Industry sign banking missouri claim simple
you good afternoon everyone and welcome to SMS billing FAQ to help navigate outstanding claims this webinar is being presented by Jennifer Barbara and Julie blue with bkd this webinar is worth one administrative hour there's a sign-in sheet attached to the handout section of the webinar if you need CEUs please complete that and return it to me I will get your CEUs back to you within a week of the webinar ending today if you have any questions during the webinar type them into the chat box and they'll be answered either during the presentation or at the end thanks everyone for attending Thank You Shauna as she said Julie and I are here presenting with you today we both work for bkd a senior living billing services team our primary focus is to help our clients with outsourcing of their billing or training needs that they may have and we also offer support to their central billing office if that's a service that they need so we come across a lot of billing questions and denial errors and we want to share some of those with you and discuss some common frustrations or denials that we see so the various payor types that we'd go for we know it can be frustrating or overwhelming so our hope is that today after this presentation you'll be able to apply some of these principles and helping assist your facility with outstanding balances you may have or frustrations that you're seeing so first we're going to look at Missouri Medicaid and one thing we want to be careful here is receiving incorrect payments due to billing errors one common thing we see with Missouri Medicaid is the surplus Missouri Medicaid subtracts the surplus at the beginning of each month so if you have a resident who was on Part A and discharged to long-term care mid month or if they went out to the hospital and came back to you if your claim is not coated appropriately that surplus may not be subtracted and you could be receiving an overpayment from Medicaid without proper review of your claims and your payments this could cause over payments and credits on your aging and if you were to be audited you could owe several thousand dollars back to Medicaid to being careful and aware of that as you're coding your claims each month reviewing us for accuracy as well as billing the appropriate revenue code if your resident wants to be on a leave or if they were out to the hospital during the month you want to make sure that those revenue codes are reported appropriately so that you're being paid the appropriate dollars also looking at Medicaid want to make sure that you're aware that with hospice Medicaid the facility does not build those dollars the hospice company fills those directly so keeping track of these as well and making sure that you're working with your hospice company to ensure that you're being paid timely and if they're getting those claims into to Medicaid currently there is no recourse if your hospice company was to be backlogged or go bankrupt if you want to make sure and have a good working relationship with them to make sure that you're being paid timing once those services have been rendered okay and next people he's going to share with that sorry Jennsen you're good okay so another big issue we run into of course of billing errors are just residents who are not approved for Medicaid and you know if they are approved for Medicaid and you know how to build a claim typically your claims are going to pay unless you build an incorrect date or maybe abscess and incorrect icd-10 codes and so the bigger issue is if they're not approved for coverage obviously your claims are going to deny so it's really important that you have good processes to track those in your facilities and one is to identify Medicaid pending separate from traditional Medicaid so that's a pretty common payer type on accounts receivable is to use the Medicaid pending payer types that way and if they have approval issues you're not confusing it with money that actually do chew you another big issue we run into is each year whenever our residents have to have their annual review days losing track of those if you have a family member or maybe the residents and the address that's on file someone doesn't get that paperwork and they don't send in that information each year and they could lose their Medicaid approval most of the time if that is missed and it's not realized until after the fact the state will typically not go back more than 90 days so if this was to be a continuing issue and it was more than 90 days when when the information was sent to the state those claims would be rejected so one easy way to tell on our next slide is to actually in the email Med system which most of you who do the billing are probably familiar with email med because you can go in there and bill your claims and of course check claim status and participant eligibility and all that great stuff but on the very bottom left you can see there's a participant annual review date and this is added I want to say a couple of years ago but some people are still not aware that this is in there and if you go into that part of the website you can check up to twelve Medicaid numbers at a time and it will show you when their annual review date is so that's just a good way to stay on top of that and maybe remind your residents and responsible parties to make sure that they send that information into the state Thank You Julie now we're going to look at Medicare Part A we know this is a big care for a lot of the facilities and one issue that's critical to skilled benefits is your qualifying hospitals say making sure that your resident had three midnight inpatient and qualifying hospital and including that on your claim some issues we see with hospital stays is that the 70s fan code does not include the day of discharge so if your resident was in the hospital for three Midnight's and a discharged on the fourth day to your facility you would include that fourth date in your span on your claim and Medicare knows that that is the discharge State but that is how it needs to be reported on your claim in order to get paid appropriately also just keep in mind if you have a claim that is rejected for a qualifying Hospital issue that claim must be corrected or cancelled in a system before new claim can be submitted we can't simply just submit a new claim once you've found the error or had a change in the claim that must be corrected or the original needs to be cancelled first but one way to avoid having a situation at times is to ask the hospital to provide you with the admission date and time that they were admitted to the hospital many times we see facilities receive a patient assume that they had a 3:00 midnight when part of that stay could have been observation or emergency room care that wasn't truly coded as inpatient and therefore causing the three Midnight's not to be a valid stay so making sure you're working with your hospitals and asking for that detailed level of information with the date and admission time so that you can have that to do your billing secondly with Medicare Part A is sequential billing Medicare requires that all part a skilled claims be set in in sequential order from a mission date and following every day until they discharge so if your claim is kicking out for the trees and I want to show you a quick screenshot of what it looks like in the direct data entry or fin system if your claim was to be rejected for a secuence sequence this is the error you would receive it would say something similar to this but there is no prior record on file and so when you see this type of denial you know that you need to check either your admission date on your claim or perhaps one of the claims in the series hasn't fully processed with Medicare so if you're working on March and your resident admitted in January you would want to verify that your January and February claim we're both fully submitted and accepted by Medicare before your March cream will process and just making sure that within that every day is accounted for whether they run in lla or had any type of issues making sure that every day is accounted for within that sequence so some other common issues we see on the Part A side is not recognizing that another payer is potentially involved so a common rejection we see of course are for residents that have enrolled in a Medicare Advantage plan so now they're no longer Original Medicare maybe they've signed up with Humana United Healthcare there's hundreds of plans out there so it's really important to make sure that that's identified and you're not incorrectly billing Medicare just because they have a Medicare card does not mean that they have Original Medicare coverage engines actually going to go through an example of how to identify that on the eligibility file here in a little bit so that's a huge rejection issue we see another one is whenever there's a Medicare secondary payer situation so a common term is MSP so the MSP means Medicare secondary payer and in those situations we have another pair that's primary to Medicare so for example if a patient had an auto accident we would have to build that auto insurance first and then depending on how much they paid or didn't pay we would then build Medicare secondary for their portion of this day another common example is working-aged where maybe the resident or their spouse is still employed and has insurance through through their employer and that would be primary to Medicare you can identify those on the eligibility files whether you use the common working files or maybe see snap or some other eligibility tool that's something someone should be checking prior to admission in addition you also have to ask certain questions to identify if there is a secondary payer so the common practice there is to use an actual MSP questionnaire that's asking questions such as is this related to an accident yes or no and those should be questions that are documented in the medical record or in some type of document request so hopefully you have a process in your facilities to do that and that information should also be conveyed to billing because they need to know if there's potentially another payer involved that maybes not showing on the eligibility files yet the important thing with billing MSP claims is one to identify what type of payer is involved you need to make sure that you send them the claim and then you have to wait on your payment or denial to then code the claims and billed to Medicare there is very specific codes and we would be happy to send you a cheat sheet if you don't know where to find those but there's codes you have to put on the claim for the type of MSP so for example if I have an auto accident I have a different code set that has to go on the claim than if it was a working-aged and if the payer paid I'm going to have certain value codes that go on the claim if they didn't pay I'm going to have specific value codes and occurrence codes to recognize that situation so the billing can be pretty tricky for MSP depending on whether they paid denied and what types of MSP payer was involved keep in mind you would eventually bill Medicare for these situations so you want to treat them like a Medicare and do your assessment that they're on Part A and with the hopes that eventually you're made whole with payment with Medicare Medicare will limit your payment to the lesser of charges or rubs or if you have a contracted rate you've agreed to so keep that in mind you could be limited to charges in some MSP situations another common situation hospice overlaps this is probably one of the number one rejections we see outside of the hospital state issues our hospice overlap if a patient has an open hospice benefit even if they're not receiving hospice if that election they call it a hospice election if that has not been revoked from their eligibility file they will continue to show as in the hospice and claims will continue to reject so if you are seeing that situation and you know their resident is no longer under a hospice day you need to find out who the last hospice agency was and let them know to do the relocation and a reboot I can't say the word but they basically have to sit in a claim with specific or career codes to revoke that election if they are under a hospice election and you're treating them for Medicare Part A or Part D services you can only do that if what you're treating them for is not related to the hospice terminal diagnosis so you have to be very careful about that because I think most of the time you could probably relate it back but if it's truly unrelated and you're certain of that you can bill Medicare that you have to use a condition code zero seven so for your claim to bypass Hospice they have to be billed with a zero seven condition code if they were to reject and you found out later that it was unrelated you could go back to and adjust the claims to add the zero seven code but if it is related then Hospice should be providing the services you should not be billing Medicare and then the fourth a big issue that causes claims not to pay for Part A that we see are of course missing an invalid information this is pretty basic stuff if we have the patient's name misspelled if we have the wrong policy number or maybe an invalid diagnosis code those are all issues that cause claims not to kick out and a best practice there in the industry is to do some type of pre clean review process most of the time that's referred to as triple check triple check is where billing and maybe MDS and therapy submissions medical records everyone's getting together to look at those claims before they're billed to the skilled payers and checking for things like do we have the right members and names on the claim do we have the right charges the correct assessment do we have the correct diagnosis codes and making sure things are accurate because the biggest thing that holds of our payment is sending invalid or incorrect link to begin with so a triple check is a very important part of that process to verify information at private pay and some issues that we see along the way with the private invoices one common error that we find is that a lot of software companies are set up to default to private pay so an example might be if you have a resident who is on partly services for therapy and they've exceeded the cap or what was the cap then those charges many times are moved to private automatically if you don't catch that and move those charges back to Medicare your patient might be inadvertently receiving those on their invoice for private when it's not due privately also you want to make sure that you're capturing those charges correctly on your Medicare Part B claim another example of charges incorrectly for your private pay could be if a patient was skilled on Part A and transferred to long-term care or private mid-month and you have ancillary charges such as pharmacy or lab charges that have been entered incorrectly into the system and end up on the private invoice again these would not be truly do privately as the patient was on a partes day so just having a process in place to review your claims for those missing pieces when they're going to Medicare but also your invoices before you're sending those out to the residents just doing a double check on those making sure that the charges truly are private and that will avoid those incorrect invoices going out to patients another common situation that we see are our billers or our clients not being aware of a collections policy it's really hard to enforce your billing staff doing timely collections if they're not aware of the collections policy and I think a lot of times there probably is a policy in place it's just that there's been turnover so no one's aware or has their hands on that actual policy but you should have a quick a quick maybe one page document that shows what steps are taken with your collections policy for example do you charge a late fee if payment is not by a certain date do you apply or assess se as maybe a check has returned those things should be outlined you should have your discharge policy outlined you should have steps for when do we make phone calls to the residents and responsible parties at what point do we send letters most
eople are sending letters are at 30 60 and 90 days typically making the first phone call after two weeks and then maybe 30 60 90 days as well at what point do we have administrative administration involved and maybe contacting the families and responsible parties definitely having those things outlined can be helpful and in some of our billing software systems you could even integrate our collections policy in there and it could probably auto generate letters for us based on those time frames so that might be something you want to look at with your software vendors as well another common issue with private pay balances being outstanding are that the resident or responsible parties feel that the statements are not accurate so they're refusing to pay those bills that's always concerning to hear that so it's really important to make sure that that we stay on top of that if someone's saying that we're building out accurate we want to be able to show that it is and if we have a problem of multiple residents complaining about bills not being accurate that might indicate that we have some kind of billing issue and a common problem that we see our cash receipts not being appropriately applied to the right patient or the right payor type so a common situation would be if mr. Smith wrote you a check for $5,000 and you applied that check to his Medicare balance what happens is your Medicare balance now decreases from your accounts receivable so now maybe my biller doesn't know that they need to follow up on a Medicare claim because guess what Medicare didn't pay we accidentally applied their private check to the Medicare balance so what happens with my private pay balance is it continues to grow because that patients there and continues to have charges the next month but that payment was never applied so now I'm sending them a statement that shows they owe for the current month plus the last month that they're saying hey wait a minute I already paid this bill and I don't know about you guys but if someone sent me a bill and I had written them a check and it wasn't showing I would be pretty upset about about it so that's something that if you're seeing that and especially from an administrative standpoint you really want to get on that pretty quickly because we ran into situations where this has happened over and over again and it's kind of like undoing a huge puzzle piece so applying accurate cash is very important also as part of good month-end procedures just making sure that someone's tying out and balance in cash to the bank statement can also help identify these types of issues another area that we see is simply having the residents uninformed about how much money they owe or potentially could owe we recommend having a conversation after admission but within two days of admission if at all possible having a conversation with the resident and have the residents family to discuss those dollars that could be owed by them if their payer doesn't cover if they get into coinsurance stays or simply because they are private pay and explain to them at that time what your collections policy looks like when are they expected to pay for these services how long do they have do you allow payment to be made in installments those types of questions it really helps the resident understand what's expected of them and then if you get into that collection issue later down the road you both feel better about knowing you you've discussed this upfront you are aware of the expectations of both when to pay and how much maybe do a lot of people who perhaps are new to skilled nursing or new to Medicare may not understand how it works or when patient responsibility kicks in but for Medicare Part A with the coinsurance being one hundred and sixty seven fifty a day that can really add up if they were there for a month on coinsurance for Medicare Part A that's over five thousand dollars and that can be a big surprise if you weren't aware or understood that process so having those conversations can really help both the resident as well as the facility gets collect those funds also something to consider is asking to review the financials if the resident is paying you privately and they may run out of funds at a certain point if they will be with you long term so having conversations with them kind of mapping out how long they will be covered for how long their finances will cover that and then when they may need to apply for systems like Medicaid and then being there to assist that family or that resident with the application process I know many times that's probably not something you're necessarily doing is the applying for them but it can be a win-win for both you and the resident the resident may not understand the paperwork understand the process of how to apply Medicaid so you can step in and be that assistant to help her in that scenario but then also you're helping secure finances for your facility making sure that there's no gap in payment if those funds were to run out on that patient so just keeping in mind with that next we're going to look at some issues with Part B billing so Part B we always say Part B is a whole lot of work for not a whole lot of money just because we're dealing with that line-item detailed charge structure for our Part B services and with that we run into a lot of issues especially in regards to modifiers so when we refer to modifiers those are actually the extra numbers it could be letters or numbers that follow your procedure codes whenever you're billing for those Part B services and there's a couple different situations that we see issues with one are for our residents that are over the therapy cap now you all might think I'm crazy to be talking about therapy caps because they went away with a bipartisan Budget Act that was signed earlier this year but the reality is all those therapy caps supposedly went away the legislation actually says that we still have to build services that are beyond the previously designated cap amount with a modifier indicating those services are medically necessary and that of course is the KX modifier so anyone that's filled is familiar with a KX modifier so keep in mind even though there really is no cap there really is a cap because you still have to have your K X's on your claim when they're over the cap amount and the cap amount that was designated for this year is 2010 dollars and physical therapy and speech therapy share a cap amount and occupational therapy has its own separate cap amount to their own 2010 dollars to meet and the 2010 dollars is based on the fee schedule amount not not your marked up charges with actual fee schedule and once they reach that amount you must fill with a KX keep in mind when Medicare processes your Part B claims they do not process process them in date order they just them in procedure code order so if I'm billing a marched claim and my patient went over the cap and let's say the 15th of the month I need to have a KX on all my services back to the beginning of the month because of the way those codes are processed if I just pick T X's on everything the 15th forward I'm going to have some things rejecting for needing that KX modifier so it needs to be on the entire claim the month that they go over that cap amount also keep in mind although there is a cap there's also a therapy threshold the therapy threshold is $3,000 PT and speech combined occupational therapy has its own amount anything over $3,000 is just at risk for post payment review so keep that in mind another issue with invalid modifiers are correct coding initiative or CCI edit these are our 59 modifiers so when you see the 59 modifiers is for CCI edit CCI edits are actually quarterly updates that CMS puts out that are codes that if done on the same day are in conflict with each other so CMS puts out this list of procedure codes and says hey if you do this code and this code on the same day you need to prove to me that these were separate and distinct which is what the 59 modifier indicates and there's a list and if you've ever looked at the CCI list there's a column one and a column two and for example in column one I might have a procedure code nine seven five three oh and that conflicts with nine seven one one six so nine seven one one six must have a 59 modifier if I build up the same day as a nine seven five three oh and if I don't have that 59 modifier that charge will not pay so what will reject and being uncovered the tricky thing about claims that are billed with missing modifiers is that you will get paid for the claim itself so you'll get a payment but you'll have line item rejections and Jen is going to show us an example of one of those here in a little bit and how to fix those but we always tell clients if you see that you have a Part B balance outstanding so remit and make sure you didn't have any non-covered charges or go into the Medicare direct data entry system and make sure nothing was non-covered because if you're missing modifiers you can go back and adjust and add those to the claim to receive your additional reimbursement so don't write that off whenever your might actually have money coming to you perfect another Part B issue that we run into or see is the g-code medicare inactive details that have to be added to your Part B service claim in a pair on every evaluation and then every tenth treatment data that resident and receiving services g-code there are three G codes per type and that is a current goal and a discharge and every G code that's required on your claim must be in a pair so that would be a current and a goal pair or a goal and a discharge pair if your claim had a current and discharge paired together that would reject and your claim would not process appropriately the only exception would be if your resident was picked up on services and ended services on the same date they were rendered so they only had one day of service you would actually include all three G codes the current the goal and the discharge on that service line to indicate that they were both picked up and discharged from service but outside of that you want to make sure that your pair is appropriate another thing we see with the G codes is that sometimes in your therapy imports if you get a data import from your therapy company or even sometimes the service log they'll have a G code pair but not on a date that services were rendered and they are required to be within a service date you want to make sure you're working with your therapy company and reviewing those dates to ensure that your G codes are on the day of evaluation and then at least once every tenth treatment date they can be earlier than that or more frequent but cannot miss that 10-day 10:00 treatment days and then also watching your modifiers G codes are required to have two modifiers per set you're going to have your modifier to indicate what type of therapy that's your PT ot and ste as well as the modifier to indicate the level of participation to whichever set they are being evaluated for so making sure that you have both modifiers and you have those pairs on the appropriate dates another common issue with Part B claims are missing or invalid occurrence codes occurrence codes if you look at a claim form are always a two digit code that's telling us something and then a corresponding date so for example with Part B services we always have to have a code 11 and an onset date for the onset of symptoms so a Part B claims should always have an 11 and a corresponding date in addition to the onset we also have to have occurrence codes for each specific modality of therapy so for example if I'm billing for physical therapy I have to also have a twenty nine and a thirty five code if I'm billing for occupational I have to have a seventeen and a forty four and for speech a 30 and a forty five so sometimes what happens with our claims is this we are billing occupational therapy charges that we're missing our recurrence codes that are for occupational therapy that can cause our claim to kick back to us vice versa if we have recurrence codes on our claim let's say for speech therapy that we don't have any charges for speech therapy services that can cause our claim to kick back to us as well and in our next slide we have an example of an actual screenshot of an error from the direct data entry system which is the Medicare I call it the online system but the system you can go into to actually check your claim status with Medicare so this is a claim that's picked back and it's basically telling us we have a revenue code oh four 3s and an O for 3x revenue code would indicate occupational therapy service and it's telling us that we do not have an occurrence code 17 which would be required if we're billing charges for occupational therapy so this is just a common example an easy thing to avoid once again if you have a good triple check or claims check process before those claims are submitted we get asked a lot of times about software systems and do they shouldn't they do this automatically and the answer is no because most long-term care facilities have contract therapy so they're not using your system to actually document services they might be sending you a charge import but that's not going to create a current code so it's a pretty common thing that billing actually has to manually put in a current code to get the claims build the next payer that we're going to look at today is the managed care or Medicare replacement plan Julie kind of touched face with this a little bit earlier but some eye item so you really want to be careful about is ensuring that your billing the correct payer from admission from the start so one of the ways to do that is to access the eligibility file within Medicare's online or direct data entry system I do have an example a lot I'm going to show you real fast and this is a part of the eligibility file or the Common working file and it will show you if your resident is enrolled in a managed care program or an option C and you can see on the Common working file it will show that if they are enrolled it will also give you their ID number not the individual ID number but the plan ID number with Medicare that have you Coventry Blue Cross Blue Shield in this example it says H one two five one that code is correlated to an insurance payer so if your resident didn't remember signing up or the family was not sure that the resident had a managed care plan you could take that code to the CMS directory on their website and it will tell you not only the name of the insurance carrier that there old with but it'll also provide you with contact information so that you can get the information you need to bill your claim appropriately it should show you also the date that they were active in that plan and then if there's a termination to that Medicare Advantage so again if the family telling you know my mom you know got rid of Coventry she doesn't have that any longer well again you would want to check this file and make sure that Medicare is showing a termination date here because if not you're going to want to hold your claim until that is showing appropriately our Medicare will not process your claim so once you've determined that you have a Medicare Advantage plan and that who will become the payer instead of Medicare you next want to make sure that the patient has coverage and what that looks like for your facility you'll want to contact that payer directly and speak to them typically they require an authorization pre service so they'll want to talk to you about what services you plan to provide for the resident how much services you plan to provide and then they usually want to talk to you and touch base with you every so many days we typically see every seven days so they'll provide an authorization number and then usually they'll provide a new member upon room review of the president's care so making sure that you're contacting them asking for the benefit information but as well as getting that authorization and needed to bill your claim and then touching base with that plan as often as indicated to making sure that you get continuing the care for the patient and you'll get paid for those services it's important to include that authorization number on your c
aim many times that way they can find that pair them up the authorization with your claim and that way you don't delay payment or the claim doesn't kick out saying you don't have an off and then you have to go through the process of proving that you did so just including those on there and tracking those authorizations also knowing but you're expected to get paid many managed care programs offer contracts where they pay you based on a variety of negotiated items some which are whether or not they want to receive the Medicare drug scores or if the billion a flat level of care and that is identified within your contract so if you're not aware of that you may ask someone in the facility if they have a copy of the contract or get with your provider relations within that insurance firm but making sure that you're aware so you know how to bill your claim appropriately if the claim needs a level of care and you submit it with rugs it could deny also if your claim does require level of care you still have to include the hips code but just making sure that you're including that with your level of care to make sure that you're getting paid appropriately another issue with managed care or Medicare Advantage plans so the hospice so we've talked about hospice for Medicaid we talked about hospice for Medicare so now we want to talk about how it impacts Medicare Advantage Medicare Advantage plans do not have a hospice benefit so if a resident is enrolled in a Medicare Advantage plan and they have an open hospice election they actually revert back to Original Medicare while they're under that hospice election so you would build your normal Medicare not Medicare Advantage so very important thing to check when you're checking eligibility in addition to identifying if they're under a Medicare Advantage plan you also want to see if they have hospice because of so you need to build Medicare keep in mind once again you can only build Medicare if the services are not related to hospice and you would have to have a no seven condition code once the hospice election is termed the month following the month it's termed they would convert back to Medicare Advantage if they were enrolled in a Medicare Advantage plan and then finally unbuild coinsurance a lot of times when we see a buildup of accounts receivable for managed care payers on an aging you can go in there and start to investigated and we find a lot of times that the claims have actually been paid but that there still an amount thinning due from insurance because it's coinsurance or a patient responsibility that was not moved over to be billed to the patient or moved under the Private pay payer type so a very important process whenever cash receipts are being posted if there are still balances remaining to to double-check and see is this coinsurance that needs billed to the resident is a potential contractual adjustment because maybe I recorded accounts receivable at the Medicare rate that maybe they only paid a level of care rate and going ahead and making those appropriate adjustments to get that money off your aging but what you don't want to do is not build a coinsurance to the resident and then identify it a year down the road because by then it's going to be much too late to try to get that that money from the resident and that can really build up over time so coinsurance we wanted to touch on dual eligible and that term refers to residents that are covered by both Medicare and Medicaid we know in Missouri that Medicaid does not pay for Medicare coinsurance any longer unless Medicare paid less than the Medicaid daily rate which is not very often but it can happen if you're maybe having to village a fault rug raid or a very low read rate so it's important though that we track our dual eligible and still build Medicaid for that coinsurance because part of your cost report settlement is that you can be reimbursed for uncollected Part A coinsurance an only part a coinsurance so Medicare Advantage plans don't count Part B doesn't count but only part a coinsurance so if you make an attempt to collect your part a coinsurance let's say on the private pay side and you're unable to collect that but you can can prove that you build the resident at least three times and you build them timely you can write off that balance and you can claim it as part of your cost report on the exhibit one of your cost report and Medicare will actually settle with you and pay you 65% of that balance keep in mind that they will take out the 2% sequestration so you really only get 63% and that balance back that is important to track our part a coinsurance so for a Missouri since they will not pay for the coinsurance you still have to build it and get the denial and then you can write off that balance and once again claim it on your cost report at year-end and then you'll get back that 63% of the balance so it's important to build those when you get your Medicaid Medicaid rimas for coinsurance that they haven't paid that's eligible it'll have a code Co 45 and the amount and that's the amount that you can write off and then claim for your cost report so a good process there is to go ahead and do that monthly as your remittance advices come in as you see that do 45 go ahead and write off the balance track it on an exhibit one and just keep track of those throughout the year instead of waiting till your end to go back and capture those balances I'm feeling a coinsurance many times Medicare will send them on to the next payer or what we call cross over and so you want to make sure that you're reviewing your coinsurance balances making sure that they are crossing over and if not that you're taking the steps needed to send those to the next payer in line one way you can track this is using your Medicare remit there is a code on the claim line payment line it shows you whether or not Medicare sent that claim forward and that would be a 19 status that shows that the claim crossed over if there's a one or a four that means the claim did not cross over and you would have to manually submit that claim to the next payer in line if you use a software to submit your claim many times they do allow for you to change the payer add that coordination of benefit information with payment information details from Medicare and electronically submit to the next payer in line if you don't have that capability you can simply print a copy of your claim and a copy of the Medicare remit showing how much was paid and how much is due and maybe a quick letter asking them to process your claim of the crossover there is the mail piece there so you have to keep track of that making sure that it truly arrived and so forth but it is an option if you don't have the electronic options to submit those also keeping in mind that some payers never crossover regardless of that code on your remit one example is a RP a RP does not cross over so you will always have to send that one manually either by paper or through your electronic submission system so keep that in mind any time you have a RP you're going to have to forward that to that payer also Medicare may have crossed over the claim and you're going to see that 19 on your remit but there's the chance that it could have crossed over to the wrong payer so making sure you're verifying that and keeping an eye on that in the fall of 17 medic Missouri Medicaid removed several ppl files or third-party liability files from their system they indicated they had a lot of files that were no longer active and they just needed to start fresh so they now will basically pay a claim with it crosses over and if that is incorrect it's on the facility then to make that correction with them and to send the money back so if you're not diligently watching your payment's and who the resident is enrolled with it's possible that a resident could be enrolled with AARP but the claim crossed over to Missouri Medicaid and then processed with Missouri Medicaid causing an overpayment and an inaccurate payment so you want to make sure that if that happens that you are sending those dollars back to Missouri Medicaid and that you're building the appropriate payer in line and that you also want to fill out a third party liability form with Missouri Medicaid to update that file and they'll have a quick example here this form can be found on the email Med web site and it basically is a tool for your facility to inform Medicaid whether or not your patient has a second payer that would be in line before medicaid pays a claim that will stop your claims from crossing over to Medicaid inadvertently and hopefully stop any overpayments for you you can also use this if a resident has an insurance reported to Medicaid that is terminated and is no longer active you can solve this form and indicate to Medicaid that they are now the second pair and in that way they'll continue to pay you another issue with coinsurance is not recognizing when someone has a true medic and Medigap or Medicare supplemental plan and one of the screenshots that we wanted to show you is actually a chart that you can google or get from the CMS website that shows the Medigap benefit so the patient has a supplemental plan by law those are sold as Medigap plans a through in depending on the state different states offer different options but if you're calling to verify coverage and they tell you as a plan B or a plan F for example you can look at the chart to see what it should and shouldn't cover and that just helps once again to kind of know what should have paid and what kind of communication do we need to have with our residents to let them know what their out-of-pocket costs are there's a lot of residents that might just have insurance that's not truly supplemental so most of the time that's not going to cover coinsurance or it might cover a very small portion of it and then it's going to bring it on to dde error yes so hopefully you guys are familiar with this dde or direct data entry keeping in mind that if you use an interface program such as a software that interacts with Yuni but looks more web friendly some of these screenshots to show you today will be slightly different but we think it's a good tool and knowledge to have if you're experiencing a lot of denials or frustrations with getting your claim through sometimes it helps to go into the original software CDE and just dig in and find out what the issues are so Julie and I are going to share with you some common errors and some common fixes to those errors in the direct data entry system so the first common error would be rejected claims and if you had a claim that rejected it depends on what it rejected for sometimes you can send a new claim and 60 issue but if it's something that's hit the Common working file you're going to have to actually either adjust the claim that rejected or cancel the claim that rejected before you can submit a corrected claim so this is a claim that rejected and it actually needs to be fixed so one thing I wanted to point out if you're in the Medicare system and you're correcting a claim under the claims correction menu you have to remember that if a claim was rejected and you're fixing let's say it rejected for no hospital stay so you could go in and you could add the correct hospital stay but you have to remember that the days are under non-covered where it says in see on the screenshot so you have to remember to move those days back to covered which is the value code 80 and then you have to go to page two which sorry as we yeah thanks to sorry best clicker today and keep in mind that all of your charges will be non covered a lot of times we see where people are going into fixed claims and they might remember to move the dais back to cupboard so move them from the value code 81 to evalute owed 80 but they forget to go into page 2 and fix all the charges so everything here under non-covered needs to be removed we don't want to have none covered charges if we're saying the claim is covered and also where the units are there's the total units filled and then the covered units filled and you have to add those units back in as well so those are just a couple steps to make sure that the claims actually fixed before us 9 and send it back to the Mac to reprocess if it was rejected to begin with and then our next thing we wanted to show you our claims that are pulled for prepayment medical review also called additional development requests or 80 hours if a claim has been pulled for prepayment review from the Mac it will go to a suspense location with an with a B as in boy 6000 code or in this example SB as a boy 6000 won so if you ever see a claim in that status we call it SB 6000 status backlinks been pulled for additional development requests there's two types of requests one is if you send your claim with incorrect dates and it overlaps another provider or a hospital it'll Kix ask for non-medical and if it says non-medical then you would want to check your dates and fix your date but if it says Medical Review if you were in the claim you hit your f1 to get the narrative it's going to tell you the claim that's listed for medical review and it's going to give you a long list of information to send in so it's important that the Diller's are catching that a lot of times the maximum ups and letters so the billers the first person to become aware that it's been selected so they can start the process of getting all the information gathered and sent into the Mac if you do not respond to the claim they will ultimately deny it for records not received next diora we see as Part B claims meeting that modifier is Julie mentioned earlier you can see on this example line six and below are all denied and they have their units under non-covered and their charges that are not covered so we would want to go in and adjust this claim to add that modifier let's show you another screen here so CDE only houses two modifiers per service on that front page so in order to adjust or add the KX modifier if that's what you would need you have to go to your service line or your page two and then hit the f11 button two times it'll bring you to this screen and as you can see here it has your revenue code and your service line and then it has modifiers and this one will allow you to add the modifiers are missing and you can f5 and f6 which brings you up and down through your service lines so you can add them from this screen to any service lines missing on your claim keeping in mind that if you are doing a correction to add the modifiers you're going to want to add your condition code d9 at the first page and then your reasons for adjustment on page three and then I also wanted to show you this so anytime you correct a claim for a modifier or a d9 condition code you have to add a remark on page four and that remark has to be verbatim and spelling matters and they will not process the claim if it does not match this exactly so if you're making a change to a claim for any of these reasons and you use the d9 condition code you'll make the changes needed you move the charges to cover to add the missing data and it puts this remark survey them into that field before you submit it back to Medicare some common knowledge gaps and these are just things we like to point out that can really impact billing one not really understanding from a billing standpoint how our MDS assessments or a PPS assessments impact payment in billing this is especially important for your part a claim and your Medicare Advantage claims that they pay based on Medicare guidelines so a lot of times we hear from billers oh I don't know that or I don't understand that but for example as a biller you should know that a 5-day assessment covers days 1 through 14 of the stay if you do not know how many days an assessment should cover then you don't know if the claim was billed wrong or possibly paid wrong so I highly encourage that we make sure that our billing staff are just as knowledgeable about that as our clinical staff and clinical staff do have an annual the the CMS resident assessment instrument for rai manual has two chapters in it with billing information chapters 2 and chapter 6 so I always encourage fillers to read chapters 2 in chapter 6 so they can kind of understand more about the impac
of assessments on billing another one is understanding the billing implications as an assessments not done correctly for example a five-day assessment has to be completed rested with a reference date of days 1 through 8 so if it's completed on day 9 it's a day late if a claim is done early or late we have to build defaults for the number of days out of compliance if an assessment was missed altogether and that residents no longer in that coverage today we have to build provider liability so there's definitely billing implications we need to understand that impact or claim so if that's something you don't feel comfortable as a biller and that it's something I definitely encourage you to get some more training on also we want to do a quick recap on compliance claims with Medicare we didn't want to spend too much time as they're not paid but they are important and so some examples of those are what we call a no pay and that's if your resident was on a skilled stay but then remained in your building you would want to track that by sending an opaque claim to Medicare until the point that that resident discharges from your facility another compliance claim is a medicare advantage shadow claim and that's a claim sent to Medicare with a special code to let them know that yes the patient's been a Medicare Advantage plan but they are receiving skilled care and that helps them track their benefit days and subtract those appropriately and then lastly on the compliance claims is your benefits exhaust and that would be a resident who use all of their benefit periods but they are still receiving a skilled level of care you would want to send that claim to Medicare to let Medicare know that yes that patient is receiving snow care and that their window should not reset as they are not in a non skilled state they are still receiving that level of care another area of gap that we see is the level of leave of absence excuse me so when a resident is on a leave of absence from your facility making sure that you're tracking that and coding that appropriately on your Medicare claim and that would be with a revenue code 180 a seventy four span to show the date that that resident was out of your facility and then that day is considered non covered keeping in mind that if the resident is discharged from you or out on a leave to the hospital and then that is longer than 24 hours you then have to discharge that patient and readmit them if they were to return to you if the resident was on a leave of absence for a therapeutic leave such as they went to see some family there is no time frame on that they can be gone a few days if they wish just keeping in mind that if they're on skilled care Medicare may want to review your claim if you have a leave of a few days they may question why that patient didn't need that skill level of care for those days as we did the other times they're in your facility and then finally just a few follow up to because in addition we'll having accurate claims billed we have to have good processes for following up on those claims one is technology it can definitely be your friend in addition to billing software systems we typically suggest having two Knology to send claim batches just like you send a claim sash to Medicare you have to have software for that most of our insurance companies we cannot directly drop files to them because of HIPAA that's we're investing in a clearinghouse which is a software vendor that allows you to drop file from your billing software to the actual payer can be very helpful so we would suggested investing in that piece of technology if you don't have that available to you and you have any type of insurance volume at all including coinsurance getting web access is another important process it's free to get web access to your payers instead of picking up the phone and calling for claim status if you can log into a website that's coming it's going to save you a lot of time so it's definitely worth the investment to do the paperwork and get those logins and passwords then to have to make phone calls over and over again documenting collection efforts most of our billing software systems have collection notes I highly encourage people to use those not just the billers but from an oversight perspective management should be able to get into a resident at any point in time and be able to see what what steps were taken to collect the balances and then finally just having consistent monthly aging reviews at minimum some clients even do weekly aging reviews that's definitely a great way to stay on top and make sure that claims and balances are being followed upon and things aren't falling through the cracks okay lastly we just want to leave you with some resources that you can use as tools as you're working through some of these tips or if you have issues down the road this is some CMS guidelines some of those manuals of juley reference they are a great tool Medicare offers a lot of great resources out on their website and those are some links for that as well as we have bkb website here for you we update the rates every year and they're free for you to download if you need those I know Part B changes you know typically every calendar year and your rugs in the fall and so having that updated in your software can be critical when you're reviewing your balances and then we also offer spot wear which is articles and webinars that are free to you that are industry specific changes updates and so if you're interested in that you can sign up and we'll send you emails just quick links to that and it will share that information with you and then lastly we just want to keep the conversation going and would love to connect with you on social media you can find us on LinkedIn or Twitter connect with us or let us know that you enjoyed the webinar if you have any questions I'll leave you with that thank you
