Claims Handling – Physician Office

WSMA Spring Seminar

March 2, 2013

Presented by: Rosalia Sabelko, RHIT, CCS-P

What is Claims Management?

The claims management process in the physician office is the internal workflow for preparing, submitting, and collecting claims.

Who is involved in the process?

All members of the physician office team have a role in the claims management process.

Registration

Clinical Staff

Physicians

Coding

Billing

Collections

Benefits of Claims Management

● Increased staff efficiency● Streamlined claims billing processes● Increased number of clean claims submitted● Reduced number of claims denied● Timely and accurate payment from the health

insurer

Elements of Claims Management

Pre-Registration– Accurate collection of patient demograhics and

health information– Verification of insurance and applicable

deductibles/copays/co-insurance

Patient Check-In– Copying patient’s health insurance card– Verification of insurance information

Elements of Claims Management

Documentation of Services Provided– Patient's history, symptoms, diagnosis and

treatment plan including labs or x-rays ordered

“If it isn’t documented, it wasn’t done”

Elements of Claims Management

Assignment of Diagnosis and Procedure Codes– Use of “encounter” or “charge master”– Is the content of the current office visit consistent

with the diagnosis and plan?– Was a complete physical performed at the

subsequent office visit?

Elements of Claims Management

Patient Check-Out– Schedule follow-up– Collect co-payment or deductible– Special payment arrangements

Elements of Claims Management

Code Verification and Review– Use the encounter form to create claim for patient– Billing specialists and coders must be familiar with

Medicare guidelines and commercial insurance carrier guidelines

Elements of Claims Management

Example of Differences between Medicare and Commercial PayerExtracorporeal shockwave lithotripsy (ESWL) is performed for a kidney stone in the right kidney and a kidney stone in the left kidney

–For Medicare, the removal of both of these stones would be entered as 50590-50 on the claim

–A commercial payer may require that this be entered as 2 lines on the claim with codes

50590-RT and 50590-LT

Resources for Coding Guidelines

http://cms.gov

http://ama-assn.org

http://humana.com/providers/home.asp

http://medica.com

Elements of Claims Management

Claim Generation– Codes and fees are entered accurately and a claim

is generated

Claim Review– Billing specialists review the claims for accuracy,

correct as needed, and submit to insurers

Elements of Claims Management

Claims Processing, Adjudication, Payment– Health insurer should review the claim, approve,

and route payment and a copy of the EOB to the physician office. Original EOB is routed to patient.

Collections/Claim Follow-up– If insurer not processing claim in timely manner,

collections staff follows up with insurer

Elements of Claims Management

Posting Payment– Collections staff should verify payment according to

contract and post in accounts receivable

Claim Appeal– If collections staff deem payment inappropriate,

investigate and appeal the denial

Documentation for Clean Claims

The patient's chart must have documentation that will support the level of service or procedure provided.

Proper documentation allows coders to translate medical documentation (words) into numbers.

Documentation for Clean Claims

CPT and diagnosis codes must accurately reflect documentation for visit– Global fee periods for surgery– Modifiers– Medical necessity

Examples of Issues with Medical Necessity

Edit Category Explanation

Procedure to Procedure Prevents payment for procedures that are contrary to the NCCI or procedures billed within a global period of another procedure.

Procedure to Provider Looks for procedures performed by specialty; ie., Urology billing for cardiac catheterization, or OB/GYN billing for kidney stone removal.

Procedure to Sex, Age, or Diagnosis Ensures that sex-specific services are not paid inadvertently; ie., prostate surgery for a female.

Diagnosis to Procedure Prevents payment of an unwarranted procedure for a given condition; ie., tonsillectomy for foot pain.

Procedure for Place of Service Prevents payment for a procedure in an obviously wrong place of service; ie., hip replacement surgery in an office setting.

Documentation for Clean Claims

The goal of this process is to pay

the right amount

to the right provider

for the right service

to the right beneficiary.

Denials and Appeals

Denials = revenue delay, revenue loss

Medicare, as well as most commercial insurance carriers, have tools you can access via websites to assist with the claims appeals process.

Denials and Appeals

Reasons for Denials– Medical necessity

– Missing or invalid CPT or HCPCS code submitted

– Incorrect patient identifier information submitted● Spelling of name, date of birth, subscriber number missing or invalid, insured group

number missing or invalid

– Procedure/surgery requires prior authorization or precertification

– Place of service does not match surgery/procedure performed

– Claim submitted for non-covered service

Denials and Appeals

Why is an Advance Beneficiary Notice (ABN) Needed?

– If Medicare deems a service “not reasonable and medically necessary”, and the patient decides to proceed with the service, the ABN is used to bill the patient for the services provided

Denials and Appeals

Documentation Mistakes– Physician “short-cuts” in documenting medical necessity

● Clear to physician; not clear to insurance claims reviewer● Claims reviewers look for

– Specific terminology– Descriptions that match insurance policies

Claims Reviews

In the health care industry, regulators are employed to ensure providers are documenting and billing according to law

– Office of Inspector General (OIG),

– Auditors from governmental payers,

– Auditors from commercial payers,

– Attorneys

Purpose of Chart Reviews

– Adherence to clinical protocols– Patient adherence with medication regimens– Provider compliance with coding and

documentation

Claims Reviews

External Chart Reviews– Medicare Risk Adjustment (MRA) Audit

– Health insurer audits

Internal Chart Reviews– 6-10 charts per physician per year

– Audit for over coding and under coding

Claims Reviews

Goals for Claims Reviews– Quality improvement

– Identify trends/top procedure codes● Used for negotiating contracts with insurance carriers

– Ensure the office is being paid according to contract

Summary

Professional and diligent efforts of the entire physician office staff help to ensure a successful claims management process.

Questions?

rsabelko@westernwisconsinurology.com