Billing

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Pamela Fell. Jackson Health System. Corporate Director. Corporate Business Office. August 13, 2014. “The Buck Starts Here. ”. The Most Important Process in the Business . Office:. Billing . – “The Buck . ID: 224992 Download Presentation

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Billing




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Billing

Pamela FellJackson Health SystemCorporate Director Corporate Business OfficeAugust 13, 2014

“The Buck Starts Here”

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The Most Important Process in the Business Office:Billing – “The Buck Starts Here”

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What do the majority of CFO’s see as the most important Business Office function?

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Collections!

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But…How many collectors do you need to collect an unbilled claim?!

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Billing: A Clean Claim is a Paid Claim!

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PAID

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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 enteredTypical hold days are:Inpatient: 4 days to allow for the 72-hour overlapOutpatient: 3 to 5 days

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Discharged Not Final Coded

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Discharged Not Final Coded

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High Variability in DNFC1 Performance

Mid-Cycle

Discharged not final coded.

Discharged Not Final Coded

Total Number of Days

n=28

71.3% decrease

Source:

Advisory Board - Financial

Leadership Council 2013 Survey of Hospital Revenue Cycle Operations

.

Slide10

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

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Experiencing Delays in the Business Office

Business Office

Refers to results from the 2013 survey.

Discharged Not Final Billed

Total Number of Days

n=76 (2011); n=31 (2013)

$18M

Average dollar amount of

discharged not final billed activity for

hospitals in the high-performance quartile1

$42M

Average dollar amount of

discharged not final billed activity for

hospitals in the low-performance quartile

1

Source:

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 systemEdits/bridge routines should be established to maximize immediate transmission to the payerClean 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 Yield

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A Widening Gap Between High and Low Performers

Patient Access

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

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 Specific

Edits

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 Edits

Each 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 facilityThese edits are ‘payer’ specific and not ‘facility’ specific; therefore, modifications might be neededNCCI EditsCCI Edits

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Clearinghouse Edits

The 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

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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 Rework

2013

n=29

2011

n=41

2008

n=25

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

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Variable Benefits of Devoting More Resources to Claims Rework

Business Office

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)

+5 days

Average increase in AR days for hospitals with more business office resources dedicated to rework

1

+24%

Average increase in

cost to collect for hospitals with more business office resources dedicated to rework

1

-54%

Average decrease in denial write-offs for hospitals

with more business office resources dedicated to rework

1

Source:

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 fileErrors usually require correction via the Health Information Management (HIM) department, Patient Access or the clinical staffAccounts 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 Claims

The 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 Report

These claim rejections are returned to the facility via the

835 file (payer rejection report) which should be worked dailyAlmost impossible to build payer level edits at the facility level for these rejectionsUntil 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 outlierCons 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 productivityElectronic billersPaper billers

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Questions?


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