Payment posting and denial management for medical billing process Payment posting and denial management are two extremely critical steps of the revenue cycle management of any solo practitioner or a healthcare organization. Streamlining these processes improves the RCM cycle leading to lesser delays in the A/R’s, ultimately guiding the way to increasing revenues along with patient satisfaction. Payment posting and its factors: In this process, the payment records of patients are recorded in the billing management software. It also includes attention to be given to claim denials - for identifying the problematic areas and their reasons along with apt actions to be taken on resolving the issues. Analysis of Explanation of benefits (EOB): The EOB contains personal details of the patient, services tendered and their respective codes, the amount of insurance which was billed, allowed and adjusted money (EOBs are accompanied with payments from insurance agency) along with denial information, co-pays etc. This information is keyed in, and an analysis is conducted to verify the above, to check if claims were processed suitably, and regular trends recorded for further analysis. Action on the analysis/patient billing: If there is money left from the insurer, the rest of the copays/deductibles/co-insurance/uncovered insurance bills are then sent to the patient for payments. This information must be passed on to the billing department at the earliest to increase cash flows. Payments must be entered within one day or less of receiving receipt. EOBs and Electronic Remittance Advise (ERA) must be obtained; 20% of the medical payments are manually entered in the system as some insurance payers do not provide ERA (835/ERA). The claims must be handed over to the A/R team for follow-up. Accuracy increases overall billing competence, and analysis leads to clearing out the causes for low inflows. Automation of processes can increase the chances of timely, appropriate and faster revenues. Denial Management and its processes: Denial management is all about bringing the number of denials down to the lowest i.e. minimizing on losing out reimbursements and maximizing the probability of payments of unpaid claims the next time. A denial management system must include charge entry analysis, tracking of payer denials, and activation of claim alerts on claim resubmissions and status. Also, denial claims must be resubmitted within a week (there are limits on the time available to a hospital to appeal a denial). Hence, tracking of denials is important to ensure that claims are not being denied for the same reasons, or expiring before resubmission.
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1. Identify: Identifying the reason for denial is the first step to getting paid successfully. Common claim denials include type, number and source of the denial, or coordination of benefits, documentation, bundled/non-covered procedures, credentialing, authorization, duplicates, referrals, medical necessity, charge entry, PIP applications, and details of accidents, pre-existing conditions, and incorrect demographics. The insurer usually mentions the claims adjustment reason codes (CARC) for each CPT, and may be accompanied with remittance advice remark code (RARC). These claims are unpaid services and are either lost or delayed revenues to the physicians' practice. Once identified, they must be analyzed upon thoroughly. 2. Manage: Denials must be directly routed into work lists. For e.g. coding related denials must be directly sent to the coder; if the responsibility is on the patient to foot the bill, it should automatically move to being the guarantor's responsibility and appear in the next cycle of statement mailings. Sorting of denials must be based on categories. Employees must streamline the work while using sophisticated software systems and regular trainings must be conducted to successfully work on denials. Also, creation of a standard workflow for each denial along with a step-wise plan and action avoids unnecessary/duplicate work. Use a checklist such as: avoid delays on identified reasons of denials and act immediately, avoid automatic re-billing, build the case on why the insurance payer was incorrect in denying the claim, remember to keep the patient posted on all details, take the help of experts if needed, and ensure that denied claims are not written off as bad debts. 3. Monitor and prevent: Monitor the employees; track, report and measure the performance of one's own practice. Processes can be revised and automated further, workflows adjusted, new technology can be purchased and trainings imparted to employees for further prevention of denials. Prevention can take place at various levels of the denial process such as during registration, coding procedures, authorizations and/or service not being a medical necessity. Accurate and efficient payment posting and denial management systems can lead to revenue cycle profitability bringing valuable returns.
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www.medicalbillersandcoders.com Copyright Š-2016 MBC. All Rights Reserved