Imagine Blog

Jennifer Kroken

Jennifer Kroken

Jennifer Kroken is a Practice Solutions Consultant for ImagineSoftware with 27 years of industry experience. She is a frequent contributor to several national radiology publications and received her MBA from Upper Iowa University.

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Winning Against Claims Denials in Medical Billing

“Denials management” conjures up several ideas: a software we should be using, a term we espouse in meetings, something to put on our resume, and something we’re supposed to be managing. But are you doing denial management effectively? How do you define “effective?” And how can you reduce claims denials in any meaningful way?


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What is Denial Management?

The term “denials management” came into favor as billing systems garnered more horsepower—we suddenly had the benefit of real-time views of our billing offices with the ability to see denials now—rather than a month after we posted them. We suddenly had useful information at our fingertips but at times, have struggled with what to do with this information.

As an industry, we have had a somewhat difficult time in defining benchmarks for what is an acceptable denial rate. Comparing a primary care office with a radiology practice holds little value—a primary care practice should have fewer denials since they control the information from the time the patient enters the practice. Hospital-based specialties, on the other hand, are at the mercy of whomever sends them the information which can run the gamut of “not bad” to “did you actually see this patient?!”

The trick in defining the problem has gotten much easier, thanks to sophisticated billing software. But the solution still lies in managing the people and the processes. When pinning down a manager with their denial management program, it’s not unusual to hear about their appeal letters. That is indeed part of the solution, but you can (and should) do much more.


How to Improve Denial Management

When setting goals for how to improve denial management, strive to achieve these goals:

  • Reduce denials
    • There is much that has assisted this effort with both billing software and the use of value-added clearinghouses. They both trigger alerts that your claim is stuck for a needed piece of information. This has greatly reduced the back-end denials seen in A/R follow-up and payment posting.
    • Root cause correction -- forming a task force with the hospital, for instance, to reduce prior authorization denials or create a team with your billing office and imaging center employees to modify processes to reduce eligibility denials.
  • Improve follow-up processes
    • Employ purpose follow-up
    • Work for efficiency gains
  • Identify compliance risks
  • Improve profitability

List of Denial Codes in Medical Billing

The above goals have the mission-critical task of defining the problem. But when you run your denials report, you may be met with a list of denial codes in medical billing referred to as “ANSI codes.” These codes refer to many the same thing using different terms. While it’s nice to have the specific reason straight from the horse’s mouth, it’s not the best for managing the process. Specific? Yes. Efficient? No. More on that in a minute… If you comb through ANSI codes, you can find these fun ways to define a “duplicate” denial:
  • 18: Duplicate claim/service
  • 23: Payment adjusted because charges have been paid by another payer (may not look like a duplicate denial, but it is.)
  • 57: Payment denied/reduced because the payer deems the information submitted does not support this level of service may have been provided in a previous payment
  • B13: Previously paid. Payment for this claim/service may have been provided in a previous payment

...and duplicates are an easy one. just wait until you see all of the ways to decipher coding denials.


Medicare Claim Denial Reasons

To get a handle on Medicare claim denials reasons, think of your denials as falling into two general classifications: compliance or administrative, followed by your “grouping” categories. If you are an Imagine user, you can map your ANSI codes to either one of these categories, where you can begin to actually “manage” your denials.

    Compliance denials are those that put the practice at risk, either for direct compliance problems or as claims submissions that could be perceived as compliance problems by Medicare—and in that case, perception is reality. Compliance denials include the following categories:

  • Coding (including bundling/unbundling)
  • Medical necessity
  • Duplicate claims (Medicare considers “excessive” duplicates as a compliance trigger. While they have unhelpfully not defined “excessive”, use caution when auto-rebilling claims. It would be best to turn off that feature for Medicare patients.)

  • Administrative denials are where you can really make a difference for your practice—these are usually due to process errors or omissions and are theoretically preventable, although hospital-based practices must do extra leg work in partnership with their hospitals to truly prevent these.

  • Eligibility
  • Missing/incorrect information
  • Prior authorization
  • Timely filing
  • Non-covered service
  • Denied-no reason given


What Are Some Possible Solutions to a Denied Claim?

Using the grouping feature makes denials truly easier to manage. For instance, you can turn your coder loose in the denials tickler by filtering all the coding denials and working through them without other denials getting in the way. It can also help with manual payment posting for the EOBs that do not specifically list the ANSI code and just give a generic denial—they do not have to search for an applicable ANSI code to post the payment.

Now once you have a handle on your denials, it is easier to begin the work of managing them. Root cause identification can lead you to physician dictation issues, a problem of referring physician not giving complete orders, an ineffective coder and hang-ups in the system getting claims out the door, to name a few. Use of Business Intelligence software can also help to drill down your coding category or timely filing—is one facility creating timely filing violations?

The process of managing your denials is doable and necessary. Effective denials management include smart system set-up, defining the problem, addressing root causes and yes…sending out appeal letters. There are nuances to each denial category and many more pages that could be written about the actual processes involved in successful appeals, but once you have defined the problem, you are halfway there.

source: http://www.x12.org/codes/claim-adjustment-reason-codes/

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Using Business Analytics in Healthcare to Power Your Practice

2019 is underway and promises to maintain the breakneck pace of change in healthcare. With the flurry of activity, it is more important than ever to maintain a clear vision of what is happening in your practice so you can make sound decisions with greater impact.

It's hard to believe a mere 15 years ago, we were managing in the rearview mirror—waiting until month end reports to find something had gone wrong or identify the beginnings of a potential disaster. Thankfully those days are over. We are living in an exciting age where administrators now have more access to data than ever before. We have rapidly moved from having static daily snapshots of data to a dynamic real-time, multi-dimensional view of your practice's healthcare business analytics.

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Thanks to Business Intelligence (BI), data provided by billing systems are more granular than ever—but how do we use this to our advantage?

It's easy to be overwhelmed upon first review of business intelligence and analytics for healthcare organizations—there’s a lot of data being measured with some falling into “mission critical” and some “nice to know”. The following are some tips to use your BI to your advantage, while not making data analysis a full-time job.


Use Daily Snapshots to Your Advantage

By now, you most likely have a baseline for a normally operating practice. If not, here are some consistencies to keep track of:

  • Average daily charges - For hospital-based practices it is normally best to exclude weekend activity so you know what a "normal Monday" should be
  • Average daily payments
  • Average trasactions - Coding, payment posting

These are typical "danger zones" where despite all our technological advances, we can quickly succumb to operational failures in billing basics.

With these snapshots, you now have a baseline for a few useful applications of business analytics in practice. For example, having identified a category where the numbers are lower than expected, you can drill down to a coder or payment poster to find they are behind in their work or discover a site of service that may be experiencing download issues. At that point, the manager can quickly deploy necessary resources to correct the issue.  Without a reference point, it will be difficult to make sense of the numbers and impossible to take corrective action promptly.


Approach Healthcare Business Analytics with a Question in Mind

Unquestionably, the most common concern of physician centers on revenue is "why is it down? The best way to answer that question is with focus. Is a particular payer the culprit? Are payments grossly out of line for one site of service from one month to the next?

Be careful not to get too bogged down in isolated numbers, since trends are more informative when defining the problem. Look for abnormalities in the data from one month to the next and then utilize the BI to drill down from there.

For instance: if upon a visual review of your BI, you find Blue Cross appears to be the issue, drilling down into payment data may show that payment posting is a couple of days behind and that alone could answer the question.  However, if the answer does not appear to be that simple, further investigation may reveal the issue lies in problems with the clearinghouse or directly from the payer.

But if everything on the top-level review appears normal, this is where BI can assist in pinpointing the source of the problem. With multiple drill-downs available, you can narrow the focus all the way down to a singular provider who may have been overlooked for a credentialing renewal.

The bottom line is to approach the data with focus, or you can spend hours of time looking at interesting, but not particularly helpful, numbers.


Let BI Be Your Guide

For the experienced BI user (who is less overwhelmed when viewing high volumes of data), allowing BI to ask the question for you could be your approach. Dashboard visuals can be particularly useful in this instance, with BI highlighting danger zones and you can take it from there. Typically, there will be a category that is noticeably “down” based on the graphs and you can often click your way to your answer.

However, allowing the BI to guide you to your issue takes a little more doing than it might first appear. If you have one coder whose productivity recently ground to a halt, there are usually operational questions to be answered (rather than a lazy employee) so take a cautious first pass of the data since the answer may not be obvious on the initial review.

The Perils of Up-To-The-Minute DataThere are far more pros than cons when working with a BI to analyze your practice. However, one area of caution is a question that every administrator has received from a doctor at some point in their career (and if you haven’t…it’s coming):

"What are we being paid for 'X' procedure?"

What should be an easy answer proves to be incredibly difficult. If your BI is counting every payment as a transaction, then make sure you are combining primary/secondary/patient payments to answer this question.  You may have had a batch of secondary payments posted yesterday which could report you are currently receiving ~$8.00 for a CT scan. Be careful not to jump the gun in providing a quick answer and instead, make sure the answer makes sense.

The BI can potentially come in with a career save when it shows you one major payer somehow paid from a new (incorrect) fee schedule and now you really are getting paid $8.00 for a CT. In that case, BI is now your new best friend. Armed with documentation, you can approach the payer for quick resolution and that is something the administrator of 2019 can appreciate.


Conclusion

Understanding that every keystroke and download becomes a data point is both exciting and potentially overwhelming. The BI is a powerful tool in understanding and perfecting your practice. Use caution when reviewing the data because more data is just that: data. Understanding is a separate issue—beating your employees over the head with productivity numbers alone is indeed an approach, but the detail as to why the numbers fluctuate almost always involves an operational issue. Healthcare business analytics provide you up to the minute information, but the basics of a sound operation still…and always will…apply.

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