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Lab bill format for Operations

today's learning objective we will describe the medical billing and revenue cycle management fundamentals we will be defining medical billing as opposed to revenue cycle management then we will examine operational workflow of the billing department such as staff an organizational chart and perhaps if your facility is small we will contrast that to a large facility in staffing needs and of course we will explore your staffing your billing office if you are just initiating one medical billing and revenue cycle fundamentals so the definition of medical billing the process of submitting and following up on claims so this is the responsibility of the medical biller to look at the claim from submission to the time the EOB or the explanation of benefits comes back from the carrier to posting the payment to following up to ensure that the claim has been paid in full revenue cycle management is the administrative part of the medical billing process it's the clinical functions that contribute to the capture management and collection of patient service revenue and as we will see the revenue cycle management process begins when the patient steps in the door so here's a simple diagram of the overall revenue cycle management you will see in the yellow the start of the claim the first bullet patient registration the minute the patient walks in the door very important to check their insurance cards make sure that they have insurance by checking the eligibility and this should be done actually if the patient calls in over the phone the collection of the insurance information is important so that the insurance eligibility is checked before they come to the office once that is done the claim is submitted after the patient is seen and these services are documented so the claim is submitted claims management will involve payment posting the medical coding the denial management if the claim is denied and then of course the appeals process if you if your facility feels that the claim was denied and you feel it should have been paid then that is what the appeal process does a our management very important and fundamental to the revenue cycle its follow-up you want to make sure that your AR is most of your buckets should be in less than 90 days if you have a are over 90 and 120 and you have a lot sitting in there then your AR is not being worked properly one thing that you would want to check is your denials your patient collections and perhaps you're not sending out patient statements on time analytics that is the clinical part of the revenue cycle management you'll want to look at your reports monthly very important and looking at these reports will help you understand your money your finances and where your claim issues may lie so let's talk about the start of the claim so patient registration as I said pre-registration and obtaining that accurate information when the patient pulls that's a new patient to make sure that you take down the correct information and then the insurance eligibility a lot of times the practice management system we'll help check that insurance eligibility but that should be done prior to the patient coming in it's very important to have a workflow where someone is designated to check that insurance eligibility 24 to 48 hours perhaps before that patient presents as a patient appointment very important to keep records of you know if the patient comes in if the patient doesn't come in a lot of times practice management systems have a great way of either putting a no-show a cancellation but it's very important to keep track of that so clean submission the second part of the revenue cycle charge entry so if you're doing you know if you have your billing department in-house the charge entry process needs to be completed accurately and timely charge entries should be done within two to three days some you know maximum after the patient presents some practice management software is connected to the EMR and if something is ordered in the EMR then it can be automatically charged but if you do not have a connection and charge entry verification perhaps should be done coding so if you work in a in a facility that has a specialty or you know services that might be very diverse it's important to ensure that the the coding of these charges is done correctly that is also related to the modifiers you know oh IG or for the office of the Inspector General has their work plan every year and a lot of times they will focus on looking at facilities that use modifiers incorrectly claim submission so once the decoding and the charges are put on the claim then the claims get submitted generally a clearinghouse which we spoke about in module 1 is used to electronically transmit these claims to the third party payors and then this Clearinghouse can generate reports that will tell you if the claim goes successfully or it is rejected and that report should be monitored daily claims management once the claims go out cleanly they come back and payment posting begins so payment posting can either be done manually or again it can be done electronically depending upon you know the status of your facility the electronic remittance process is the electronic posting and that allows the staff members to review and work from an exception report so this report will include that's the electronic report and it will include any details coming back from the payer once it's posted or it's not posted because of a denial then it becomes the process of denial management so the best practices recommendations of the denial management is always to to track and trend your denials the best way to do that is as I said to review your reports monthly you will look at your denials by bucket perhaps it's a registration problem perhaps it's an eligibility issue but always denials should be tracked by payor type and of course then by provider it's very important to track them by provider because as we spoke about in credentialing if you're getting a lot of denials for a provider perhaps there they are no longer essentials with a particular carrier or it expired appeals as I said if you feel that is denial should have been paid appearing a denied claim doesn't guarantee payment but it is sometimes worth appealing especially for those large claims accounts receivable as I was speaking about your buckets of your your accounts receivable so the a or follow-up is a very important part of your billing department most insurance carriers are required to pay or deny the claim within 30 days of receipt now we know Medicare is generally two weeks which is great but other carriers you know generally have up to 30 days claim follow-up you should begin following up after 70 days following the claim submission for your payment patient collection very important part of your practice establish policies associated to financial responsibilities patient collections who sends out your patient statements is there a collection agency what's the timeframe you allow patients also patient collections is very important at the front desk when the patient presents if they have a balance it should be brought to the patient's attention and the patient statements sometimes is a large volume you know of patient statements why because patient responsibility for deductibles coinsurance co-payments has increased as we know so the responsibility the financial responsibility is shifting to the patient so that's why there is you know over the years has been a large volume increase in patient statements so it's very important to follow up on that and one thing I'd like to say about co-payments and deductibles they should be absolutely collected at the time the patient comes to the office they also its best practice to collect it prior to the service so as I was speaking about looking at your reports monthly is very important to you know gain those KPIs reports or key performance indicator reports depending on the size of your practice you know how many reports you you want to look at who's going to look at those reports but generally for monitoring and control of your finances you would want to look at the reports indicated here accounts receivable aging by carrier or patient so that is what the bucket saw is zero to thirty thirty to sixty generally the last bucket would be greater than 120 and you really should not have that much outstanding in over 120 CPT volume build and paid by carrier you want to monitor what CPT codes you are billing could there be perhaps a decrease in one CPT code from month to month that can be maybe because the provider is on vacation but you should keep track of your CPT volumes and if you see a decrease you know question it and find out why collections by carrier also very important and that goes along with the CPT volume are your collections going up great are they going down why why is the collections going down that could match the contract your carry your contract as we had discussed it's very important to monitor the expiration of your carrier contracts so you want to make sure that you're being paid what you're contracted to be paid by you carrier collections by CPT code that's another indication of what your being paid by your carrier patient volume by month that's very important you wanted to your trends are your patient volumes going up are they going down are they going down and you don't have enough scheduled appointment slots there's a lot of things to look at when you're looking at your patient volume and your system financial summary that gives you the overall of your your collections your net your gross so here we have a sample sample productivity report that you might look at depending upon your your billing system if you outsource your billing you know however you do it it's just it matters that you look at your report so this is a sample productivity report and as you'll see you have your CPT codes some of the payments and then the percentage of the payment so you can see by looking here that one 200 one seems to carry the highest percentage of the payments from this report and this is a year to date is another report as I was speaking about AR it's too simplified AR report here you see your current you're over 30 over 60 over 90 this is very important to look at this is you know very condensed but it just gives you an example of what you should be looking at for your AR this is a sample of the system financial summary report generally when you run your system financial summary report it gives you the month broken down to date which is a great thing and this one is a great example of what we were speaking about about patient volumes so here you'll see your patients started 260 9 what happens in February and March you know that would be something to to look at and then they go way up in April so just by looking quickly at this you can get a lot of information but the information should be looked at and the wise and what should be answered so let's talk a little bit about operational workflow in the billing department so the workflow and productivity are of course essential for the clinical practice success the billing workflow is only one portion but the whole facility does depend upon that effective billing department so this is just a quick diagram of the medical billing workflow so you'll see for optimum workflow you start with insurance verification if there is no insurance you should stop right there pull the patient find out what the problem is patients change their insurance is very frequently these days so don't assume that mrs. Jones was in last week she's coming in in two weeks don't assume that she has the same insurance then when the patient comes in ensure that all the patients demographics are correct you don't have to scan a lot of places now scan the insurance card which is great you don't have to scan the in patients insurance code at every visit but it's important to collect that card at every visit or just take a look at it as you're pulling the patient up on your practice management system if you have one you know you're looking at the patient's information and just pass me their insurance culture verify that it's the same you want to ask if there's any change of phone number or anything as such because you know that a or follow-up is very important and get in touch with the patient that's a problem number three this is the part that's important the coding the ICD and the CPT coding ensure that your services are billed correctly it'll save you a lot of work in the end charge entry when someone entering those charges or as I said they're coming over electronically that's very important that they will code it correctly then we have claim submission clean claims will depend upon perfect demographics correct ICD codes and CPT codes and charge entry once the claim is submitted it comes back as we said could be electronically or it has to be manually posted denial management is next we're going to work on your denials and of course if something is denied and you want to appeal it it becomes appealed at this point the a or follow up as I said is very important you want to make sure your a our follow-up is worked daily and then reporting you want to look at those reports monthly whether you outsource or whether it's billing department in-house so front desk operational workflow very important okay they have a direct impact on the overall success appointment scheduling patient demographic entry insurance verification point of service patient collections as I said if the patient has a balance please ask for it at that time it should you know if your system has a tickler whereby a box can pop up with a patient balance I suggest that it be turned on and I would also train the front staff to make sure that they understand you know how to address this you know there's a way to ask a patient for a balance and everyone at the front desk should understand how to you know how to have a ticket and asking for balances so of course the front desk is the front first line of communication incoming telephone calls another part of the etiquette appointment scheduling performing the initial pre-registration with the new patient obtaining the patient demographics greeting patients outgoing telephone calls collecting payments again co-payments coinsurance deductible is very important and then not just up you know communicating with the patient but also communicating with the clinical staff when patients arrive you know the front that should be aware of who's sitting in the office how long they've been sitting in the office it it goes from patient satisfaction if the patient is address communicate so-and-so is running late but always make sure that you have that communication with the clinical staff another important part of the front desk operational workflow is a telephone system a lot of times I'll go into an office and you know oh I get our telephone systems is horrible well the best thing to do is to call your telephone system as a patient and see what the issues are that is it's very frustrating for patients when there is so many choices on a telephone tree or they get sent to voicemail so call that system as a patient and perhaps you can see what issues really are there so patients accounts receivable so as I had said the insurance industry industry has shifted and the patient responsibility for the finances has increased you know a lot of patients have higher deductibles higher co-payments then those catastrophic coverage plans non-covered services a lot of times insurances all carriers will have different plans and some services won't be covered whereby the patient you know a lot of times doesn't understand why patients really don't read their their insurance their insurance contracts as thorough as they should you know and there's a lot of plan limitations on certain covered services so the front desk billing staff as it says here should be educated on a regular basis on how to address patients and the procedures on how to handle the patient collections and how to speak to patients about their insurance let's talk about staffing your billing office whether you be a small facility or a larger facility so you know usually billing is considered by FTEs or a full-time equivalent so the Medical Group Management Association which is MGM a provide data on staffing for departments of providers of facilities and in 2015 in their summary report they said that 2.7 FTE support staff as the average staffing required per provider so that includes front office business operations support staff for multi specialty with primary and specialty care services so that's 2.7 FTEs so it's important to ensure that you have enough staff to support your facility it is said that a lot of times if there is staff equivalent to support the facility that the facility runs more smoothly so here we have a sample staffing model of a fairly large facility now if you have a smaller facility a few of the functions can be integrated but at the top you have your billing manager so you have your billing manager who should have experience in every one of these second boxes such as they should understand what the front desk clerk does they should understand what the medical coder does the charge entry claim submission payment posting and accounts receivable so underneath the billing manager of course you have your front desk sometimes that is underneath an office administrator or a front desk supervisor but underneath the front desk you then have your registration and scheduling your insurance eligibility and then your collections of your monies next you would have your medical coder and this is what I was saying it's very important to understand all your CPT and ICD codes should be correctly placed on those claims you don't want to keep billing incorrectly as I said you know putting in current modifiers on claims because that's a flag for your facility so that medical coder is going to review those claims for accuracy communicate any coding issues with the billing manager if they're constantly seeing incorrect modifiers put on claims bring it to the billing managers attention it could perhaps just be a simple simple things such as education to either a provider or to someone else charge entry as I said that's important that could be just be be something that's monitored if your EMR is doing the charge entry over into the billing system but an important part of that charge entry is reconciling those charges to the schedule you want to make sure that for every patient that you saw that day there is a charge and that could mean also checking your p.m. are to make sure that all the charts are signed if a chart isn't signed an EMR a lot of times the charge will not be released claim submission so that person is either going to prepare paper claims or prepare electronically they're going to also be responsible for correcting those rejected claims you know they upload the claims to the Clearinghouse and they also will run the reports from the Clearinghouse to look at how they would scrub and what was rejected the payment poster they're going to enter the insurance and patient information they'll look at the EO B's very important to look at those Yogi's because those ELB explanation of benefits will say what the carrier is paying you for your service and as I said it's very important that you're getting paid with your contract to be getting paid accounts receivable the explanation of benefits reviewed for denials where your denials break them down into categories and then of course any ne AR reports the claim follow-up should be looked at and it's in a in a very organized manner perhaps by date and then by large amount and broken up for staff members to work on so the key billing staff roles are the billing manager the coder the charge entry the claim submission the payment poster and the accounts receivable clerk okay so now like I said if you have a smaller facility perhaps you can have one or two of these intertwined into one role but it's important that that person or that staff member have time to do each of those functions so the billing manager very important key responsibilities maintain an extensive knowledge of the practice management and the EMR system they should know how to work those systems back and forward they should be able to design implement and enforce the billing policies streamline the effective billing processes the job descriptions which was only to go over for all the billing positions easy to use grids managed-care contracting expiry Buhl's analyze the financial reports before giving them to either you know the CEO or administration and of course they should coach and train always have training and billing whenever usually in November the new CPT codes come out they should be holding you know training sessions nearly so that everybody is on the same page with the new codes and of course provide cross-training and that's very essential to every size billing department if somebody is perhaps out and they're supposed to be working a are we should be able to cross train at least one staff member so their skills of course understand all aspects of medical insurance billing ultimate knowledge of the cpt icd-9 as I said EMR and practice management knowledge effective communication is always very important for a manager detail-oriented and ultimately they should be able to read those monthly reports very important the medical coder so this person should know what codes are mostly used by your facility and should know the modifiers inside and out that medical coder also should be responsible to conduct conduct internal boards and coding reviews to ensure that the commentation in the chart meets what is on the charge ticket it's very important just looking at the claim for correct coding is great but we also must make sure that the coding reflects what's in the documentation that's very important because carrier audits they should be a CPC or a professional certified coder of course conduct education and training sessions because if they do do those internal audits and the documentation seems to lack what is on a charge ticket the coder should be able to educate the provider in what is missing the charge entry claim reconciliation clerk so that is important outstanding charges by providers very important function as I said that could be because maybe a chart isn't signed but it's important to take that list of your patients of that day and ensure that you have a charge for every patient that has presented its and that's where you'll also find that perhaps somebody didn't click a box for no show or a cancellation but everything should be reconciled and it's very important for that charge entry claim reconciliation clerk to work with that billing manager to ensure that all charges are correct and obtained so this person really should have also knowledge of CPT icd-9 coding and very very important attention to detail as I said if you find your charge entry claim reconciliation clerk you know constantly is getting missing charges that's an important investigation that needs to be done perhaps there's a provider who doesn't understand closing the chart or you know you just have a provider who isn't closing the charts on time so it's very important for that that clerk to understand and report to the billing manager what they're finding in their reconciliation and charge entry so the claim submission clerk of course is going to create those electronic files that are going over to the carrier and they're going to make sure that those those scrubber reports before their sense are taken care of if there's rejection they should work on those rejections and the reports that they're going to review or the claim denials the payer denial and the rejection patterns they're going to look for rejection patterns from that Clearinghouse and again they're going to work closely with the billing manager to identify any problem reports or or patterns so this person medical billing and the claim cycle very important clearing has functions they should be very abreast of any change in the Clearinghouse function any updates they should be responsible for any communication with that Clearinghouse to ensure that they're you know the electronic function is running up to speed the payment posting clerk important data entry of the insurance you're looking at the co-payments to see if how much they are you're looking at any deductibles you're looking at the adjustments in right hook because ing to you a fee schedule for your facility you want to look at any adjustments of the allowances and make sure that you're getting paid correctly from your carrier as I said you're going to post youjin oil and of course you're going to be monitoring those denials is it a problem with demographic is it insurance in eligibility and you're going to investigate unidentified cash and any misdirected payments so the payment posting clerk again as everyone really should have a medical billing and coding guidelines and understand those Yogi's or the explanation of benefits backwards info is every carrier sends a different ELB so they should be able to understand every part of that ELB and they should be highly organized the accounts receivable clerk very important to maintain and generate the AR reports there should be a method to how the accounts receivable is being worked up you don't want to let your work up go out to over 120 days this person should really understand the payer websites a lot of payers now have great websites and excellent customer service skills counts receivable clerks will have contact with patients perhaps in collecting large balances but it's very important also that they understand the insurance balance benefits and eligibility guidelines and they should be proficient in submitting Appeals so if your staffing a smaller office so if the practice is in personally performing the billing operations you should always be monitoring their KPI or the K key performance indicator reports and as I said let's review productivity charges receipts adjustment detail the denials and the Clearinghouse edits that's always very important to review even if it's not being done in-house practice management and EMR systems those should be utilized to the fullest extent especially for billing and of course ensure your staff is hired and and adequately trained for their particular function so if you're you you thinking about absolutely new medical billing or keeping it in half you have you know this is pros and cons many practices choose to outsource it because it's just easier the pros to that reduction in billing errors that you can see on your side because you're not doing it reduction in practice expense for staffing benefits etc ensure billing compliance the medical billing company must be responsible for optimal compliance additional time to focus on patient care current knowledge of specialty specific billing and coding guidelines so if you're looking for a medical billing company and you have a specialty there are medical billing companies that are specialty focused so then you can look for one that perhaps has extensive experience in your specialty detailed financial reporting on a scheduled basis yes medical billing companies should provide and most of them say that they do provide but a lot of times I have encountered practices that actually do not look at those reports they'll receive them from the medical billing company and perhaps file them because medical billing you know really isn't a thought because the billing isn't in half so you really need to be careful about that if you do outsource your medical billing make sure you receive those reports on a monthly basis and that they are reviewed cons to outsourcing patient satisfaction patients have to pull the medical billing gender instead of calling your office you know sometimes the patients feel more comfortable calling your office you don't have any direct supervision of the staff perhaps you know you don't even know where the staff is located lack of control of your billing processes and procedures you have to be concerned about privacy and security always make sure that your medical billing company is HIPAA secure lack of communication regarding denial trends and other revenue impacting concerns in other words if you're not looking at those reports you know things can slide by you could possibly have a denial trend that's rising if you're not reviewing it and not addressing it with the medical billing company hidden fees and variable costs when you do decide if you do decide to outsource your medical billing ensure that the contract has everything that you expect them to do a lot of times the vendor will charge for separate items such as sending out patient statements or sending to collections so everything that you want them to be responsible for ensure it's in your contract so let's address a case study so we told a medical center okay so the challenge this medical center in North Carolina it was facing an uphill battle in 2007 operating losses were approaching 3.5 million it was a community hospital at only 50 days of cash on hand and accounts receivable were languishing at 77 days as I said you shouldn't really have anything over 120 and 77 days the club and increased bucket is is is not good so the executives knew their revenue cycle was the cause of the all these however they weren't exactly sure how to correct it perhaps they were looking at their reports or asking for reports that could detail their difficulties so solution so the center augmented their patient access process by implementing stringent pre registration processes verifying insurance prior to appointments and proactively discussing with patients what associated out-of-pocket costs would be along with payment options as I said I can't stress enough it's very important the registration process ensure not only is the insurance information correct but the patient's contact information and any other associated identification numbers and always try to collect that payment upfront or have a strong financial policy in place so the result was healthy posting 5.5 million operating profit days of cash on hand increased threefold days and accounts receivable will cut nearly in half so it is possible once you start having a streamlined process at your front desk and ensure that the workflow is effective to keep your AR a day so today's session highlights so we discussed medical billing and how to maximize collection and reduce time to payments and how how effective workflows and skilled staff can help we discussed the revenue cycle management processes from start to finish again start at the front desk and then ends at follow-up staff models we discussed the different part of the billing staff organizational chart and of course depending upon the size of your facility how you would designate that model job descriptions were also gone over perhaps if you're thinking of developing your billing department you can use those job descriptions as a base and determining the health of your revenue cycle through filling reports very important to look at those reports monthly and to ensure that you see the trends and address those trends if you do have them so profession too many assignment this is just something to think about and how it pertains to your facility review your office policies and procedures any deficient front desk and billing operational policies that you might have perhaps you need a policy on effective insurance eligibility take a look at your policy do you have policies compare your current front desk and billing department job descriptions some facilities do not have job descriptions so anything that was in this presentation can be used as a baseline and in composing any job descriptions that you might want for your billing department review the required skills for your job description you want to make sure that your staff members fit the responsibilities you are assigning to them you want to assess any training programs that are available very important as I said billing training perhaps once a year when those new codes come out conduct a training session you know ongoing lunch and learn anything just to make sure that the whole billing department is on the same page create an outline of your billing staffing model see see perhaps maybe it's not effective review your AR and productivity reports for 16 and 17 identifying any significant trends well there are any significant trends and perhaps look at 17 and 18 and see how they differ from 2016 and 2017 so we've come to the end of module 2 I hope you have enjoyed it and think about what we went over in those many assignments you have come to the end of module 2 of the step-by-step initiating and/or enhancing billable services online learning module series thank you for trusting your training and technical assistant needs with sustainable strategies for Ryan White hiv/aids program community organizations program for questions regarding today's module please contact us at hrs a at P CDC org for more information about our program products and services please visit our webpage on the target HIV website thank you