Controlling Managed Care Denials – Part 1

(For those of you that missed my presentation at the Florida Healthcare Association Conference, here are some of the highlights of what you missed.)

Managed and Insurance Denials

What are these denials?  What causes them? What can you do to prevent them and how can you get them paid? What processes can you implement to not get these denials to begin with? To get there we have to start at the beginning.  I know, I know we’ve talked about some of this before.  These are important points that bear repeating and were the building points of our wildly successful presentation.

Obvious statement of the day:  CLEAN CLAIMS GET PAID.  The important question here is; what do you need to do to ensure your claims are clean and paid?  Like a lot of things, who you have doing the work is often as important as what they do.

– All things Good and Bad start with your A/R Manager

This is one of those obvious and undeniable truisms.  You may be the administrator, or even own the place, but it is your A/R Manager or Business Office Manger who controls what happens with your claims.  We consistently see with our clients that one of the keys to consistent billing and A/R success is having the right people for the job.  This is a quick recap of an important part of the presentation.  When hiring a new A/R Manager, hire for personality and drive over experience.  There are a few personality traits I believe are vital for success.  Here are the top 3 related to Managed Care.

• Assertive:     You want someone who is confident and aggressive enough to ask questions, question when the answers  seem incomplete, and be able to keep going until they get clarification.  This is especially true in dealing with managed care claims.  Unfortunately there are many ill-informed, or at least less than enthusiastic, people working in the claims departments at every insurance company.  This fact means that you will need to be assertive, and press the person for more if the answer you are getting doesn’t sound right. This is where you lose many of your claims: they deny, you call, you have problems getting a real answer, get busy and you give up.  You can’t afford to hire someone who will give up anywhere near that easily.

• Self Motivated:     Something about SNF Billing seems to change every week.  You really need someone who doesn’t wait to learn about changes through denials. You want someone who likes to learn and is motivated to stay current.  The ideal person loves to work from a position of knowledge and power, someone who will be motivated to research, follow-up and do critical, fun things like reading and understanding your Managed Care contracts.  All too often when we are called in to help clean up a mess, we find a B.O.M. who has been in the position for years, is set in their ways, and waits to be told what to do when there are changes.  It is usually their complacency and lack of assertiveness that results in the A/R mess.  Things finally get too big to ignore and we get to come in to clean up.

• Common Sense:   Unfortunately, common sense doesn’t seem to be that common anymore (if it ever really was).  You need someone who knows when they are being brushed off, or “snowed” by insurance companies.  This is especially true when trying to get answers on the phone.  It really is amazing how often the first call on a claim gets nowhere. Our rule is keep calling until you get: 1) someone you can understand, 2) someone who seems to know what they are talking about, 3) someone who understands that SNF claims are different from professional bills and finally, 4) is actually willing and able to look for answers and not just drink their coffee while they have you on hold.  If we don’t have at least the first 2 covered, we thank them, hang up and call back until we get a good one.

You need someone who quickly notices when something changes or there is a new trend in denials, then takes the time to understand it.  Things are changing so quickly that you cannot train anyone on everything they will need.  You need someone who will take the training they get and use it to understand the rest of their little world.

-Collections begin at Admissions

This is one of our main sayings around here because it is TRUE!  Everything starts at pre-admission and admission.  The contact information, insurance, financial, it all is vitally important to getting paid.  It is amazing how many facilities out there do not understand that a bad admission is more expensive than an empty bed.  For this discussion on Managed Care billing, here are the two most important parts of an admission.  If you are unlucky enough to have a significant number of aging accounts, you may want to start the process of identifying trouble claims and cleaning up your aging.

• Verify ALL insurance information-Out most successful clients make sure that steps are taken to get as complete of a picture as possible.  The facilities with the “heads in beds” mentality are the ones that get in the most trouble.  It is not always possible to check everything, but you must try, and you must document.  We see that a good percentage of managed care claim problems are with residents admitted as Medicare primary who are really managed care primary, and vice-versa.  We need to warn you that the Medicare Common Working File is not always right.  That being said, it is one of the first places you must check.  This means you still check it for everybody, and any insurance companies are contacted on day one.  Ideally this is all worked out during the pre-admissions process.  Document each and every call in your system’s billing notes, it only takes one problem admission’s claims getting paid each year to more than pay for  the time and bother of covering all your angles.

• Obtain and Update Authorizations– It is getting harder and harder to get a retroactive authorization for any claim.  So you need to know if you need an authorization before the admission. You need to know the requirements, timeframes and direct contact numbers for extensions and reassessments.  Coordinating with the MDS coordinator or whoever is in charge of your authorizations will be of key importance to your success.  We can’t stress enough how important it is to DOCUMENT everything.  Document every call, which case managers talked with and who originally authorized the initial the stay.

-Communication

• Authorizations & Level changes –The quality of communications within your facility among the people and different departments is a huge factor in billing success.  One of the nasty little things about billing managed care is the concept of paid as billed.  This means that they will pay you at either what you should be paid under your contract, or what you bill them for, whichever is less.  So don’t get underpaid; stay on top of changes in level of care.  If the billing department is billing at level 1 and clinical has assessed it as a level 2 this is not easily caught without good, consistent communication.  If the claim is billed at the lower level, it will most likely be paid as billed.  This means there will be no aging balance difference to trigger research.  The billing department will see it as paid correctly and may never know that you were shorted $150/day.

-Contract Requirements

With managed care, you need to KNOW the requirements for all of your contracts.

• Billing Format– We urge our clients to keep a file/binder with valid examples of how to bill different claims under different contracts.  You need to know if you bill like Medicare or not, what revenue codes are valid, what needs to be itemized, do they just want one Room/Board line?
• Authorization Requirements–Do you need one and do you need to update? What forms do you need to use? Is there a portal or other electronic method to update the authorizations? What triggers a reassessment? What department oversees the authorizations?
• Available to everyone- make sure that everyone that may need one at least has easy access to a copy of the contract and billing binder.  This includes the Billing office, administrator, admissions, nurse in charge of authorizations, etc.

– -To be concluded in Part Two, so stay tuned – –