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Billing: Dedicate time to improvement

Billing: Dedicate time to improvement

Kit ShellhouseQ. What part of the revenue cycle can I focus on that would assist in collecting all revenue vs. continuously writing off balances due?
 A. To achieve success, there needs to be a root-causes analysis. To get started, it’s always best to look at the organization’s top denials, who owns the denial, what part of the process is contributing to the denial and then finally what process changes can be implemented to prevent future denials. The key to success is continued trending and monitoring to ensure denials are minimized. For example:
CO50 tends to be on the list of your most common denials and is holding revenue.
Common culprits in this category:

  • Portable oxygen was dispensed, but test was taken during sleep. 
  • A diagnosis code-driven item, such as nebulizer, billed without a qualifying diagnosis.
  • A claim selected for prepayment audit, but failed.

Solutions:

  • Reviewing intake protocols for properly qualifying patients.
  • If the patients do qualify, are they inputting the qualifying information in your software?
  • The front-end billers should be monitoring for these types of data entry errors prior to the claim submission.
  • Are there solid processes for gathering documentation and responding to audits?

Other payers/contractors CO109 - Claim/service not covered by this payer/contractor & 
CO22 – May be covered by another payer per coordination of benefits.
Scenarios that may be contributing:

  • Patient’s payer is primary compared to insurance billed.
  • A claim was submitted to a secondary insurance without the primary EOB.
  • The patient was enrolled in an HMO.

Solutions:

  • Is the staff checking eligibility enough?
  • Is the staff going beyond verifying the patient is eligible to make determination?
  • Compare the address Medicare lists to what is listed in your software.
  • Is the staff maximizing rental months in a SNF situation?

Dedicate the time to improve and collaborate with your team to prevent future denials. This will springboard you to collecting your well-deserved revenue.
Kit Shellhouse is vice president, ECS North. Reach her at [email protected]

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