Create Interoperability Now for Changes Ahead

As the use of various technology systems continues to increase within medical practices, interoperability between those systems becomes critical. An article called, “Interoperability a Key to Effective Communication” on the AAPC website states, “Disparate computer systems must communicate structured data in a way that both systems understand.” Consequences of having disparate systems could mean a…


Importance of E/M Outliers for Current Clients

In today’s coding environment, internal auditing is an important business process for avoiding costly repayments and other punitive measures for bad billing. Evaluation and Management (E/M) services are always highly monitored by auditors since those services represent such a large percentage of Medicare Part B billing. What to know Your internal auditors ought to be familiar with their…


Importance of E/M Outliers

In today’s coding environment, internal auditing is an important business process for avoiding costly repayments and other punitive measures for bad billing. Evaluation and Management (E/M) services are always highly monitored by auditors since those services represent such a large percentage of Medicare Part B billing. What to know Your internal auditors ought to be familiar…


CLDPP to Combat Increasing Payor Rules

AMA’s 2012 National Health Insurer Report Card provides interesting insight into what the revenue cycle might look like in the next few years (Learn more about the AMA 2012 Report Card, here). There are two interesting observations on the data that need to be considered with respect to what types of tools provider organizations will need in the future…


AMA’s 2012 National Health Insurer Report Card

The AMA has published its National Health Insurer Report Card, comparing data from seven commercial payors and Medicare on key administrative metrics. While there have been great improvements that have saved the healthcare industry billions of dollars, this report shows a few interesting findings that directly correspond with a physician’s bottom line. Click HERE to continue reading. 


Finalized ICD-10 Implementation Date and Stage 2 Meaningful Use Requirements

Today, CMS made final a one-year proposed delay (from Oct. 1, 2013, to Oct. 1, 2014) in the revised ICD-10 implementation date.  The CMS final rule report ends months of speculation about the timing of ICD-10. Practices and providers will need to make preparations well in advance of the conversion date to prevent revenue losses.

In addition, an extended timeline for early adopters of Meaningful Use has been adopted. The Stage 2 rule gives providers more time to meet Stage 2 criteria. A provider that attested to Stage 1 of meaningful use in 2011 would attest to Stage 2 in 2014, instead of in 2013. Therefore, providers are not required to meet Stage 2 meaningful use before 2014. For more information, please click here.  


Creating a Closed Loop Denial Prevention Process

So, how do you create a Closed Loop Denial Prevention Process?  It requires a rules engine capable of finding claims that are destined for denial; preferably before they are posted to the PM system so that backend modifications and corrections are not needed and without creating a lag time prior to submission with negative cash flow impact.

With AccelaSMART, White Plume clients use their denials experience and payor communications to proactively set up customized rules. These rules are designed to prevent denials and improve 1st Pass Pay rates (the rate at which claims are paid with the first submission).  The customization available within AccelaSMART allows users to set up the specific criterion that applies to their services, coding, master files, providers, region, plans and other details about a specific claim to ensure it will pass the payor’s edits.  Think you don’t need that much granularity?  Remember, United Healthcare applies over 82,000 rules to adjudicate claims over and above the industry standards.  Think about that. 

Diagram 1 depicts a Closed Loop Denial Prevention Process, starting with the advent of a new policy or denied claim, building a customized rule to catch conditions that will trigger a denial, enabling the rule for all billers to use and thereby preventing the denial from happening again.

Diagram 1. – Closed Loop Denial Prevention Process
closed-loop-diagram

The great thing about a Closed Loop Denial Prevention Process is that it is scalable and uniform across an organization.  The process can be applied consistently for each biller, regardless of their experience, skill sets and day-to-day distractions.  It improves productivity with workflow designed to minimize errors and streamline corrections.  Using a closed loop process significantly reduces the time clinicians spend on getting claims paid and puts process improvement at the right point in the life cycle of a charge. 

Ultimately, a Closed Loop Denial Prevention Process improves cash flows and profitability by ensuring claims can be paid as they should be, quickly and completely.


Preventing Reimbursement Denials in Context

To better understand what a closed loop denial prevention process is, let’s first examine what the opposite would be and study what normally happens when a payor implements a proprietary rule.  According to AMA’s 2012 National Health Insurer Report Card, Aetna has over 62,000 proprietary rules in addition to over 1 million edits that are considered “industry standard”.  Table 1 shows the total number of claim edits by rule source, by payor.

Table 1. – Total number claim edits by type and payor

 

Aetna

Anthem

Cigna

HCSC

Humana

Regence

UHC

Medicare

CPT

 36,266

 36,796

 36,509

 36,796

 36,796

 36,815

 31,135

 36,568

ASA

 1,070

 1,070

 1,070

 1,070

 1,070

 1,070

 1,070

 1,070

NCCI

 860,694

 860,765

 860,765

 860,765

 860,765

 860,765

 860,765

 860,765

CMS

 184,220

 185,371

 185,365

 185,371

 185,371

 185,371

 169,178

 185,371

Payor-specific

 62,335

 76,726

 1,190

 123

 5,033

 5,000

 82,868

 19,683,450

 

In an environment where payors have free reign to define their rules and disclosure is optional; providers have to keep up with the ones that apply to their specialty, location, services, patient panel and other criteria.  Sometimes, advanced notification of the rules’ implementation is communicated in a newsletter, typically weeks before enactment.  Billers rely on manual methods (sticky notes) and to a large extent – their memories – to comply with these rules and count on their clearinghouse to catch what they have missed. 

But clearinghouses don’t always supply the means to catch all the proprietary rules and don’t delve into the granular nuances that aren’t applied nationally.  Catching these types of corrections is normally left to the intellectual capital found in a key employee or two who just “know” how to get claims paid; based on previous denial experience and their diligence in keeping current with new rules.  They are a valuable commodity and subject to the frailties of mankind, if not the lure of a better position or a different career path.  This describes the open loop process of denials prevention – relying on staff to remember and catch a soon to be denial before it is submitted.

Now how do you create a closed loop denial prevention process? Stay tuned for the next post! 


What is a Closed Loop Denial Prevention Process?

  • Closed loop; noun – a control system with a feedback loop that is activepayor-rule-changes-per-month
  • Denial; nounthe refusal to satisfy a claim, request, desire, etc.
  • Prevention; noun – an action that stops something from happening
  • Process; nouna systematic series of actions directed to some end

As the name implies, a Closed Loop Denial Prevention Process is one designed to prevent denied claims. This process uses a system of rules and edits to provide consistent feedback that is dynamically available each time conditions are present that will result in a denied claim.  The process alerts users to the potentiality of the denial and instructs modifications that will prevent the denial from occurring.

Beats the heck out of sticky notes. 

Even if they have never thought about the term closed loop denial prevention, this is a process that White Plume users know well.  They’ve most certainly been keenly aware that AccelaSMART™ is a dynamic, interactive method of finding potential denials and fixing them prior to creating charges and submitting claims.

So how do you actually prevent denials through a closed loop denial prevention process? Stay tuned… 


Even with EHRs, Practices Continue to Manually Code

In a recent report by the Office of Inspector General (OIG), OIG auditors observed that the majority of physicians who have adopted EHRs continue to code Evaluation and Management (E/M) services manually—even though most major EHR vendors offer technology that will code E/M services automatically.

For the past decade, the OIG has kept a close eye on E/M coding because the level of E/M visits reported are trending higher at present than in previous decades. EHR adoption is intended to increase the accuracy of medical coding (e.g., E/M codes); however, this report suggests that physicians still prefer to code E/M visits the “old fashioned” manual way rather than adopt a new technology to automate the process. 

The OIG report did not offer any insight as to why physicians are still coding E/M visits without the help of EHR tools. Some theories include: E/M modules cost more money on top of an already expensive EHR system, E/M templates are not user friendly to the physicians, or physicians may not trust any EHR system to code for visits that affect such a large percentage of the revenue. Regardless, physicians often code E/M visits incorrectly, resulting in either over or underpayments.

If EHRs are not proving useful in coding this area of medical services, then physicians must look to other sources to avoid coding errors during claims review.