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Processes for Rejections & Denials – RCM Insight

Processes for Rejections & Denials – RCM Insight

Last month we looked at tools for getting clean claims out the door on the first try.  Many billers or practices stop monitoring claims once the leave the practice management program, but this is where you are likely losing money. The unfortunate truth is you need to use the tools available to you to catch rejected and denied claims to ensure proper and timely payment.  Today we will look at rejections and denials, and the resources you have (or need) to work efficiently.

The terms rejection and denial are used interchangeably in the billing world but they have distinct differences, including how you are notified.  Let’s start with defining the differences.

Rejected Claims

  • Claims can be rejected by the clearinghouse OR the payer
  • Rejections are based on submission guidelines
  • Rejected claims have not been entered into your payers system for adjudication
  • Notified through a claim status report (ANSI 277) that comes back into most practice management programs from the clearinghouse
  • Corrections do not require a resubmission code

Denied Claims

  • Claims are denied by your payer
  • Denials are based on policy coverage
  • Denials have been accepted for adjudication and deemed unpayable
  • Notified on remittance advice (ANSI 835/ERA)
  • Payers may require a resubmission code and original reference number when submitting a corrected claim

If you are using a clearinghouse and receiving your claim status reports electronically, you will be notified quickly about rejected claims.  There are two ‘checkpoints’ that will look for errors.  The first is your clearinghouse, the second is the payer.

At each checkpoint claims will be Rejected or Accepted, these status updates come to you through a claim status report.  If your practice management system is able to process these reports (ANSI 277) your claims will be updated with the accepted or rejected information you will be able to correct any rejected claims within your practice management system.  When you see an error, start with checking who has rejected your claim.  This will be the point of contact if you have questions about the rejection or how to correct it. If you are not already, make it a daily task to get your reports, correct any rejected claims, and resubmit those claims.

When a claim has been accepted by your clearinghouse and the payer it enters the adjudication system.  This is where the payer will make a determination on payment based on the members coverage and your contract.  The denials will appear on your remittance advice with a payment or as a zero dollar payment, indicating that they have reviewed your claim and they have determined no payment is applicable.  If you are enrolled with you payer for electronic remittance advice (ERA) this file will come electronically and your practice management system will be able to list or identify denied claims.  These claims will either need to be researched further for clarification on the denial or written off.  It is vital that your practice management system can handle these scenarios appropriately so you do not lose money for payable services.

This is another scenario where technology can seem scary.  However, efficiently monitoring and working is well worth the learning curve.  If you are already sending electronically and not using the claim status report or electronic remittance advice – coordinate with your clearinghouse and practice management system to find out how these reports can save you time and money.

If you would like more information on creating workflows for rejections, denials, or enrolling with a clearinghouse, let RCM Insight help! Visit us at www.rcminsight.com to request a consultation.

[Contribution by Stephanie Cremeans with RCM Insight]

Dark Web Breaches: Steps you can take, to avoid being a victim

Dark Web Breaches: Steps you can take, to avoid being a victim

It’s no secret that the Dark Web is a scary place to lose your information, but what if it affected your entire company? Medical Records information sells anywhere from $1-$1000 by identity thieves!

What is a “breach” and where has the data come from?

A “breach” is an incident where data is inadvertently exposed in a vulnerable system, usually due to insufficient access controls or security weaknesses in the software. Data breaches are becoming more common and sometimes out of your control.

How can you protect yourself and/or your organization?

  1. Carefully monitoring where you store and enter your passwords can be extremely beneficial to help minimize the risk of a hack and keeping personal or patient information protected.
  2. Routine password changes and monitoring where you store and enter your passwords, can be extremely beneficial to help reduce the risk of becoming a victim to a hacker. Passwords should be long, unique in characters, capitalization, and alphanumerical.

If you believe you might have revealed sensitive information about your organization, report it to the appropriate people within the organization, including network administrators. They can be alert for any suspicious or unusual activity.

Firefox Monitor says, “Your password is your first line of defense against hackers and unauthorized access to your accounts. The strength of your passwords directly impacts your online security.”

Live Compliance can help. Live Compliance aggregates breaches and enables you to assess where their personal data has been exposed. Dark Web scanning is built right into the Live Compliance portal. Keep an eye on employees whose information was involved in a breach (and where the breach took place), and the suggested next steps to take.

What can I do to ensure this doesn’t happen to me or my organization?

At Live Compliance, we make checking off your compliance requirements extremely simple.

  • Reliable and Effective Compliance
  • Completely online, our role-based courses make training easy for remote or in-office employees.
  • Contact-free, accurate Security Risk Assessments are conducted remotely. All devices are thoroughly analyzed regardless of location. Conducting an accurate and thorough Security Risk Assessment is not only required, but is a useful tool to expose potential vulnerabilities, including those such as Password Protection.
  • Policies and Procedures curated to fit your organization ensuring employees are updated on all Workstation Use and Security Safeguards in the office, or out. Update in real time.
  • Electronic, prepared document sending and signing to employees and business associates.

Don’t risk your company’s future, especially when we are offering a free Organization Assessment to help determine your company’s status. Call us at (980) 999-1585, or email me, Jim Johnson at Jim@LiveCompliance.com or visit www.LiveCompliance.com

For more information about DarkWeb breaches please contact us at (980) 999-1585 or email us at support@livecompliance.com

[Contribution by Jim Johnson at Live Compliance]

Patient Information, Time Savings, and the EZClaim Eligibility Feature

Patient Information, Time Savings, and the EZClaim Eligibility Feature

Can you add up the number of hours your billing team spent during any given week or month waiting on-hold with insurance companies to get patient billing information? Does your staff invest hours of their valuable time seeking out the smallest of details to get paid? Are you aware that integrated eligibility, through EZClaim’s medical billing software, can reduce that time on-hold to a fraction of the total?

It is estimated that the average biller can spend up to 2-hours on-hold just to get an insurance company on the phone. Add to that an average of 10 – 15 minutes to talk through a patient and most companies will only address one or two patients at a time. To add to it often there are multiple insurance companies to call. As you can tell you quickly have a considerable amount of time lost making phone calls. Instead of spending hours on the phone with insurance companies, make best use of your staff’s time by checking to see if you have the integrated eligibility feature in your billing software. 

Getting started is as easy as getting set up with a clearinghouse (EZClaim clearinghouse partners). Once you are signed up with a clearinghouse for the electronic claim submission program, they will have an integrated eligibility feature that is integrated into EZClaim.  Once you sign up with this feature, you can send a batch request of 50 patients at one time and if needed, send multiple requests in a day. Do this by selecting an active patient list collectively or send them individually in smaller amounts. Either way the time savings will be exponential.

Eligibility response reports often come back within seconds making the process nearly real-time. When a response comes back you have the real-time eligibility information. You will get details on if they are covered or not, their active dates, deductibles, co-insurances, co-pays, and what amounts they are subject to and what will be deducted. With EZClaim eligibility integration built in you save valuable time. To learn more contact EZClaim’s website, email, or call 877.650.0904.

ABOUT EZCLAIM:

EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.

7 Tips for Patient Collections

7 Tips for Patient Collections

Collections aren’t the most glamorous part of running a practice. Perhaps the only thing worse than making collections calls is receiving them! Unfortunately, collections are necessary and if done correctly, it will allow you to collect on accounts that have sat stagnant for months, sometimes years.

In our years of experience managing collections for small and medium physician practices, we’ve identified seven best practices for optimizing your collections.

  1. Speak their language.There are so many ways to communicate these days. Routinely ask and record how your patients prefer to be contacted. Phone? Email? Text? Mail? Patient Portal? For best collections results, communicate with your patients using their preferred communication method.
  1. Allow multiple payment options.Similar to communication methods, there are several payment methods that different people prefer. For some, a payment plan might be their best option. For others, credit card payments. For yet others, cash or checks. Sometimes, patients want the ability to finance their medical procedures through a healthcare financing company like Care Credit.  And with today’s ever-changing technology, look into text message billing reminders with links to pay from their phone – and even QR code-driven options! Make sure your practice can accept multiple forms of payment to optimize your collections.
  1. Coach your staff.We encourage you to train your patient-facing staff to implement some basic key principles: Be a good listener; Talk in terms of the other person’s interest; Make the other person feel important and do it sincerely.  By implementing these simple practices, your patients will feel less attacked and more heard – which in turn will hopefully lead to increased payments.
  1. Optimize technology.Most practice management systems, patient portals, and/or EHR platforms have advanced notification settings where you’re able to reach out to the patient (via their preferred communication method, of course) with reminders, balances, past-due alerts, etc.  Using technology to automate parts of the process can reduce the heavy lifting for your staff.
  1. Discuss costs upfront.Being upfront about the costs of your patient’s care is one of the most effective ways to minimize collections. If you offer a limited number of services, consider listing the prices on your website or marketing collateral. If you’re a general practice, ensure your staff is communicating with patients before treatment regarding costs and how they plan on paying for their care. A shift we’ve seen over the past several years in healthcare is having a Patient Financial Counselor on the front end. This roles’ primary responsibility is to know what the patient is coming in for, verifying their benefits & coverage – and then reaching out to the patient before the appointment to provide them with an out-of-pocket estimate and payment options. That way, when the patient presents for the appointment, they are already aware of their financial obligations, and not surprised a few months later with a bill they were not expecting.
  1. Incentivize your collections staff.Collections can be tedious and tiresome. Consider offering incentives to help the task feel a little more exciting – small prizes can go a long way in motivating! Some incentives we’ve seen include PTO, cash, practice logo wear , and gift cards – based on the amount they’ve collected.
  1. Enlist expert help.Consider partnering with a healthcare-focused organization that specializes in collections. The tricks they’ve learned by working with other practices may decrease your outstanding balances in a shorter amount of time than doing so internally.

Implementing these tips can help reduce your collections timeline and increase the amount you’re collecting.

There are many great organizations that can help you in these areas – and MedCycle Solutions is one of them. If you’re wondering how partnering in these areas could work for your practice, let’s connect.   Ranadene (Randi) Tapio, MBA, CMRS, CPCS is the Founder & CEO MedCycle Solutions, which provides Revenue Cycle Management, Credentialing, Outsourced Coding, and Consulting Services to a number of healthcare providers in a variety of specialties. To find out more about MedCycle Solutions services please visit www.MedCycleSolutions.com.  You can reach Randi via email at Randi@MedCycleSolutions.com or call 320-290-6448.


ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.