clearinghouse-reportingMost practice management / medical billing software systems can send medical claims to a payer. Creating and sending a claim is a relatively simple process; tracking the claim, working denials and your ambiguous AR is what separates superior billing software system from the rest.

Example: A medium size family practice with just three physicians and two mid-level practitioners that see 30 patients in a single day. The practice is open Monday – Friday.

150 claims per day X 20 working days = 600 primary claims per month + 100 secondary claims per month = 700 Total Claims

Based on MediTouch First Pass Rate data, the practice may only have 5-10 rejections or denials, but there may be many cases where payers underpay and there may be cases where the practice may be bumping up against the Timely Filing Deadline.

Since most practices are staffed based on standard claim volume ratios, there are never enough billing and collecting resources to track all the claims that may require special attention. The issue is compounded for billing companies that may track tens of thousands of claims per month.

Medical Claims Denial Management Software

Examples of categories of claims that may require special attention:

  • Underpayment
  • Close to Timely Filing
  • Rejects and Denials
  • Pending Payment > 30 days (no ERA)
  • In User Hold > 30 days

In addition, it may be important to organize the above captioned categories by payer, provider or a specific time span because in medical practices certain billers are responsible for specific payers or providers.

Rule Examples

  • All Aetna clams that are paid less than 80% of the contracted fee schedule
  • Dr. Smith’s Cigna claims that were denied because of Timely Filing
  • All Blue Cross claims that have a claim amount greater than $1000 dollars that were rejected
  • All claims that have not been “Sent to Payer” within 30 days of the DOS
  • United claims in appeal > 2weeks

Scoring a Rule

Not every rule should have the same priority. For example; a claim bumping up against the Timely Filing Deadline has a high risk of never being paid, compared to a claim that has already been paid but may be Underpaid per your contract. In this example you may want to assign a Risk Level of 5 to the Timely Filing Deadline rule and a Risk Level of 2 or 3 to your Underpayment rule.

Working Medical Claims

Once rules are created, the MediTouch Claim Worklist Engine will search and retrieve claims that match your rules and then prioritize those claims for you. Initially your team will want to investigate a claim and then they typically will use the Worklist Interface to perform the following actions:

  • Assign a Follow Up Timeframe
  • Reassign a Risk Status
  • Assign a Worklist Category
  • Enter a Note
  • Exclude the Claim from the Worklist
  • Mark the Claim as Completed

High risk medical claims should be worked to completion, meaning that if a call is made to the payer and the payer says they will reconsider the claim the payer should be pressed to offer a timeframe for finalizing the claim. In this case the claim should be assigned a follow up timeframe on the Worklist Interface. The claim will be temporarily removed from the Worklist to avoid “clutter” and it will reappear at the designated follow up timeframe that was expected based on your contact with that payer. If the claim was not handled as expected by the payer, additional follow up with that payer may be required. The claim will stay on the Worklist until your case is solved. All notes and status changes are made part of the claim’s “permanent record.”

Takeaways

Most medical billing software platforms don’t have tools that assist the user in systematically reducing their AR. In addition, practices need a mechanism that looks at payment and compares it to the contracted fee schedule. Manually sifting through hundreds of claims is impossible, only software can efficiently “bubble up” the claims that require the attention of your billing team. If you are not systematically working your claims based on a sophisticated rules engine, you are essentially trusting that the insurance companies have your best interests at heart … need I say more?

*For MediTouch Users: If you’d like more information about how the Claims Worklist works, log into the MediTouch support site and paste this link into your browser: http://support.healthfusion.com/index.php/claims-work-list/. Here is some information on the Claims Worklist Rules: http://support.healthfusion.com/index.php/claims-work-list-rules/.