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.
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
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]
It IS POSSIBLE to improve medical billing revenues, and here are a few ways to do just that.
Healthcare practitioners, whether established or just starting out, have many overwhelming tasks: Managing a practice; Seeing patients; Working to staying up-to-date on administrative tasks; The whole host of compliance at the federal, state, and local level; and Overseeing the billing.
One of these that can lead to loss of revenue is not properly managing the medical billing, which can also lead to HIPAA fines and rejected claims. However, there is a solution: a medical billing system that balances the budget and optimizes revenues of medical practice.
EZClaim, an expert in the medical billing software market since 1997, provides a solution that improves the efficiency of an office’s billing process in many ways. The following are the primary reasons.
Reduce Coding Errors Medical procedures become codes, codes become claims, and claims become revenue. Any error in this process can make claims to be denied, your workload can be increased, and revenue can be lost. To help in avoiding errors, it is essential to use billing software that offers the easiest implementation and access to descriptive diagnosis and treatment codes. EZClaim’s medical billing solution offers ease-of-use in coding, billing, and strong partnerships with Clearinghouses which act as an additional ‘safety net’ for catching errors.
Administrative Support Most medical practices are a small team of people tackling a wide range of tasks, so when one cannot understand the function of the billing software, accessing reliable support is very important. EZClaim prides itself on having dedicated support experts available, and that was how the company was established. Founder and President Al Nagy has said, since day one, “We are a support company that happens to sell medical billing software.”
Maintain Industry Compliance It is important to recognize that industry compliance and a practice’s revenue go hand-in-hand. Filing and batching inaccurate and non-HIPAA compliant claims can often be traced back to an outdated healthcare revenue management system. Conquering these tasks requires a focus on multiple fronts: A properly trained billing team, clear office procedures, patient payment policies, and a reliable medical billing company. These are all ways to help buttress against non-compliance and rejected claims.
Streamline Workflow Recently, a study was done that showed almost 80% of medical bills contain errors. These incorrect medical claims often end up as lost revenue originally, not to mention the additional cost of resubmissions and collections. One of the best ways to resolve this problem for your practice is to make use of both well-trained, experienced billers and coders, combined with a competent medical billing solution that aids in catching these errors. EZClaim software features a library of standard validation, the ability to add custom validation, and integrates with Alpha II for full claim scrubbing.
Follow up Errors will and do occur, so establishing a system for follow-up on all denials will close the loop and protect against lost revenue. Being consistent with the follow-up process, and having a medical billing solution that tracks these things will help close that gap.
Collections Finally, probably the most important aspect that optimizes a practice’s revenue is to get paid. Portals and payment collection systems definitely help with this, but having collections integrated into the medical billing system is, of course, the best. EZClaim has pain-free payment processing integrated into their solution, called EZClaimPay. It solves all the problems associated with payment processing: Bank deposits, reconciliation, statements, changing fees, and ‘finger-pointing’ when there is a problem. EZClaimPay’s robust platform will greatly increase a practice’s collections success, and improve their revenue.
ABOUT EZCLAIM: EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at email@example.com, or call a representative today at 877.650.0904.
Concerned about the claims process during COVID-19? Well, Alpha II remains on the forefront of the coding and billing changes during the COVID-19 public health emergency (PHE). They understand this is a confusing time for providers, practices, and hospitals.
Now more than ever, practitioners are relying on the revenue brought in by accurate claim submission. So, if you would like more up-to-date details, join us for our Bring Revenue Integrity to the Claims Process During COVID-19webinar on June 16th at 1 p.m. ET, and learn how to recover revenuebased on the waivers allowed under the PHE. Click here to register for the webinar.
We have also compiled a comprehensive COVID-19 billing and coding FAQ document of questions received during our highly-attended webinar series. Click here to download the resource.
As guidelines for coding and billing of COVID-19 services are revised regularly, Alpha II is implementing these critical changes to regulations and coding guidance—almost immediately.
Alpha II empowers precision across the revenue cycle process so you can experience reduced cost, improved cash flow, and increased revenue. Through its software-as-a-service (SaaS) solutions, Alpha II supports coding, compliance, claims editing, value-based quality reporting, and revenue analysis.
For more details about how Alpha II’s solutions can keep your coding, billing, and editing current, view our website or fill out our contact form to ask us a specific question.
Alpha II is a preferred partner of EZClaim, and their software is integrated into our medical billing software. For detailed product features or general information about EZClaim, visit our website atezclaim.com/
If you are a member of the MEDICAL BILLING COMMUNITY, the norms of the day-to-day have changed. With the recent COVID-19 pandemic and the ‘stay-at-home’ order, you may find yourself with either more time on your hands and/or an increase of claims with new patients. During this time, we want to offer you a couple of suggestions so that you can make the best use of the additional time you have, and also help you improve your billing processes.
The first thing to consider is to review your Accounts Receivable (AR)—to collect payments due you to INCREASE YOUR INCOME. According to the American Medical Association (AMA), claim denial rates range between 0.5% and up to 3% or more, and that 90% of claim denials are preventable. Some of the most common claim denial reasons can be rectified by correcting claim management workflows, including claim submission and patient registration procedures. The following are a few of the most common oversights for claim denial.
Use EZClaim software to check automatically for missing information, including absent or incorrect patient demographic information and technical errors
Make sure you do not have duplicate claim submissions
Check that claims do not have services previously adjudicated
Review for claims with services not covered by the payer
Make sure the time limit for claim submission has not expired
Secondly, revisit and resubmit open claims. Surprisingly, 31% of providers still use a manual process to resubmit. Our partner,TriZetto Provider Solutions (TPS), has anAdvanced Reimbursement Manager Pro (ARM) that has two great tools that can improve your ability to tackle collecting and repaying underpaid and overpaid accounts. Below are some key features that can be automated by their software, and will help to improve your billing processes:
Identify common errors and payer trends
Analyze contract performance
Customize and assign work into queues
Quickly access information from interactive dashboards
Automate the appeal process
Thirdly, know thatEZClaim and our partnerTPS have worked together to bring you the most powerful medical billing software tools to solve claim denials. Our partnership not only simplifies the billing process but also helps resolve denied claims in an efficient way. In addition to that, ourcustomer support team is available to help you learn best practices with these tools, and support you however you need it.
Finally, if you are frustrated with your current medical billing solution, investigate how EZclaim’s medical billing solution may work for you. You can eitherschedule a one-on-one consultationwith our sales team ordownload a FREE TRIALto check it out the software yourself. For additional information right now, contact EZclaim’s sales team at877.650.0904or send an e-mail firstname.lastname@example.org.
A recent medical billing webinar on Telehealth that EZclaim hosted is now available to review.
On April 30th, EZClaim hosted a Telehealth Updates Webinar for our clients with guest speaker Sandy Giangreco Brown – Director of Coding and Revenue Integrity Health Care at CliftonLarsonAllen, LLP
We had one of the largest viewing audiences 101 active attendees in the session. Sandy shared informative billing codes and direct links to update hands-on information for billers actively coding Telehealth sessions. For those of you who missed it, we have provided on our website the recorded sessionezclaim.com/webinars and can provide the presentation slides too! Just send a request to email@example.com
We continue to get views of this presentation and look forward to hosting more hot topics with the CLA Team.
With the onset of COVID-19 came a great opportunity for clinics and hospitals to offer Telehealth and Communication Technology Based (CTSB) services. The Centers of Medicare and Medicaid Services, or CMS, have provided many updates to the available services that can be provided and billed to the patients to help practices not only stay afloat financially but also and most importantly, to keep their staff safe and provide excellent care to their patients!
There were new guidelines released even after this webinar on 4/30/2020 (which can be found here – https://www.cms.gov/files/document/se20016.pdf, and now includes audio-only Telehealth for services such as psychotherapy, tobacco cessation and medical nutrition counseling as well as diabetes self-management training. CMS is also increasing the payments for the Audio Only services from $14-$41 nationally to $46-$110.
As of April 30, 2020, in order to bill Telehealth, RHCs are now required to bill the G2025–CG–95 from January 27, 2020, to June 30, 2020. Then from July 1, 2020, to the end of the PHE, they will be billing the G2025 with an optional 95 modifier, per CMS SE20016 Medicare Learning Network Transmittal.
FQHCs will need to report three (3) codes for their Telehealth Services:
G0467 (or other appropriate FQHC specific payment code)
99214–95 (or other FQHC PPS Qualifying Payment Code)
CLA is on the frontlines and closely monitoring and analyzing activities related to Telehealth and other virtual health regulations
As your practice adjusts to Telehealth going forward, EZclaim’s medical billing solution can help you simplify patient billing and help you get paid for Telehealth visits. (Our recent medical billing webinar on Telehealth may just help you better understand the current situation).
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