3 min read

9 Effective Habits Every Biller Should Adopt

By Prime Care Tech Marketing on Thu, Jan 21, 2016 @ 03:00 PM

iStock_000050766304_Small.jpgWhat makes billers effective? Habitual attention to specific details and consistent execution of routine, yet critical tasks. I’d like to share with you what our team considers to be nine habits of highly effective long term care billers. Caution the resultant success can be addictive. That's a good thing. 

  1. Make sure your census is correct. We can’t stress this enough. Work closely with the Director of Nursing to make sure the night shift nurses are indeed taking a midnight census. Here is an example of what could happen if they don’t. Let’s say Mrs. Brown is discharged to the hospital, but the discharge is not correctly noted. Because she is still considered in the census, you may bill for the entire month incorrectly. Daily stand-up meetings are great opportunities to confirm the census count and to review the previous 24 hours’ admissions, discharges, and bed holds. Whatever procedures are in place to track the census, relentlessly encourage accuracy and timeliness.
  2. Check eligibility regularly. Do this at least monthly. For example, residents can change from the traditional Medicare model to a Medicare HMO plan at any time. It’s impossible to bill for Part A days when the resident has already exhausted the days available in the Benefit Period.
  3. Triple check during the month-end close. We’ve mentioned month-end triple checks before. If your facility or facilities a significant volume of Part A and Part B claims each month, you may be willing to check a random sampling of bills during this meeting. But what should you cover during the triple check?
  • Consistency of nursing and therapy documentation – Make sure that the nursing documentation supports the therapy documentation and vise-versa. If the resident needs therapy to learn to ambulate, nursing and therapy documentation needs to support that.
  • Verify that the medical record supports the intervention performed – This is, of course, dependent upon the supervising clinician’s judgment. Make sure the team addresses this issue.
  • Verify therapy minutes – Confirm that the minutes to be billed are consistent with the RUG level’s requirements.
  • Charting – Especially for skilled Part A services, clinicians need to chart as required. Make sure clinical documentation has progress notes, noting that the resident needs skilled intervention.
  • Benefit days availability - Communicate available Part A days.
  • MDS assessment reference dates - Verify the MDS-assessment reference dates are accurate for the 5 day, 14 day, 30 day, etc.
  • Physician orders - Make sure that physician orders have been received and have been implemented.
  • Physician certification/re-certification – Make sure the attending physician has certified or recertified the need for skilled services and that the record includes reliable documentation.
  1. Know your payer contracts – As we discussed in the last blog, review your payer contracts regularly.
  2. Make sure the business office staff is continually learning – Dr. Covey referred to it as sharpening the saw. If you are an AR manager, this is important. The world of claims processing and billing requirements change constantly. Challenge yourself and your staff to learn something new every day. Also, acknowledge that turnover among billing staff exists which means in some cases, you must start over again. Take advantage of the webinars provided by the MACs when available.  They’re free!
  3. Get organized and know where to find and plan what needs to be done by when. Remember today’s technology can be your best friend with digital calendaring, automatic reminders and alerts, software-based task lists, and more.
  4. Don't be an island to yourself - Be transparent in your billing practices and routines. Just as back-up and failover procedures are critical to IT, so is “cloning” yourself extremely important. Billing must be on time. Train others to pick up where you may have to leave off, just in case.
  5. Foster positive working relationships among staff members – An atmosphere of open dialogue and trust contributes to a smooth-running operation. Have a go-to person in each department. Those “insiders” can give you the information you need quickly and accurately.
  6. Be the go-to person yourself – Let trust and dependability begin with you.

Okay, I am sure you can add to the list, but we suggest you keep it short and do what matters most in your role as a biller. It just makes good cents.

Topics: triple check census payer contracts effective billers eligibility business office staff get organized daily stand-up meetings
3 min read

Six Resolutions Every AR Manager Should Make

By Prime Care Tech Marketing on Thu, Jan 07, 2016 @ 07:23 PM

iStock_000081689631_Small.jpgAh, yes, it’s that time of year – time to make those New Year’s resolutions. Exercise, diet, vacations, revisit the old “bucket list”, maybe even finances. Finances? Now a financially-focused resolution or two should resonate with any AR Manager. Maybe we can help you kick off 2016 right with some helpful resolution hints. They may not be earth-shaking taken independently, but together, they can certainly have a positive impact for you and your team.

Resolution #1 - Make sure that pre-admissions screening covers all the financial bases before the admission. This may sound overly simplified, but it is so essential with numerous moving parts. It is a time not only to be informed, but to inform not just once, but regularly after the admission.

  • To be informed – All members of the admissions team must know who the payer is and the proper billing procedure - how much, how long, and for what services. Not only immediately after admission, but should the length of stay outlast such coverage as Medicare or private insurance, the team, the family, and resident must know who will pay. You might say that you want to make sure all your “bucks” are in a row.
  • To inform – This is something that some providers forget to proactively pay attention to and communicate. Communicate to whom? The rest of the team, the party (private or third party) who will be paying the bill, and the family. Providers need to keep in mind that placing a loved one in a facility is traumatic and unavoidably new. Prior to and on admission, family members/responsible parties encounter so much information. Your team needs to compassionately and frequently remind them of expectations and their loved one’s status. Changing from one payer to another should never be a surprise. Fostering a positive relationship with responsible parties throughout each resident’s stay will pay big dividends in the long run.

Resolution #2 - Make sure the census is correct, up to date, and entered correctly in the billing software. Whether your facility or facilities are still laboring under a manual census tracking and recording process or you are enjoying the benefits of electronic charting, knowing who is in what bed each midnight is critical. Even electronic charting still requires the personal touch, that is, someone has to make the rounds to confirm the beds are occupied, on hold, or vacant.  

Resolution #3 - Make sure to conduct a triple check before submitting any bills or claims. We are not going to elaborate on the triple check process at this time, but stay tuned for helpful tips in future blogs.

Resolution #4 – Stay informed by attending seminars and webinars. Medicare, Medicaid, Bundled Payments, ACOs, VA, etc. are changing and unless you and your team are informed about what has changed or is about to change, you may be a day late and a dollar short. State and Federal agencies, your state and national trade associations, industry media publishers, and others conduct education sessions throughout the year to help you effectively manage the revenue cycle. Plan on attending as many of these as possible.

Resolution #5 - ICD10 training and updates. Although you and your team are usually not the initial coders, you still have to be ICD10 savvy. The key here is specificity – the highest level of specificity. You have our permission to review those codes and if you are uncertain about the codes specificity, push back on admission and during the triple check. At primeCLAIMS, we have seen many claims rejections since the ICD10 implementation due to a lack of specificity.

Resolution #6 – Stay on top of your Days Sales Outstanding (DSO). Discuss DSO with your team and set goals to reduce it to an acceptable level – ideally around 30 days. However, realistically identify what is in your control. For example, Medicaid in some states pay much later than others. Consider that carefully, set goals thoughtfully, and collect aggressively.

Making and successfully achieving resolutions specific to your department’s and business’s needs can make 2016 truly a Happy New Year at least financially.

It just make cents.

Business Intelligence

Topics: DSO AR managers ICD-10 days sales outstanding triple check private pay Medicaid census billing software ICD-10 training pre-admissions screenings Medicare private insurance
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. Our Managed Care Master App can help. 

Keeping it all in one place – a ready reference

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. Or better, if you don't want to physically maintain contracts, check out our Managed Care MASTER app for housing your contracts online with easy-to-reference contract summaries.

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

The managed care billing process can be easier to manage if providers will:

  • Use available technology, like Managed Care MASTER, or set up a reference binder for each contract and its summary. 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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