Pamela Fell Jackson Health System Corporate Director Corporate Business Office Corporate Business...
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BILLIN G Pamela Fell Jackson Health System Corporate Director Corporate Business Office August 13, 2014 “The Buck Starts Here”
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Transcript of Pamela Fell Jackson Health System Corporate Director Corporate Business Office Corporate Business...
BILLING
Pamela FellJackson Health System
Corporate Director Corporate Business Office
August 13, 2014“The Buck Starts Here”
2
The Most Important Process in the Business Office:Billing – “The Buck Starts Here”
3
What do the majority of CFO’s see as the most
important Business Office
function?
4
Collections!
5
But…How many
collectors do you need to collect an unbilled claim?!
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Billing: A Clean Claim is a Paid
Claim!
PAI
D
7
What is a Clean Claim?A clean claim is a claim untouched by a
biller and clears all edits at the payer. These claims will pay without human in intervention in less than 30 days
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When a patient is discharged, the claim must be final coded before submitting to the payer. Also, there’s usually a bill-hold time for all charges to be entered
Typical hold days are:Inpatient: 4 days to allow for the 72-hour
overlapOutpatient: 3 to 5 days
Discharged Not Final Coded
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Discharged Not Final Coded
High Variability in DNFC1 Performance
Mid-Cycle
1) Discharged not final coded.
Discharged Not Final CodedTotal Number of Days
n=28
High-Performance Quartile Median Low-Performance Quartile
2.3
6.1
8.0
71.3% decrease
Source: Advisory Board - Financial Leadership Council 2013 Survey of Hospital Revenue Cycle Operations.
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Discharged Not Final Billed
These are accounts being held in the facility’s financial system where a claim has not produced that is missing data elements required for billing in addition to final coding.
Examples are:Missing authorization numbersPayer ID numbers missing or invalidRevenue codes with a credit balances
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Discharged Not Final Billed
Experiencing Delays in the Business Office
Business Office
1) Refers to results from the 2013 survey.
Discharged Not Final BilledTotal Number of Days
n=76 (2011); n=31 (2013)
High-Performance Quartile Median Low-Performance Quartile
4.8
7.2
10.2
5.0
8.0
10.8
2011 2013
$18MAverage dollar amount of
discharged not final billed activity for
hospitals in the high-performance quartile1
$42MAverage dollar amount of
discharged not final billed activity for
hospitals in the low-performance quartile1Source: Advisory Board - Financial Leadership Council 2013 Survey of
Hospital Revenue Cycle Operations; Financial Leadership Council 2011 Revenue Cycle Benchmarking Survey.
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Claim has Been Released from DNFB; Billing Process
Begins!
Claims import daily from the facility’s patient financial system into the EDI billing system
Edits/bridge routines should be established to maximize immediate transmission to the payer
Clean claims should be released daily via the 837 file, even though many payers do not accept transmissions on weekends and holidays. This ensures the claims meet the first transmission from the clearinghouse
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First-Pass YieldA Widening Gap Between High and Low Performers
Patient Access
1) The low-performance quartile for this comparison is 74.5%.
First-Pass Yield
n=60 (2006); n=36 (2008); n=49 (2011); n=29 (2013)
Percentage of Claims Arriving in the Business Office Error Free
High-Performance Quartile Median Low-Performance Quartile
79.8%75.5%
69.7%
77.0%
66.5% 65.0%
86.5%80.0%
70.0%
92.5%
85.0%
70.5%
2006 2008 2011 2013
Source: Advisory Board - Financial Leadership Council 2013 Survey of Hospital Revenue Cycle Operations; Financial Leadership Council 2011 Revenue Cycle Benchmarking Survey; Financial Leadership Council 2008 Member Survey of Revenue Cycle Operations.
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Understanding the Claims Rejecting to Your
Editor
Facility SpecificEdits
Payer Specific
Edits
Clearinghouse Specifics/AMA Edits
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Billing Process - How to Make Your Billing Editor ‘Your’ Editor
This is an ever evolving process. New billing requirements are entered by your EDI providers daily
Requires the effort of the entire billing teamBillers and collectors should be encouraged
to bring corrections to management for possible electronic correction
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Facility Specific Edits Edits Causing Claims to Reject to the Editor
Some of the more common edits are:Admit source 1 must have an ER chargeTrauma Center 5 must have a trauma level
chargeOccurrence code 11 can not be after the
admit datePOA Indicators (1 vs. blank)
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Payer Specific EditsEach major payer has their own set of edits
that are maintained by your EDI systemPayer specific edits may not always conform
to UB04 guidelines. Bridge routines must then be built at the facility
These edits are ‘payer’ specific and not ‘facility’ specific; therefore, modifications might be neededNCCI EditsCCI Edits
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Clearinghouse EditsThe clearinghouse changes the format of
the billing file to conform with the payer specific EDI guidelinesLoops and segments aren’t standard
across all payers
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Sources of Rework Prior to Initial Submission
No Consistent Trend in Predominant Source of Errors
Source: Advisory Board - Financial Leadership Council 2013 Survey of Hospital Revenue Cycle Operations; Financial Leadership Council 2011 Revenue Cycle Benchmarking Survey; Financial Leadership Council 2008 Member Survey of Revenue Cycle Operations.
Mid-Cycle
Sources of Errors Leading to Business Office Rework2013
n=29
2011n=41
2008n=25
27%
15%
25%
10%
23%
16%
12%
47%
5%
20%
26%
12%
28%
10%
24%
Insurance Information
Demographic Information
Coding
Physician Documentation
Other
Insurance Information
Demographic Information
Other
Coding
Physician Documentation
Insurance Information
Demographic Information
Coding
Physician Documentation
Other
Mid-cycle
Patient Access
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Resources Allocated to Rework
Variable Benefits of Devoting More Resources to Claims Rework
Business Office
1) Refers to those in the 75th percentile for 2013 survey results.
Percentage of Business Office Resources Devoted to Reworking Claims Prior to Initial Submission
n=45 (2011); n=30 (2013)
25th Percentile Median 75th Percentile
5%
10%
15%
7%
19%
35%
2011 2013
+5 daysAverage increase in AR
days for hospitals with more business office
resources dedicated to rework1
+24%Average increase in
cost to collect for hospitals with more business office
resources dedicated to rework1
-54%Average decrease in denial
write-offs for hospitalswith more business office
resources dedicated to rework1Source: Advisory Board - Financial Leadership Council 2013 Survey of
Hospital Revenue Cycle Operations; Financial Leadership Council 2011 Revenue Cycle Benchmarking Survey.
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Discharged Not Sent to Payer
If a claim drops into the billing editor and can not be corrected and released the same day, the claim becomes part of the discharged not sent to payer file
Errors usually require correction via the Health Information Management (HIM) department, Patient Access or the clinical staff
Accounts should be assigned to an internal report by errors and areas of responsibility and distributed to the appropriate departments for correction
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Submitting the ClaimsThe claim has passed all the previous edits
and has been transmitted to the payerFinal level edits at the payer site could
be:Can not ID patientIncorrect DOBIncorrect subscriber IDBaby’s nameNot eligible for date of service
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Payer Rejection ReportThese claim rejections are returned to the
facility via the 835 file (payer rejection report) which should be worked daily
Almost impossible to build payer level edits at the facility level for these rejections
Until the claim is on file at the payer, billing owns the claim and it’s their responsibility to get the claim on file
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Late Charges: To Bill or Not To Bill?
Pros to billing late chargesMedicare regulations require all services
provided to be billedAccount will re-adjudicate in the contract
management system Changes could throw account into an outlier
Cons to billing late chargesUsually no additional reimbursementBillers must be knowledgeable on all
contractual termsCollectors have to ultimately write-off the
charge(s), which necessitates another account review. If not caught, could transfer to bad debt
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What Should be Monitored and Trended?
DNFBDNSP – Claims holding in the editorDaily electronic submissionsClean claim rateBiller productivity
Electronic billersPaper billers
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Questions?
