Streamline Your Revenue Cycle: Part 4
Part 4: Establish complete and accurate charge capture and remittance advice.By Linda Martien, CPC, COC, CPMA Charge capture is critical to your overall revenue cycle and it’s important for you have an understanding of how it relates to the livelihood of your practice. Very simply, it’s the acquiring of information for use in a medical claim document. Without a reliable charge capture process, poor coding and lost charges can cost providers a lot of money. Charge Entry Charge capture starts with the superbill or charge ticket, which can be on paper or generated from your electronic health record (EHR). Although the medical practice may have coded thoroughly and correctly, reimbursement hinges on the charge entry process being completed accurately and in a timely manner. Something as basic as verifying demographic information and insurance numbers could make the difference between payment and denial. Tip: For more information on verifying patient information, see “Streamline Your Revenue Cycle,” Part 2, pages 40-43, in the September 2014 issue of Healthcare Business Monthly. With electronic billing, practice management systems may include a front-end edit capability to check for required data elements and coding edits. When errors are identified, immediately correct and share the information with those entering the data. This will help to prevent similar errors in the future. The Charge Master Listing in the system should allow you to make changes to the listing as codes change, new technology or procedures are implemented in the practice, and providers develop their own particular practices. Claims Transmission Clearinghouses are often used to electronically transmit claims to third-party payers. Generated reports alert the practice if payers reject their claims. Rejections should be dealt with immediately. If errors are the result of data entry or there are trends in the errors, inform staff members and take steps to implement processes that will prevent similar errors from reoccurring. Notify your clearinghouse when submitting claims for unusual services or claims for payment methods requiring certain information or modifiers, or when you are participating in clinical trials or studies. Clearinghouses sometimes unknowingly strip claims of crucial information for these types of services, which can lead to lengthy delays or outright denials. Payment Posting Set up electronic remittance with payers, when feasible. With such a remittance process, staff members only need to work the exception report. It’s crucial that payer contracts and fee schedules are built into the system, so payment posting can be more accurate. Medical practices and facilities should establish an automatic small balance write-off amount. This saves time cleaning up small balance accounts, and may actually save money by avoiding re-billing, postage, staff time, etc. Many hospitals use a guideline of $40-$100, while physician practices are lower, at $10-$20. Don’t set your amount too high or too low. In today’s economy, it’s important that practice income isn’t left on the table. Match the total payments received to the total payments posted per batch in the system. Identify zero payments, partial pays, and low pays to determine if they’re a result of incorrect payments or denials. Resolve such accounts using a denial management process. Denial Management Denial management can encompass any aspect of the revenue cycle that may result in no or low reimbursement. The reasons for the denials can include incomplete or inaccurate insurance information, lack of pre-certification or prior authorization, not capturing all of the tests or procedures, diagnoses and procedure coding errors or omissions, past filing limits claims submission, or a denial due to not meeting medical necessity. Best practice is to trend and track the denials when posting the payments. Track denials by payer, type of denial, and provider. Staff members must be assigned to work denials on a regular basis — daily for a large medical practice, and at least weekly for smaller practices. When trends in the denials are identified, providers and staff members should be informed and processes put in place to avoid similar denials in the future. By working the denials in a timely manner, processes likewise can be corrected on a timely basis. Third-party payers have specific instructions for appealing denials. Follow the instructions; do not haphazardly retransmit claims because this can result in duplicate claims. Medical practice staff members who are responsible for denial management should develop a first-name relationship with provider representatives at high-volume payers. Reimbursement generated from successful appeals can be tracked to demonstrate the value of monitoring and working denials. To prevent denials, specific staff members should be assigned to monitor correspondence, instructions, bulletins, etc., from high-volume payers. Share information with the appropriate providers and staff members so claims can be completed and transmitted according to payers’ specifications. Remittance Advices The Centers for Medicare & Medicaid Services (CMS) provides Health Care Payment and Remittance Advice guidance on its website. You can apply this to other payers, as well. CMS describes the remittance advice as the document sent to the provider (facility, physician, or non-physician provider) explaining how the claim was processed and pertinent payment information, such as whether the patient has met his or her deductible and if co-payment or co-insurance is due from the patient. The term “remittance advice” often is confused with “explanation of benefits” (EOB). Remittance advice and EOB are not the same thing. Remittance advice is sent to the provider and EOB is sent to the patient. According to CMS, after a claim is sent to Medicare (or another payer processing a claim), either an electronic remittance advice (ERA) or a standard paper remit (SPR) is sent with final claim adjudication and payment information for multiple claims. ERA or SPR information is itemized for each claim and/or line, showing the provider associated adjudication decisions (each adjustment, and its value) with the claims/lines he or she submitted. Adjustments are at line, claim, or provider level. Line or Claim ERAs ERA adjustment reasons are reported with standard codes. For a line or claim level adjustment, three sets of codes are used:
- Claim Adjustment Goup Codes (Group codes)
- Claim Adjustment Reason Codes (CARC)
- Remittance Advice Remark Codes (RARC)
|Table A: Example work process|
|Best Practice Application||Results|
|Capture remittance advice details electronically, when possible||Eliminates costs to pay internal staff or bank to key and generate information files|
|Automatically enter data in practice management system to create payment advice note document or other type of clearing document||Provides greater accuracy and efficiency from integrating data Provides complete visibility and audit trail of transaction|
|Automate the matching of the payment advice to the customers’ open items||Faster, more accurate processing: Eliminates time-consuming and error-prone manual reconciliation|
|Automate the cash application post process (matching payment to invoices): Matches No matches||Reduces manual intervention to small percentage of exception handling Maximizes revenue by reducing the amount of unapplied cash at period end Enhances customer service through the timely clearing of payments|
|Generate performance reports||Enables increased efficiency, and higher productivity levels and system functionality Enables quick and accurate troubleshooting Identifies master data (customer record) issues|
- Assure charge master is complete and accurate.
- Complete charge capture timely and accurately.
- Work with your practice management software and clearinghouse to assure essential information and changes are communicated.
- Assign staff to review remittance advices and work small balances, rejected claims, and claims not paid.
- Work denials in a timely manner to collect all monies due.
Linda Martien, CPC, COC, CPMA, is associate director of reimbursement at Nuo Therapeutics, formerly Cytomedix, and brings her 30-plus years of experience in coding, billing, auditing, management, and consulting. She is a member of the AAPC Chapter Association board of directors for 2014-2017, and is a past member and officer of the National Advisory Board. She also has held various officer positions for the Columbia and Jefferson City, Missouri, local chapters.