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From Registration to Accounts Receivable – The Whole Can of Worms

2007 UBO/UBUConference2007 UBO/UBUConference

Briefing: Tips for Avoiding Denials

Date: 21 March 2007

Time: 1010 - 1100

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Objectives

To provide information to the attendees that will allow you to reduce the number of denials you now receive from insurance plans/payers and pharmacy benefit plan managers/PBM’s

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

It’s a Team Effort throughout the MTF Gathering of Patient Demographics CHCS Data Entry Provider Chart Documentation Record Coding General – Data Quality Ancillary Services Coding – Data Quality Coding Audits Provider Table Accuracy NDC Code Accuracy

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Gathering of Patient Demographics

Patient Name

Patient Date of Birth

Patient Address

Copy of Patient Insurance ID CARD – COPY Front and Back

Insured Individual Name

Effective Dates – Term Date

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Coverage Through? Employer/Retiree Plan

Insurance Company Name

Subscriber/Patient ---ID!!! – Many are not SS# any longer – HIPAA & many have a distinct

number after for each individual covered by the policy Plan Code

Group #

RX BIN #

CLAIMS Filing Address – RX vs. Medical

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

CHCS Data Entry– Verified Information only – OHI/SIT new Classifications accurately entered – Occupational Visits – not billable –special MEPRS – Accident Case – Now - Block 11 of DD Form 2569

New DD Form 2569 this block will no longer be present

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Documentation – clinical– Provider documentation of ALL services rendered– Coding Audits – Pre-Billing – Statistical reports– Education and Training

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Coding – General– Code only what is documented– Audit and Educate– 24 hour stays– Inpatient/outpatient overlaps

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Coding – Ancillary Services – Be Specific – Utilize data from Civilian Ordering Physician

Request it if not provided

– Reflect actual service not general – CPT Code Book

Annually update deletions and additions

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Provider Tables– Specialty– Non Privileged Provider vs. Privileged Provider– DEA Codes– License #’s– HIPAA Taxonomy– NPI #’s

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

NDC Items– Frequency of Updates– Ownership of Updates– Expired items – Zero $’s – NO RATE– Days Supply and Quantity – CHCS Conversion table issues

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Most Frequent Denials– Non Participating Provider– Medicare EOB Required– Unable to identify patient as subscriber– Duplicate Claim

Ancillary care not linked can cause this

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Front End Impact on Back End A/R Functions– Incorrect data

Cause payer denials Cause claim rejections Cause slow down in payment Cause payers to question credibility of future claims

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable

Preventing Denials

Front End Impact on Back End A/R Functions (Cont’d)– Insufficient data

Cause payer denials Cause claim rejections Cause slow down in payment Cause payers to question credibility of future claims

– Staff frustrations

– Leadership questions

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Communicate and educate your partners – Leadership of MTF– Providers– Check-In Personnel– Coders– UBO/PAD Office– Payers & PBM’s (Pharmacy Benefits Managers)

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Preventing Denials

Communicate and educate your partners (Cont’d)– Make suggestions– Partner with your TPC/OHI staff – Provide Briefings on outcomes and impacts– Monitor when changes are to be made– Provide Feedback on weakness and SUCCESS

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable In Summary

T = Top down support needed for best outcomes to be

achieved

E = Everyone has a part in providing data for claims

submitted

A = A/R overall is affected by the accuracy of claims

data

M = Money in the bank with less denials and more

claims paid as submitted

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2007 UBO/UBU ConferenceFrom Registration to Accounts Receivable Quiz

Who owns accuracy of Data on claim?

One of the most common reason for denials?

Reason for performing pre-billing coding audit?

Monitor out comes and statistics, why?

Share the success with whom?