Hayes' Healthcare Blog

Insurance carrier setup neglect: a costly oversight - Part 2 of 2

Posted by Angela Hunsberger on March 2, 2016 at 9:00 AM

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In last week’s blog Angela Hunsberger outlined the importance of cleaning up the insurance carrier list to ensure efficiency to maximize payor reimbursement.  More than consolidating an old list, she explained the nuances of paper vs. electronic claim submission and suggested partnering with the billing team to tackle the list.

Continued in Part 2 of a two piece post, Angela provides an instructional roadmap detailing six steps of insurance carrier cleanup.   This article will provide the knowledge and tools needed to revamp carrier settings and revel in the financial payoff of a job well done.

6 Steps to Insurance Carrier Cleanup

Step 1: Run Reports to find paper setup

As Lao Tzu said “The journey of a thousand miles begins with a single step”. A good starting point is to run a report to find carriers setup as paper. Some systems will allow you to export this data into Excel. Filter out the carriers that must go paper including Worker’s Comp or Automobile. Work with your billers to learn why carriers are set up on paper and get a clean list of carriers that could go electronically but are not yet set up.

Step 2: Look at recently filed paper claims

It is not enough to look at the setup because it doesn’t tell the whole story. You must take a look at recently filed paper claims as well because that proves what is actually happening with paper claim filing. Electronic claim submission is often overridden and claims are commonly dropped to paper because they are rejected during submission and the staff do not know how to fix the claim. Rather than troubleshooting, they drop the claim to paper, stuff it in an envelope, and seal it with a wish and hope it will go through.   This scenario is not ideal but is common. The problem with this workaround is two-fold. Paper claims miss the “extra scrub” from the clearinghouse and the setup continues to be overwritten causing more work and the issue to continue with future claims. Sometimes the paper claims also get denied and I see the claim submitted a handful of times before it is “written off”. Tisk. Tisk. This point in the discovery typically reveals a need for EDI troubleshooting training. Using real rejected tickets talk through the issues to learn about techniques to find and fix EDI errors. Billers like to learn about clearinghouse tools and ways to understand and fix rejections. This training can be delivered by a system analyst (such as myself) or by your vendor support.

Step 3: Clearinghouse payor list

Clearinghouses offer a master payor list containing the payor ID numbers you need to enter in your insurance carrier setup. Each clearinghouse has their own payor ID numbers so these numbers may vary between clearinghouses. Here are some tips in finding your insurance carrier on the clearinghouse payor list. Filter for professional or institutional payors. You can also filter by state to narrow down the list. While you can search by name, the name may not match what you have in your PM system. A helpful search mechanism for this is to search by the Emdeon number that is found on the back of the patient’s insurance card. Without going into detail, the Emdeon number serves as a “universal ID” number that is recognized among all the clearinghouses. Usually, when you search for the Emdeon number on the clearinghouse payor list it narrows down the list enough to find the carrier you are looking for. If you search the list and your carrier is not found, most clearinghouses will still allow you to send the claim to them electronically and they will drop it to paper and mail to the payor on your behalf. To accommodate this, clearinghouses offer a generic Payor ID number for you use. It is possible you are charged a small per claim fee, but the extra tracking and scrub is worth it.

Once you find your clearinghouse payor ID number for that carrier and enter it into PM, you can start sending claims. Sometimes the payor will require EDI Enrollment first. The payor list will tell you if EDI enrollment (or any other steps) are required prior to claim submission. The process for EDI enrollment is simple but the processing time will vary per payor and sometimes take well over a month. In the meantime, send the claim to the clearinghouse using the generic payor ID so they will drop the claim to paper. Remember to go back and update the electronic payor ID once the enrollment is processed.

In my visits with billing offices, it is typical when staff tell me they do not know where to find the clearinghouse payor list or how to use it. This fact alone tells us how our insurance lists get out of date. Ask for training on the payor list if needed. After this exercise the only claims being sent on paper should be because additional documentation is required or the claim type prevents electronic submission.

Step 4: Set up eligibility

The clearinghouse payor list also provides the electronic eligibility payor ID to enter into PM. Chances are you are paying a flat per provider rate to use this service. If you are paying a flat fee and you are already in the setup anyways, why not ensure you are getting the most for your money by setting up real time electronic eligibility? Contract structures vary and some charge per inquiry but most should be flat fee. The setup is pretty easy and straightforward and once the number is keyed into PM, you are ready to start using it. Enrollment is not typically required.

Step 5: Remittance

When setting up any insurance carrier to go electronically, it is a good idea to enroll in electronic remittance at the same time. Electronic claims are sent in an ANSI 837 file and the EOB’s come back in an 835 format. These structured files are often cross-referenced for analytical data mining and reporting. The more remittance you can get back, the better your reporting will be.

The goal of remittance is not to replace your payment posters. Rather, remittance removes the manual labor of keying in numbers. Claims still need reviewing after the remittance file is processed. Remittance response settings in your insurance carrier setup can make that job easier.

Remittance files contain nonpayment reasons that can be used for tracking and trending when services are not paid. Leverage this information in your insurance carrier setup in EDI response processing to triage the unpaid follow up or appeals process.   In your PM insurance carrier setup, single out common denial codes for follow up. I commonly see EOB’s come back with unpaid line items. Since the balance is $0, payment posters close the claim and move on to the next task. Right here is a huge liability for revenue loss. A $0 claim does not always mean the claim lifecycle is over. Denial codes are your call to action on where improvements need made in your practice. Denial code frequency and impact to your revenue cycle are your compass to process improvement. The goal is to use tracking and trending to prevent and decrease the quantity of denials and decrease % of denials/charges ratio by implementing a more automated, organized, and efficient process for tracking and working non payments. Tweak automation based on nonpayment codes to reduce data entry along with uncaught mistakes.

Regarding remittance, some clearinghouses use an algorithm based on your claim submission history versus when an 835 EOB file is typically returned. They use this data to flag possible late payments and call them to your attention.

Two last benefits of electronic remittance are the ability to better able recall an EOB. 835 remittance files are received in PM as structured searchable data making it easier than sifting through scanned copies of paper EOB’s. Lastly, 835 remittance files often prep claims for secondary electronic filing by automatically populating the line information and coordination of benefit values.

Step 6: Audit carriers currently in place

It is not enough to convert paper claims to send electronically. You also want to look at the settings in your carriers currently setup to go electronically. You may find outdated settings and unused features. I see this mostly in remittance response processors or old dusty settings causing more work for billers. Perhaps the carrier was set up using the generic clearinghouse paper payor ID but then the EDI enrollment was accepted or the payor recently offered an electronic connection but the Payor ID was never updated. Lastly, double check the carrier is setup to send and receive electronic eligibility and that you are enrolled for remittance for all possible carriers. A quarterly review would be optimal.

A lack of knowledge is no excuse.

Take it from a road warrior with eyes in the field for over ten years. Onsite workflow assessments and system evaluations continue to unveil dusty mucky disorganized insurance carrier files. Truthfully, I am more surprised when I see a pristine list. Even then, there is still room for improvement when it comes to the remittance processing settings and eligibility. I see overgrown insurance carrier lists including multiple insurance carriers for the same payor. There are outdated carriers setup to send on paper when they can be sent electronically. Sadly, I also witness practices paying provider fees for remittance and/or electronic eligibility but the features go unused (or are underutilized) because the insurance carrier is not setup.

Considering you have reached the end of this article, I can conclusively tell you “lack of knowledge is no excuse”. Be a hero and tackle that list. I’d love to hear what you find.

To read the first post of this two-part miniseries, visit us at www.hayesmanagement.com or simply follow this link.

Topics: revenue cycle management, electronic healthcare information, Healthcare insurance

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