denial claim analysis webinar monday, march 29, 2010 optimizing billing practices billing claims...

DENIAL CLAIM ANALYSISDENIAL CLAIM ANALYSIS

WEBINARWEBINAR

MONDAY, MARCH 29, 2010MONDAY, MARCH 29, 2010

Optimizing Billing PracticesBilling Claims Self Assessment

Your presenters

PresenterStephanie Ceponis, Lead Site Financial

Analyst 213-386-5614 ext. 4534, ceponiss@cfhc.org

ModeratorChuck Marquardt, Director of Training

213-386-5614 ext. 4583, marquardtc@cfhc.org

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All phones are muted.

Questions can be asked via chat throughout the session or raising your hand in WebEx.

Lines will be opened at the end for additional questions.

Objectives

The participant will be able to do the following: Complete the Excel workbook, CFHC Billing

Claim Denials Analysis;

Analyze data to identify problem areas in billing claims;

Describe plans of action for a variety of possible denial scenarios.

What are we going to learn?

How to utilize the CFHC denial analysis tool .

Some common denial codes and the key pieces to review to help reduce the frequency of the particular code.

Action plans – ways to reduce denials.

Rejects & Denials

Poll #1

Does your agency work or follow up on rejected or denied claims as part of standard practice? Yes No

Rejects & Denials

Poll #2

Has anyone analyzed the rejects and denials to see where they are coming from? Yes No

Rejects & Denials

Poll #3

What is a common denial code your agency receives? Write in your response to the right of your screen.

Rejects & Denials

Poll #4

What is the purpose of rejects and denials? Write in your response to the right of your screen.

Start thinking…

Poll #5

What can we do to eliminate or minimize the number of rejected claims? Write in your response to the right of your screen.

Start thinking…

Poll #6

Which group in your agency originates the most rejects? Clinicians Front desk/receptionists Eligibility workers Billers Multiple sources

What You Will Need

All RADs from 6 months or less.

A Staff person to enter data. This does not have to be a biller, and could be

administrative staff.

10 – 20 hours of data entry time, depending on the number of claims submitted.

5 Simple Steps

The Billing Claim Denials Analysis can be completed in 5 simple steps:

1. Collect data2. Enter data3. Analyze data4. Create a plan of action5. Implement the plan

5 Simple Steps

The Billing Claim Denials Analysis can be completed in 5 simple steps:

1. Collect data2. Enter data3. Analyze data4. Create a plan of action5. Implement the plan

5 Simple Steps

The Billing Claim Denials Analysis can be completed in 5 simple steps:

1. Collect data

2. Enter data3. Analyze data4. Create a plan of action5. Implement the plan

The Analysis Tool

Overview of the Analysis Tool

An Excel workbook with 5 sheets1.Summary denials sheet

Data entry with some formulas

2.RAD denial data sheet

Data entry tab where the “meat” of the denials gets entered

3.RAD denial summary sheet

Populated from RAD denial data tab – no data entry unless you need to customize

Overview of the Analysis Tool

4.Chart

Data table is on RAD denial summary tab

5.Collection Report

Data entry

Summary Denials Worksheet

Automatically sums the paid, duplicate and denial claims

Divides the number of denials by

total number of

claimsDivides the number

of duplicate and denied claims by the

total number of claims.

Recap – Summary Denials Worksheet

Enter data in cells A through F.

Cells G, H and I use formulas.

Gives you summary data for the whole RAD not just denials.

RAD Denial Data Worksheet

For the code breakdown on the next sheet only one denial

code can be entered

You must put a 1 in this column to

feed the code breakdown on the next sheet

Recap – RAD Denial Data Worksheet

Enter data from RAD into cells A, B, D, E and F.

Only one denial code can be entered into cell G.

A number “1” must be entered into cell H for each completed row.

RAD Denial Summary Worksheet

Cells B and C have formulas

that use information

from the cells in the RAD Denial Data Worksheet

Let’s see a zoom view of this!

Recap – RAD Denial Summary Worksheet

All information is populated from the RAD denial data sheet.

No data entry is needed unless customizing the denial code list.

If customizing, remember to copy the formulas from prior cells.

5 Simple Steps

1. Get the data2. Enter the data

3. Analyze data4. Create a plan5. Implement the plan

Pie Chart

Let’s see a zoom view of this!

Clinical40%

Billing20%

Other20%

Registration

20%

Collection Report Worksheet

$ Owed column has conditional

formatting to highlight amounts

$50 and above.

Analysis Tool Recap

Summary denial and RAD denial data worksheets are the primary data entry sheets.

RAD denial summary worksheet does not have any data entry unless you need to customize the denial codes.

Data table for chart is already formulated – chart will automatically be created from data entered.

TIPS TO REDUCING THE NUMBER OF REJECTED AND DENIED CLAIMS

Common Denial Codes

RAD #0117

This procedure is payable only twice per month Ongoing education and

counseling codes (any combination of HCPCS codes Z9752-Z9754) can only be billed twice in 30 days, per recipient, per provider

RAD #9518

The referring provider must be a Family PACT certified provider The referring Doctor must provide

their NPI# to the rendering Doctor to be reimbursed on Family PACT services.

The NPI# must be in correct field on claim form.

RAD #0315

Recipient information on claim does not match eligibility information on file for this person Verify the name, sex code, date of

birth and client’s ID #

RAD #9655

The frequency limits for this procedure have been exceeded. Resubmit claim with documentation indicating medical necessity for the test Verify if the frequency limit has been

reached prior to rendering services

Lab reservation must be made via the Laboratory Services Reservation System (LSRS) with NPI

Claims must be billed with same NPI reservation was made under

5 Simple Steps

1. Get the data2. Enter the data3. Analyze data

4. Create a plan5. Implement the plan

Planning

Staff trainingChange how information is collectedChange the superbillGet specialized training

Possible Changes

Staff training regarding the completion of the Client Eligibility Certification form.

Modify the superbill to reflect only those procedures your agency provides.

Clearly separate what is in-house lab versus outside lab.

Perform quarterly chart billing audits.

Possible Changes

Create a daily chart review prior to billing.

Create clear steps to rectify questions prior to billing.

Provide training to clinicians regarding coding.

Resources:

Family PACT www.familypact.org

http://familypact.org/en/Providers/policies-procedures-and-billing-instructions.aspx

(PPBI, Provider Bulletins, Superbill)

Resources (cont.)

Medi-Cal www.Medi-cal.ca.gov

http://files.medi-cal.ca.gov/pubsdoco/billing_tips.asp

(Provider manual, Bulletins, CMC info)

5 Simple Steps

1. Get the data2. Enter the data3. Analyze data4. Create a plan

5. Implement the plan

Questions????