Transcript Denial Claim Analysis - California Family Health Council

Optimizing Billing Practices
Billing Claims Self Assessment
DENIAL CLAIM ANALYSIS
WEBINAR
MONDAY, MARCH 29, 2010
Your presenters
Presenter
 Stephanie Ceponis, Lead Site Financial Analyst

213-386-5614 ext. 4534, [email protected]
Moderator
 Chuck Marquardt, Director of Training

213-386-5614 ext. 4583, [email protected]
Tools you can use – Feedback Toolbar
Raise
Hand
Yes No
Feedback
Results
Emoticons
3 2
Floating Toolbar
 Use the floating toolbar to communicate in
today’s session.
Participant
List
Polling
Q&A
43
Q&A
Type Question
Click Send
54
Polling
5
Webinar etiquette
 All phones are muted.
 Questions can be asked via chat throughout the
session or raising your hand in WebEx.
 Lines will be opened at the end for additional
questions.
Objectives
 The participant will be able to do the following:

Complete the Excel workbook, CFHC Billing Claim
Denials Analysis;

Analyze data to identify problem areas in billing claims;

Describe plans of action for a variety of possible denial
scenarios.
What are we going to learn?
 How to utilize the CFHC denial analysis tool .
 Some common denial codes and the key pieces to
review to help reduce the frequency of the particular
code.
 Action plans – ways to reduce denials.
Rejects & Denials
Poll #1
 Does your agency work or follow up on rejected or
denied claims as part of standard practice?


Yes
No
Rejects & Denials
Poll #2
 Has anyone analyzed the rejects and denials to see
where they are coming from?


Yes
No
Rejects & Denials
Poll #3
 What is a common denial code your agency
receives?

Write in your response to the right of your screen.
Rejects & Denials
Poll #4
 What is the purpose of rejects and denials?

Write in your response to the right of your screen.
Start thinking…
Poll #5
 What can we do to eliminate or minimize the
number of rejected claims?

Write in your response to the right of your screen.
Start thinking…
Poll #6
 Which group in your agency originates the most
rejects?





Clinicians
Front desk/receptionists
Eligibility workers
Billers
Multiple sources
What You Will Need
 All RADs from 6 months or less.
 A Staff person to enter data.

This does not have to be a biller, and could be administrative
staff.
 10 – 20 hours of data entry time, depending on the
number of claims submitted.
5 Simple Steps
The Billing Claim Denials Analysis can be
completed in 5 simple steps:
1.
2.
3.
4.
5.
Collect data
Enter data
Analyze data
Create a plan of action
Implement the plan
5 Simple Steps
The Billing Claim Denials Analysis can be
completed in 5 simple steps:
1. Collect data
2. Enter data
3. Analyze data
4. Create a plan of action
5. Implement the plan
5 Simple Steps
The Billing Claim Denials Analysis can be
completed in 5 simple steps:
1.
Collect data
2. Enter data
3. Analyze data
4. Create a plan of action
5. Implement the plan
The Analysis Tool
Overview of the Analysis Tool
An Excel workbook with 5 sheets
1.
Summary denials sheet
Data entry with some formulas
2. RAD denial data sheet
Data entry tab where the “meat” of the denials gets entered
3. RAD denial summary sheet
Populated from RAD denial data tab – no data entry unless you
need to customize
Overview of the Analysis Tool
4. Chart
Data table is on RAD denial summary tab
5. Collection Report
Data entry
Summary
Denials
Worksheet
Automatically
sums the paid,
duplicate and
denial claims
Divides the
number of
denials by
total number
of claims
Divides the number of
duplicate and denied
claims by the total
number of claims.
Recap – Summary Denials Worksheet
 Enter data in cells A through F.
 Cells G, H and I use formulas.
 Gives you summary data for the whole RAD not just
denials.
RAD
Denial Data
Worksheet
For the code
breakdown on
the next sheet
only one denial
code can be
entered
You must put a
1 in this column
to feed the code
breakdown on
the next sheet
Recap – RAD Denial Data Worksheet
 Enter data from RAD into cells A, B, D, E and F.
 Only one denial code can be entered into cell G.
 A number “1” must be entered into cell H for each
completed row.
RAD Denial
Summary
Worksheet
Cells B and C have
formulas that use
information from
the cells in the
RAD Denial Data
Worksheet
Let’s see a zoom
view of this!
Recap – RAD Denial Summary Worksheet
 All information is populated from the RAD denial
data sheet.
 No data entry is needed unless customizing the
denial code list.
 If customizing, remember to copy the formulas
from prior cells.
5 Simple Steps
Get the data
2. Enter the data
1.
3. Analyze data
4. Create a plan
5. Implement the plan
Pie Chart
Let’s see a zoom
view of this!
Other
20%
Billing
20%
Registration
20%
Clinical
40%
Collection
Report
Worksheet
$ Owed column has
conditional formatting
to highlight amounts
$50 and above.
Analysis Tool Recap
 Summary denial and RAD denial data worksheets
are the primary data entry sheets.
 RAD denial summary worksheet does not have any
data entry unless you need to customize the denial
codes.
 Data table for chart is already formulated – chart
will automatically be created from data entered.
Common Denial Codes
TIPS TO REDUCING THE NUMBER OF
REJECTED AND DENIED CLAIMS
RAD
#0117
 This procedure is payable only
twice per month

Ongoing education and counseling
codes (any combination of HCPCS
codes Z9752-Z9754) can only be billed
twice in 30 days, per recipient, per
provider
RAD
#9518
 The referring provider must be a
Family PACT certified provider


The referring Doctor must provide their
NPI# to the rendering Doctor to be
reimbursed on Family PACT services.
The NPI# must be in correct field on
claim form.
RAD
#0315
 Recipient information on claim
does not match eligibility
information on file for this person

Verify the name, sex code, date of birth
and client’s ID #
RAD
#9655
 The frequency limits for this
procedure have been exceeded.
Resubmit claim with documentation
indicating medical necessity for the
test

Verify if the frequency limit has been
reached
prior to rendering services

Lab reservation must be made via the
Laboratory Services Reservation System
(LSRS) with NPI

Claims must be billed with same NPI
reservation was made under
5 Simple Steps
Get the data
2. Enter the data
3. Analyze data
1.
4. Create a plan
5. Implement the plan
Planning
 Staff training
 Change how information is collected
 Change the superbill
 Get specialized training
Possible Changes
 Staff training regarding the completion of the Client
Eligibility Certification form.
 Modify the superbill to reflect only those procedures
your agency provides.
 Clearly separate what is in-house lab versus outside
lab.
 Perform quarterly chart billing audits.
Possible Changes
 Create a daily chart review prior to billing.
 Create clear steps to rectify questions prior to
billing.
 Provide training to clinicians regarding coding.
Resources:
 Family PACT
 www.familypact.org

http://familypact.org/en/Providers/policies-procedures-andbilling-instructions.aspx
(PPBI, Provider Bulletins, Superbill)
Resources (cont.)
 Medi-Cal
 www.Medi-cal.ca.gov

http://files.medi-cal.ca.gov/pubsdoco/billing_tips.asp
(Provider manual, Bulletins, CMC info)
5 Simple Steps
Get the data
2. Enter the data
3. Analyze data
4. Create a plan
1.
5. Implement the plan
Questions????