Kareo - Denial Management: Tested Techniques That Get Claims Paid
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Transcript of Kareo - Denial Management: Tested Techniques That Get Claims Paid
PAGE 1 KAREO | CONFIDENTIAL
Denial Management:Tested Techniques the Get Claims Paid
Starting Now…
PAGE 2 KAREO | CONFIDENTIAL
How to Participate Today…
Follow us on Twitter @GoKareo
We’ll be tweeting live using the hashtag #KareoTip
Join our other social media channels for constant updates!
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
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
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
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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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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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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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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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
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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Action
Following the Payers’ Process Helps to Avoid
Creating another Denial for a
Duplicate Claim
©2013
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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
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
PAGE 22 KAREO | CONFIDENTIAL
Request
• Review by expert in your specialty
Appeal
“peer review”©2013
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Carbon copy –State insurance commissioner
–Medical director
Appeal
List of insurance commissioners:www.naic.org/
state_web_map.htm
©2013
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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Conclusion
•Measure
•Monitor
•Prevent
•Work
©2013
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
PAGE 27 KAREO | CONFIDENTIAL
Discover Kareo’s Role
“…Make Your Practice a Best Practice!”
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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Discover Kareo’s Role
•Eligibility Verification
•Dashboard• Status of Claims
• Ready to send• Denials• No response• ERA with denials
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Discover Kareo’s Role
•Eligibility Verification
•Dashboard
•Edit Claims• Remarks
• Reasons
PAGE 32 KAREO | CONFIDENTIAL
Discover Kareo’s Role
•Eligibility Verification
•Dashboard
•Edit Claims
•Top Denial Reasons
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Discover Kareo’s Role
PAGE 34 KAREO | CONFIDENTIAL
Denial Management:Tested Techniques the Get Claims Paid
Thank You!