Wiki Total A/R Over 90 Days

[ntovatt]

What is the standard everyone is using for total A/R over 90 days or 120 days?
I work for an Orthopedic practice in the Sacramento area.
It looks MGMA standards for A/R over 120 days is 25% or less with high performing practices at 10% or less.

At what point, do you consider your A/R over 120 days as "full worked" without being resolved?
Of course you want to take note of the denial trends, but is it common to write off denied surgery claims?

 

[SharonCollachi]

When you're talking about denials, I don't think you can talk about acceptable percentages, because there is no acceptable percentage (IMHO). If an error occurs in obtaining authorization, checking benefits, etc., you learn from that error so it isn't repeated. If an insurance continues to erroneously deny claims so that you are spending a lot of time appealing, then you should drop that insurance company.

The only thing we have over 120 days are things we have agreed to wait on (legal claims where we agree to get paid at settlement of the case).

 

[thomas7331]

What is the standard everyone is using for total A/R over 90 days or 120 days?
I work for an Orthopedic practice in the Sacramento area.
It looks MGMA standards for A/R over 120 days is 25% or less with high performing practices at 10% or less.

At what point, do you consider your A/R over 120 days as "full worked" without being resolved?
Of course you want to take note of the denial trends, but is it common to write off denied surgery claims?

It's been a number of years since I worked in A/R management, but I would consider 25% over 120 days to be quite high in most of the practices I've worked with - at 120 days we would usually aim for closer to 10%. With the technology that is currently available to very eligibility and benefits and to electronically scrub and submit claims, there just aren't a lot of reasons that most practices would need 4 months to get a quarter of their services paid on average. Of course these metrics can vary quite a bit from one practice to the next depending on the types of services that are being billed and the payer mix and other factors, so there isn't a single standard that applies equally to everyone.

In my experience, you would not make a distinction between something being 'fully worked' vs. resolved - these mean the same thing to me. If an amount is on the A/R, that should be an amount that can still reasonably be expected to be collected and still needs work. There are only two cases I can think of that would warrant leaving something on the A/R for an extended period of time that was 'fully worked' but still not paid: 1) claims that have been approved for payment but are pended for funding which has been delayed for some reason (e.g. waiting on some kind of a settlement or bankruptcy payment to be approved and no further action is necessary); or 2) accounts on which the practice has agreed to accept installment payments over an extended period of time. If you have a high volume of either of these types of situations (or other unique situations that might cause an aging past 120 days), these accounts could certainly be isolated and reported separately to explain an inflated aged A/R. Otherwise, in my mind, an account is not 'fully worked' until a final decision has been made as to whether or not to continue pursuing payment - if you have decided not to further pursue payment, then the claim should be written off as uncollectible so that it does not artificially inflate the A/R. A write-off can always be reversed in an unexpected payment comes in at a later date.

If your providers are completing documentation in a timely manner, your registration staff is accurately capturing patient insurance information and your coding and billing team is adequately staffed and preparing, submitting and following up on claims correctly, you should not be seeing a lot of claims require more than 120 days to get to a decision point. But again, every practice has unique challenges.

Hope that helps some with your questions?

 

[TJAlexander]

I'm actually working my A/R over 90 days today and need an opinion about a denied claim. We seem to have a pretty high denial rate with this one payer in particular. In this case, we pre-authorized 29880 but according to the operative report, the provider discovered a 1.5 chrondral lesion and performed a microfracture (29879) to treat the lesion. I submitted the claim as 29880-RT, 29879-59,RT and included the operative report. The procedure was denied for not having prior authorization. I requested a reconsideration based on the information in the operative report but the denial was upheld. I've contacted the payer to ask for a specific reimbursement policy regarding this particular situation and they were unable to point me to anything in particular other than the CPT code requires prior authorization.

My question is, what do we do when a provider performs additional procedures during surgery with a prior auth? Do I direct the provider not to perform any other procedures other than what we've received prior auth for? I've been billing for this surgical practice for 18 months now and this is the first time I've seen this denial. Usually, the operative report explains the medical necessity for the additional procedure.

Any advice?

 

[SharonCollachi]

I'm actually working my A/R over 90 days today and need an opinion about a denied claim. We seem to have a pretty high denial rate with this one payer in particular. In this case, we pre-authorized 29880 but according to the operative report, the provider discovered a 1.5 chrondral lesion and performed a microfracture (29879) to treat the lesion. I submitted the claim as 29880-RT, 29879-59,RT and included the operative report. The procedure was denied for not having prior authorization. I requested a reconsideration based on the information in the operative report but the denial was upheld. I've contacted the payer to ask for a specific reimbursement policy regarding this particular situation and they were unable to point me to anything in particular other than the CPT code requires prior authorization.

My question is, what do we do when a provider performs additional procedures during surgery with a prior auth? Do I direct the provider not to perform any other procedures other than what we've received prior auth for? I've been billing for this surgical practice for 18 months now and this is the first time I've seen this denial. Usually, the operative report explains the medical necessity for the additional procedure.

Any advice?

Does your state have a mechanism where, after you've exhausted appeals with the carrier, you can send the appeal to the state for a neutral third party to decide? We have this in California.

 

[thomas7331]

My question is, what do we do when a provider performs additional procedures during surgery with a prior auth? Do I direct the provider not to perform any other procedures other than what we've received prior auth for? I've been billing for this surgical practice for 18 months now and this is the first time I've seen this denial. Usually, the operative report explains the medical necessity for the additional procedure.

Any advice?

You should definitely not direct your providers in any way on what they can or cannot do during a procedure - those are medical practice decisions and the provider needs to do what is right for the patient and not be influenced by payment considerations in the middle of a surgery. How a physician practices is really outside the scope of billing and coding and it best to just stay clear of that.

That said, it's a very common thing for providers to do additional or different things than what was originally planned in advance because complications or unexpected findings are always a factor that can alter the course of a surgery. All payers should recognize this and have a way to update or correct an authorization when necessary. Your payers should be able to give you a process to follow for situations like this, and if they won't resolve the problem when you dispute a claim denial, I'd recommend bringing it to the attention of your payer network or contract representative and get their assistance on reaching a solution.

 

[TJAlexander]

Does your state have a mechanism where, after you've exhausted appeals with the carrier, you can send the appeal to the state for a neutral third party to decide? We have this in California.

There was recent legislation in Georgia but it isn't in effect as of yet, unfortunately.