2 min read

Ensure Managed Care claims flow smoothly

By Prime Care Tech Marketing on Sat, Mar 19, 2016 @ 07:00 AM

iStock_000026202961_Small.jpgPartnering with a clearinghouse with connections to many payers makes submitting claims easier and keeps cash flowing consistently. Keeping cash flow in a steady stream means understanding how managed care works – knowing the systems, procedures, and requirements are critical. A clearinghouse, like primeCLAIMS, has connections with multiple MCOs and has built into its system the pertinent requirements, procedures, and systems no matter the size of the MCO. It’s worry-free - especially when working with a clearinghouse well established in and familiar with LTC and managed care. The clearinghouse will have the people who can effectively help you, because they have done it themselves.

Getting on board with an MCO – the application process

A real clearinghouse partner, like primeCLAIMS, will send you the correct form with instructions regarding how to fill it out. It can help you confidently connect the dots and fill in the right blanks with the right information. Before submission to the MCO, you can send a copy to the clearinghouse so that its experts can review it for completion and correctness and help with follow-up. The clearinghouse can also anticipate when you should receive the response and will be there for you until you receive the final approval. It plays an active advisory role throughout the application process and it’s that personal touch that truly identifies a clearinghouse as a real partner.

Medicaid Managed Care can be a different animal

Once you have the contract, knowing how and when to submit claims can be stressful for operators, especially since many states with Medicaid Managed Care, like Tennessee, Arizona, and California, among others, have multiple contracted Managed Care Organizations (MCOs) to run the program. It’s complicated. However, you can let the clearinghouse ease some of the pain for you. It knows what information is required, where to send the claims, and how to deal with the MCOs, even the very large ones.

Example: Some MCOs have a 90-day filing limit policy. In contrast to the traditional 12-month initial claims submissions window for fee-for-service Medicare and Medicaid models, if MCOs do not receive the claims within 90 days, they won’t pay. The clearinghouse will help you submit claims within the filing time period.

Another example: Medicaid recipients can either select an MCO or the state selects one for them. A further wrinkle in the process is when the Medicaid recipient moves from one MCO to another and you may not know about it. The result? Billers will be submitting claims to multiple MCOs in any given month. The clearinghouse will help you stay on top of these this.

Note: Creating secondary payer claims should be a primary concern

When Medicare Managed Care is the primary payer, you may still need to submit claims to another payer to pick up the co-insurance. The clearinghouse should create the secondary claims automatically.

Note: Rejecting claims, not a batch of claims

If there are errors in the claims, primeCLAIMS isolates individual claims not the entire batch. While you are fixing the rejected claims, primeCLAIMS submits the rest of the batch for payment. This avoid unnecessary payment delays.

Summary

Having the right clearinghouse partner can help your inbound cash flow freely no matter how complicated the MCO payment process can be.

It makes cents.

Claims Process

Topics: clearinghouse MCOs Managed Care Organizations secondary claims MCO application Medicaid Managed Care primeCLAIMS fee-for-serv
3 min read

Simplifying the Managed Care Claims Process

By Prime Care Tech Marketing on Thu, Nov 19, 2015 @ 07:00 PM

ClaimsAn associate of mine at primeCLAIMS, recently related a turn of phrase that I agree can apply to working with managed care organizations (MCOs), “If you’ve seen one contract, you’ve seen one contract.”  Depending on the number of managed care organizations your company or facility works with, billing the right payer and submitting the correct claim with the correct information can be quite complicated. MCOs have parallel as well as divergent policies for correct claims submission. Knowing what those contractual requirements are and fulfilling those requirements is the key. So, how does a biller keep this as simple as possible?

What’s in each contract – knowing what is covered, not covered

The devil is in the details. And since each MCO contract may be different from the others, billers should understand what’s in each. The contracts may specify:

  • Levels of care by RUG scores or service levels, which specific diagnosis codes are allowed, how many days are considered co-pay days, which ancillaries are covered in the base rate and which may be billed separately or not at all, if a pre-authorization[1] and re-authorizations for a stay is needed, and so forth. Most will agree that no two MCOs are alike. Knowing what services and procedures are covered is essential to and getting paid at the proper pay rates without unnecessary delays.

Caution: Billers need to be mindful that facilities may admit a resident/patient who is to be covered by managed care, but with whom the provider does not yet have a contract. In that event, the provider may not receive full pay for services rendered since the MCO in question may consider the claim out-of-network.

What’s in each contract – knowing how to complete the claim form

Billers need to have a working knowledge of what each MCO expects to have included in the claim form as stipulated in each contract. We recommend that billers have access to the contracts and to know what each requires.

Keeping it all in one place – a ready reference

Wikis are everywhere on the internet these days. Our support teams use wikis to have a ready reference when assisting our customers with questions they may have or to help them troubleshoot an issue they may be dealing with. So, why not create a hard copy MCO contract wiki? We advise all providers to compile all of their managed care contracts into one location, perhaps a tickler file, a file drawer with a folder for each contract, or a binder. In front of each contract, providers should place a completed summary form highlighting what each payer will pay for under what circumstances using which codes, paying how often. Each summary sheet highlights the essentials that must be included in each claim and should serve as a reference tool during the triple check meeting.

Set up the system correctly the first time

Another best practice to help simplify the process is to set up each contract’s claims requirements within the billing software, such as rates, included and excluded diagnosis codes, etc. Word to the wise - Take the time now to set it up properly or deal with possible problems later[2].

Last Word

Keeping the managed care billing process can easier to manage if providers will:

  • Set up a binder or book in which to keep each contract and its summary/cover sheet. All billers need to become familiar with each contract.
  • Correctly set up the contract provisions within the billing software.
  • Refer to the contract summary sheets during the triple check process.

One More Last Word

My primeCLAIMS colleague, Mike Giel, suggested we mention that in the contract negotiation period, providers need to discuss what provider enrollment procedures the MCO requires before claims can be submitted electronically. Think of it this way. The contract is the key to opening the claims flow door. The enrollment form opens the door. Completing, submitting and receiving approval prior to submitting the first claim will ensure that the door is open and remains open so that claims can go and payments come in unhindered.  

It just makes good cents.

[1] Example: Pre-authorizations are usually required to pre-approve a specific length of stay. Providers may need to get authorization to extend the stays beyond the initial authorized period. If providers don’t secure a reauthorization, they will have to worry about who will pay for the rest of the stay. Knowing that in advance can eliminate frustrations for all involved: the resident, the resident family, and the provider.

[2] Note: Contracts have a life of their own and can change over time. When those changes occur, record them in the contact binder and billing software set up.

 Claims Process

Topics: claim form triple check MCOs MCO contract Managed Care Organizations MCO claims RUG scores levels of care

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