Issues For Discussion
• Duplicate Claims – Claim Status Applications
– IVR or electronic verification of claim at payer
• Service Date Invalid
– Should practice management system catch this?
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Debrief
• Share what your group discussed.
• What were your “a‐ha” moments?
– What were they?
– How can we do things better?
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Resolutions to Intake Claim Rejections
• How does your organization stop these trends?
• What are some of the processes you used to alleviate these rejections?
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Resolutions to Missing/Invalid Data Rejections
• How does your organization stop these trends?
• What are some of the processes you used to alleviate these rejections?
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Resolutions to Technology Rejections
• How does your organization stop these trends?
• What are some of the processes you used to alleviate these rejections?
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Learning Assessment Questions & Answers
Due to the interactive nature of this educational content, there are no learning assessment questions and answers for this session.
Marianne.Swank@walgreens.com
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