Transcript Claims Processes: A Mirror for Organizational Competence

Claims Processes: A Mirror for
Organizational Competence
Center for Substance Abuse Treatment
DSCA Meeting
October 21, 2009
Crystal City, Arlington, VA
Understanding Claims Processes
 Submitting prompt, clean and accurate claims
that get paid in full the first time they are
submitted is a worthwhile fiscal and
organizational goal that communicates your
competence
 Efficient and effective claims submission allows
providers to support services and staff, benefit
from utilization and fiscal data, evaluate and
accumulate financing, and be accountable
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Patients, Payers and Purchasers:
Expectations
 Patients: fair, accurate and prompt billing for covered
services by covered, supervised and licensed providers
who are accountable and audited/errors are rectified
promptly
 Payers:
prompt, accurate billing according to policy and
procedures set out for each customer/purchaser of that
payer; eligible providers and organizations are enrolled
with payer; billing is for services that are covered,
medically necessary, appropriate and complete
 Purchasers/Payer Customers: claims are submitted
according to procedures and time/benefit limits, medically
necessary and appropriate for covered individuals, claims
reflect direct covered services provided accurately by
approved practitioners
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Typical Requirements and Considerations
for Claims Submission
 Provider is enrolled in payer and purchaser’s plan; knows benefit
coverage rules, checks patient eligibility and is licensed, certified,
eligible, has sufficient administrative and clinical staff to function
competently, has signed contract with payer that sets out rates,
rules, denial, UM processes, timing of payments, audit
requirements, performance reporting, incentives, if any
 Provider follows procedures in submitting claims and can do so
according to payer and purchaser preference (paper, electronic,
fax, mail), also understands appeal and error correction
procedures, can track status of services, provider of record and
can verify services billed
 Providers are expected to request claims policy and procedure
manuals, attend trainings if offered, understand differences in
coverage and eligibility rules by customer/purchaser (even state
by state), able to follow eligibility rules, can check eligibility and
understands coverage rules, understands covered and excluded
services and provider types, can review and correct errors and
denials (tracking), able to audit, demonstrate compliance with
performance measurement and management/QM
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Considerations Continued
 Providers must have a functioning contemporary MIS and Web Browser
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(their own or shared or contracted) that can track individual and batched
claims and ascertain status of payment or denials, track payer
conformance with payment rules
Can submit claims as specified by payer/purchaser: paper, electronic,
EDI/clearinghouse, Internet/Web, scanned or faxed or mailed
Provider understands if he/she/organization is a covered provider under
each plan of each payer. EG: NM Medicaid covers state-licensed
alcohol and drug counselors but some payers do not allow them to bill
Services and organizations must be eligible, non-experimental,
certified/licensed, provided according to coverage rules and limits, copayments collected, benefits understood by purchaser
Services must be provided within the scope of the provider’s license
Claims must include relevant service or procedure codes, date and type
of service, provider type/name/ID, coding conforms to coding manuals
and current coding conventions and initiatives
Patient eligibility has been verified at time of service (especially for plans
that churn like Medicaid)
Provider records consistent with claims submitted as to extent, nature,
provision of service by eligible provider/organization, to eligible
recipients
Coverage Criteria
 Often specified in P and P manual, or Summary or Detailed Plan of
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Benefits Provided by Payer
Medically necessary and appropriate (need to seek out definition,
which can change by customer and payer, also check formulary
status for medications
Services include all assessments, testing, therapies, medications, to
be completed within specified time frames and within benefit rules
Frequency and place of service conform to medical necessity,
documented evidence base
Treatment agency requires patient participation in treatment
planning, progress reporting, documentation of family/guardian
involvement if appropriate
Provider records available for payer auditors review on request
Services are provided in an eligible setting (example of services in
ineligible settings)
Injections/infusions and tests are performed according to national
standards, reflect appropriate levels of accuracy
Non-covered, excluded services are understood (e.g. Rolfing,
hypnotherapy, biofeedback, V-codes, milieu therapy, strictly
educational or vocational services, ECT, services solely for custodial
care
Prior Authorization, Utilization
Management, Outcomes Analysis
 May occur before, during or after service billing is
submitted or payment is provided
 Providers need to ask about these processes,
when in the claims process they occur, how to
appeal denials and answer questions (information
needed to be on hand to talk to UM manager)
 Understanding reconsideration and adjustment
processes is important to your cash flow, as is
correcting errors and insuring that claims have
complete and accurate information when they are
submitted the first time
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Reimbursement
 Can be per service, per episode, case-based, negotiated fee – or
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not, batched, capitated, partially capitated
Reimbursement claims must be submitted in/on proper format
Movement towards electronic submission (but not necessarily
electronic payment), also use of EDI/clearing houses, enrolled
fiscal agents
Providers expected to understand role of usual and customary
payments
Providers may be asked to offer prompt pay discount
Providers need to know state’s prompt/clean claim laws (differ by
state)
Some practitioners are not eligible to bill directly, nor are
supervisors allowed to bill on their behalf
Services must be covered and provided by eligible practitioners
in approved locations, frequencies and amounts, duration
appropriate
Payments may be reduced if outpatient services are offered in an
inpatient environment when they could be provided in a covered
outpatient setting
Management of Eligibility
 Involves ability to check patient/client eligibility prior to
providing service – or willing to eat the cost
 May need to check “dumb” terminals or Web, accept
tape dumps and process updates to benefits and
eligibility (part-time, full-time, active, retired, out of
state, dependent coverage or not, married or not, etc.)
 Need to be able to challenge and correct payer errors
(e.g. names, dates, location/setting, type of service,
frequency, duration, etc.)
 Need to have good access to accurate eligibility in
order to do this
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Provider Credentialing/Network
Status
 Certain types of providers may not be eligible to bill,
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even for covered services
Network status for an MCO may be time-consuming,
rates negotiated must be accurately reflected by
service
Payers expect records, reports, MIS to conform to
JCAHO, CARF, NCQA formats and requirements
Primary source verification may be required
Providers must be eligible, contracted and enrolled in
order to be paid
Outcome and performance measurement, audits and
reports may be required by service, by client, by
episode of care or case for network and/or noncontracted providers
Fee Schedules and Negotiated
Rates
 Fee schedules and/or negotiated rates or pay for
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performance may pertain to specific services
 Fee schedules and rates must be accurately
reflected, updated as needed
 Submitted claims should have been checked for
financial and claims/clinical information accuracy
and completeness (scrubbing) – can be done by
fiscal agent or clearinghouse
 Payers may create performance report card,
including claims/UM performance, adherence to
contracted rates/fee schedule, minimal number of
“outliers” or errors
Service Tracking/Cash Flow Management
 Must have or contract for MIS that can track service provision
 Providers need prompt, accurate claims payment in order to have
consistent and sufficient cash flow
 What stops claims process? Errors, missing information, lack of
understanding of eligible services, providers or locations for care or
types of services
 Must be able to maintain client and transaction security and
confidentiality (42 CFR) and still submit claims promptly (releases must
be signed promptly)
 Must understand own costs compared to reimbursements received
 Must be able to do incident reported (e.g. deaths, morbidity,
complications of services, procedures, medications
 May be wise to use billing services with scrubbers, code updates,
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prompt submission capabilities, bad debt management, denial tracking
and advocacy, clean claims laws’ dispute management, overlooked
procedures and codes, reports of final adjudication decisions (with
record of adjustments)
Do’s and Don’ts of Filing Clean
Electronic Claims
 Do
 Verify, file and keep all transmission reports
 Track clearinghouse claims to ensure transmission
 Ensure your software embodies clean claims rules
 Verify that your software correctly and visibly prints
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on appropriate claims forms
 Call your vendor (if any) to address deficiencies
promptly
 Track status of appeals or adjustments
 Keep track of negotiated rates in master file by
payer
Example: Optum Behavioral Health
Solutions (UBH Online)
 Has both public and private sector customers
 Accepts EDI and electronic claims
 Has function to check eligibility of various services, codes,
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medications, providers, organizations, level of service, location of
service
UM manual is available on line or in print
Covered services and other requirements differ very substantially by
purchaser and by time (annual or more frequent updates)
Requires agreement to audit and/or recoupment of funds, as
specified by purchasers
Generally pays clean claims from eligible providers in four weeks
Has electronic system functioning 24/7 at 99.7% uptime
Can check status of claims on line via claims inquiry function
Has certain browser requirements
Covers some but not all MAT’s, covers SBIRT if eligible by purchaser
Example: AHCA
Florida/Medicaid
 Providers expected to be under contract with each county
 Providers must be Medicaid enrolled
 Providers must be licensed (except for recovery services)
 Providers must have certified administrative and clinical
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capacity, appointment times, etc.
Claims must be submitted only for covered providers and
services
Claims payment may be extended due to need to deal with
Federal and state share of claim
Services provided must have been authorized, eligible
Providers may use Medicaid enrolled billing agents or
approved clearinghouses to submit claims to counties (no
direct provider billing of Medicaid)
Reimbursement for SBI(RT):
Examples, Variations
 Approved codes through commercial insurance CPT
codes, Medicare G Codes and Medicaid HCPCS
Codes
 Medicaid: H0049 : Alcohol and/or Drug Screening
 H0050 : Brief Intervention (no codes for BT or referral
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services)
CMS G- Codes (Medicare)
GO396: 15-30 minutes for positive screens only)
GO397: more than 30 minutes
CPT Codes (Commercial Health Plans)
99408: 15-30 minutes
99409: more than 30 minutes
SBI(RT) Code Implementation
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Varies by state, county and payer/purchaser
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Very specific processes apply for review of all new codes and/or requests to open
coverage for existing codes not currently open in systems such as Medicaid (many
codes are dormant)
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Providers can check state/county websites or provider bulletins or call payers in some
states for code approval updates and rules for using codes
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Very little utilization reported to date, due to providers not knowing or using codes or
states/counties not implementing them
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States can approve code implementation but codes still have to be funded in order to be
used by providers (legislators may disagree with agencies)
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States/counties may report that codes are turned on before they are actually
implemented and funded (tend to count those that are in process but processes can
take long periods of time if reviews are negative or processes are not followed)
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Codes may only be reviewed and approved yearly
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Payers may not agree with states regarding turning various codes on; may frustrate
state/county directions to do so; may also have lengthy review processes (need to
check status)
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Many code implementation reviews are affected by “other considerations” including
what other codes are being implemented, reviews of science or cost-effectiveness
SBI(RT) Code Implementation
(Continued)
 Processes can be arcane and are often not known to SSA’s
 Code implementation and funding may require “champions” on code
committees that resemble health plan pharmacy and therapeutics
committees – may require evidence base and cost effectiveness data to be
submitted, may have several hearings, may be opaque – not transparent
 May be debatable whether or not SBI(RT) requires Medicaid state plan
changes
 In some states that have implemented codes, few or no claims have been
submitted (hard for providers to know when the processes are implemented
for which services)
 New, implemented codes may be listed in fee schedules updates (annual) –
time lag
 Codes may be subject to subject matter expert review (clinical) as well as
economic and other considerations
 CMS has set aside Medicaid funds to pay MD’s to conduct SBI but not many
states have actually announced that they are reimbursing for the SBI codes
 Payment levels for SBI may be modest
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 Some payers are pushing the use of new codes; some are not
The Claims Story
 Varies by payer, purchaser, provider types, locations/settings, evidence
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base required, certification and licensure, UM requirements
Is necessary and not avoidable to understand
Requires accuracy and good MIS
Is feasible but complicated; requires training of staff
Varies by type of service even within plans of benefits and purchasers
May not yet have been updated for parity conformance
Is essential for your fiscal health and future
Is moving rapidly to at least electronic submission and/or the Web
Can be mastered through persistence and precision
Clean claims can yield positive cash flow, prompt payment
Can be useful to paint a favorable picture of your operations and
effectiveness
Are often part of performance management
Can tell a good story – or a bad one
Do’s and Don’ts of Filing Clean Electronic
Claims
Don’t
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Use any punctuation or decimals on electronic or other claims
Fold claims (if paper or fax)
Label claims (i.e. second request)
Write out claims by hand
Use lower case letters
Stray outside lines of claim boxes
Forget to check to see if claims print is dark enough to be legible
Attach post-it or other notes
Use staples or paper clips
Mark up claims with highlighters
Use circles or other marks on claims
Attach anything to claims other than requested extra information
Add notes or instructions to your claims
Send unnecessary attachments
Submit copied claims forms
Give insurers, managed care plans or other payers reasons to reject your claims
(inaccurate, illegible, not covered, lacks dates or other critical information)