Wiki Auto Drop of Claims Query

debellis59

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Hi Everyone:

I'm not sure if this is the right forum for this, but nothing else seemed to quite fit. Our employer has recently made the decision to Auto Drop claims for our providers who they claim meet coding accuracy that allows this. They state that 80% of providers industry wide are able to auto drop claims without coder review. They will not provide us with where they come up with this "industry standard" that states this. In addition, the "coding" that they are going by is for CPT only and does not include HCPCS, ICD-10, modifiers, etc. So long as the provider has not had one of us change too many CPT codes, they feel they can auto drop the claims. However, SO MANY have come back already because of missing modifiers, incorrect diagnosis order, etc, but they state we can just work them on the back end when they are denied. For example, we have providers selecting 20605 for knee injections, not using a modifier ... so these are being denied, but still we get nowhere in this argument.

I am the ONLY one of the coders that had my arguments approved against my providers being able to auto drop their claims. I do OBGYN, MFM, Newborns, Lactation, PreOp services and was able to successfully argue that these services are unique and why. However, not one single other specialty, nor the FP/IM services, have been able to fight this. Even though providers don't remember modifiers for additional services, laterality, etc., sometimes selecting incorrect procedure codes altogether, they want to continue with this. Even the cardiac coders are unsuccessful in fighting this mess. In addition, one of the directors in the past has tried to tell my coworker and me that we can always work claims when they come back and tried to push us to not even read the chart notes ... I changed jobs because of her, but here she is again! Yes, the same company, different location.

Is there an "Industry standard" for this? And if so, where can I find this information? I can't imagine that any "industry standards" for an auto drop of provider claims would only be for CPT coding and not take into account diagnoses, modifiers, procedures, etc.

Any help someone can provide would be extremely helpful.

Thank you!
 
There are some discussions around the topic: https://www.aapc.com/discuss/thread...-m-level-chosen.192805/?view=date#post-528327

It comes down to being an internal procedure. If that's how the practice wants to operate... If they want to run the revenue cycle this way there is not much a staff member can do.
The cash flow and revenue cycle is going to be VERY negatively impacted if the claims are not passing the internal scrubber or clearinghouse and not even getting to the payer. Or, if they get to the payer and get denied or require apeal you are causing delays and more issues by not sending clean claims on the first pass. Unfortunately, in most practices, there is no way to review 100% of charges, most do not do 100% charge review, it is sent through the practice management system scrubber and coders generally work exception reports or reject report type queues. Of course, this is different from place to place.

The way I have gotten "through" with this type situation is the money trail, also if you start getting more records requests, pre-pay reviews, denials, rejections, audits, etc. If your internal system is not set up correctly with edits to stop the claims from auto-dropping that's a problem. The practice is putting themselves at risk by doing this.

AAPC, MGMA, AHIMA, and other reputable organizations generally have benchmarks. If it's an EHR vendor or billing company that stands to make money by telling practices this, beware.

On top of that WHY WOULD ANY practice want to do re-work and denials/rejection work when the claim could be billed correctly from the start!!!???!? This drives me absolutely crazy. Don't get me wrong, claim scrubbers and auto billing have a place, when set up correctly. There should be dashboards and data coming back from the clearinghouse or interal billing system to show the rejection, denial and payment rates. Money talks. If this was a new system, you need a before and after picture of the money flow (or lack there of).
 
There are some discussions around the topic: https://www.aapc.com/discuss/thread...-m-level-chosen.192805/?view=date#post-528327

It comes down to being an internal procedure. If that's how the practice wants to operate... If they want to run the revenue cycle this way there is not much a staff member can do.
The cash flow and revenue cycle is going to be VERY negatively impacted if the claims are not passing the internal scrubber or clearinghouse and not even getting to the payer. Or, if they get to the payer and get denied or require apeal you are causing delays and more issues by not sending clean claims on the first pass. Unfortunately, in most practices, there is no way to review 100% of charges, most do not do 100% charge review, it is sent through the practice management system scrubber and coders generally work exception reports or reject report type queues. Of course, this is different from place to place.

The way I have gotten "through" with this type situation is the money trail, also if you start getting more records requests, pre-pay reviews, denials, rejections, audits, etc. If your internal system is not set up correctly with edits to stop the claims from auto-dropping that's a problem. The practice is putting themselves at risk by doing this.

AAPC, MGMA, AHIMA, and other reputable organizations generally have benchmarks. If it's an EHR vendor or billing company that stands to make money by telling practices this, beware.

On top of that WHY WOULD ANY practice want to do re-work and denials/rejection work when the claim could be billed correctly from the start!!!???!? This drives me absolutely crazy. Don't get me wrong, claim scrubbers and auto billing have a place, when set up correctly. There should be dashboards and data coming back from the clearinghouse or interal billing system to show the rejection, denial and payment rates. Money talks. If this was a new system, you need a before and after picture of the money flow (or lack there of).
Thank you so much. We do use Epic and have a good scrubber, but it doesn't stop claims with unspecified laterality to actually go out, nor does it always get the modifiers. I know that's a setup issue to some extent. We were recently "partnered" with the local teaching hospital so we're completely dependent on them doing those updates. And we aren't a priority. I do appreciate your help and the links.
 
A company I once worked for actually purchased an EMR thinking that it could replace the coders. This was back in ICD.9 days. Boy were they wrong and it took time, but they learned their lesson and the coding team was saved. I totally agree with Amy. Keep track of the problems that arise with this specific workflow. It may take some time for the light bulb to go off. Keep track of the issues and at some point they won't be able to ignore it.
 
Hi Everyone:

I'm not sure if this is the right forum for this, but nothing else seemed to quite fit. Our employer has recently made the decision to Auto Drop claims for our providers who they claim meet coding accuracy that allows this. They state that 80% of providers industry wide are able to auto drop claims without coder review. They will not provide us with where they come up with this "industry standard" that states this. In addition, the "coding" that they are going by is for CPT only and does not include HCPCS, ICD-10, modifiers, etc. So long as the provider has not had one of us change too many CPT codes, they feel they can auto drop the claims. However, SO MANY have come back already because of missing modifiers, incorrect diagnosis order, etc, but they state we can just work them on the back end when they are denied. For example, we have providers selecting 20605 for knee injections, not using a modifier ... so these are being denied, but still we get nowhere in this argument.

I am the ONLY one of the coders that had my arguments approved against my providers being able to auto drop their claims. I do OBGYN, MFM, Newborns, Lactation, PreOp services and was able to successfully argue that these services are unique and why. However, not one single other specialty, nor the FP/IM services, have been able to fight this. Even though providers don't remember modifiers for additional services, laterality, etc., sometimes selecting incorrect procedure codes altogether, they want to continue with this. Even the cardiac coders are unsuccessful in fighting this mess. In addition, one of the directors in the past has tried to tell my coworker and me that we can always work claims when they come back and tried to push us to not even read the chart notes ... I changed jobs because of her, but here she is again! Yes, the same company, different location.

Is there an "Industry standard" for this? And if so, where can I find this information? I can't imagine that any "industry standards" for an auto drop of provider claims would only be for CPT coding and not take into account diagnoses, modifiers, procedures, etc.

Any help someone can provide would be extremely helpful.

Thank you!
We too are going through the same situation, in fact I could have written this word for word. Searching for the elusive "Industry Standard" is what led me to this very thread. We too have been told to "auto drop" the charges, and correct them on the backside for any denials that come back or "if" the scrubber catches them. We too have been told this was a nation wide standard of practice. In our experience and opinion, financially going from releasing all clean claims to this new practice has our coding team in amazement. We have tried to present the high risk associated with it and have failed to be heard. No real "plan" of transition was put into place. I feel this is going to be a hard lesson learned. If anyone has more data, or their practice is "auto realeasing" charges with no coding review first, please share.
 
I think it's worth pointing out the nuances. Folks could be talking about multiple different processes. If the claims are going through an internal scrubber and coders are working exception reports or going to the clearinghouse but being rejected, that's one thing. If they are making it all the way to the payer and actually getting denied that's a different thing.
 
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