AR Accounts Receivable Case Study

BILLING ERROR ISSUES 

AIMA ACTION

ISSUE: MISSING THE CODES
Incorrect/incomplete codes entered and billed.

ACTION: Pre-billing audit to summarize the billable codes for DOS and pick correct codes to bill. 

ISSUE: HIGH CLAIM BILLING LAG
Claim billing lag over ten days from the DOS.

ACTION: 24-48 hours turnaround time on coding/billing from the DOS. We reduce the billing lag to a maximum of three days.

ISSUE: DOS MISSED TO BILL
Several
DOS/appointments not billed without a specific reason.

ACTION: Reconciliation of appointments before billing. Summarize the billable appointments and send routine exceptions avoids any missed billing.

ISSUE: CPTS BILLED WITH NO CHARGE AMOUNT
Incorrect settings in the PMS. Many CPTs billed with zero charge amount.

ACTION: Reconfiguration of all fee schedules and set standard billed amounts for all the CPTs in the system.

ISSUE: CPTS BILLED WITH INCORRECT CHARGE
Many CPTs billed less than the allowed amount by the payer.

ACTION: Establish standard fee schedules as per the provider's requirement. Set the billed amount as 1.5 times Medicare allowable across the system.

ISSUE: CLAIMS BILLED TO WRONG PAYERS
Claims billed to incorrect payers, for instance, Medicare instead of Medicare HMO or billed to secondary instead of primary.

ACTION: Implement verification reports to identify the right payers to bill on DOS. 

ISSUE: CLAIMS BILLED WITH MISSING/INVALID AUTHORIZATION
Claims billed without required authorizations or entered with incorrect auth/reference. 

ACTION: Post-billing audit to identify any vital info omitted in the claim. Scrubbing rules in the clearinghouse portal to avoid further rejections or denials. 

CODING ERROR ISSUES 

AIMA ACTION

ISSUE: INADEQUATE CODES BILLED
E&M, testing and procedural codes incorrectly billed, resulting in denied or underpaid claims.

ACTION: Pre-billing audit of all chart notes, procedure notes and test results. We identify the correct codes as per the provider documentation.

ISSUE: INCORRECT/MISSING MODIFIERS
The previous biller did not append the correct modifier or failed to use modifiers when required.

ACTION: Coding audit to identify the requirement of modifiers on E&M codes and distinct procedures and append the correct modifiers for better reimbursement.

ISSUE: GLOBAL PROCEDURES BILLED
Procedures billed without checking the global periods.

ACTION: Reduce the volume of denials from payers by appending the correct post-op modifiers once a consultation or procedure is complete during the post-op period. Claims not covered as per the post-op coding guidelines are written off with provider approval.

ISSUE: INCORRECT DOCUMENTATION
Incorrect and incomplete chart documentation identified during payers during audit resulting in a penalty.

ACTION: Streamlined process to create clean coding/billing practices and meet payer audit requirements. Daily check of provider documentation and advise providers on any incomplete/missing/unsigned notes in the system.

ISSUE: INCORRECT UNITS
Codes billed with incorrect units exceeding maximum allowable units.

ACTION: Coding audit to identify and fix incorrect unit cases.

ISSUE: MEDICAL NECESSITY NOT CHECKED
Incorrect usage of ICD/CPT combination and not checking the medical necessity and claims denied for incorrect NCD/LCD guidelines.

ACTION: Once consult/procedure is complete, the new method identifies the proper LCD/NCD guidelines for correct billing.

ISSUE: PAYER GUIDELINES NOT FOLLOWED
Payer guidelines not followed on coding. For instance, Medicare, Medicaid, and Medicare/Medicaid replacement payers have specific guidelines on coding.

AUTHORIZATION OR REFERRAL ERROR ISSUES 

AIMA ACTION

ISSUE: AUTHORIZATION NOT OBTAINED
Authorization or referrals not received before services resulting in many claim denials.

ACTION: Pre-verification and
Authorization processes to request referrals from PCPs. Completed in advance to allow sufficient time to follow up on the status of authorization or referrals to ensure all information in place before seeing a patient.

ISSUE: AUTHORIZATIONS/REFERRALS NOT UPDATED
Authorizations or referrals not correctly updated in the system, resulting in claims billed with expired authorities.

ACTION: Authorization and follow up process to update the information accordingly and
identify expired authorization/referrals to eliminate denials.

DENIAL ISSUES 

AIMA ACTION

ISSUE: CLAIM PENDED FOR ADDITIONAL DOCUMENTATIONS
Claims denied/pended for additional documentation without address resulting in non-payment.

ACTION: Tracking denials and correspondence with denial management within 24-48 hours of receipt.

ISSUE: ERAS NOT RECEIVED
Claims paid on time without obtaining EOBs or ERAs on time to post the payment in the system.

ACTION: Electronic claim and payment transactions to save time and speeds up reimbursement. Practice enrolled for EFT/ERA with maximum payers. 95% of payments now deposited through EFT, and payment explanation loaded via ERA directly into the system. Payments posted on time and payment lag reduced.

NON-COLLECTABLE DENIAL ISSUES 

AIMA ACTION

ISSUE: SECONDARY DENIED AS PRIMARY PAID MAX
When secondary claims get denied due to the primary claim paid more than the secondary allowable amount, the balance should be written off with the provider's consent. Balances not addressed and sat in the AR bucket for a long time, increasing the aging balance.

ACTION: Monthly review of non-collectable denials and writing off upon provider approval.

ISSUE: NON-COVERED CHARGES AS PER PROVIDER PLAN
Claims denied as non-covered as per provider contract and no contract with the payer.

ISSUE: TFL CROSSED
Claims billed after TFL deadline.

ISSUE: CLAIMS DENIED AS NO AUTHORIZATION
Claims denied as no authorization obtained before service and no retro approval provided.

ACTION: Credentialing and contracting processes with new payers, communicated to the front team or patient on non-accepting payers/policies.
Introduction of billing reconciliation, pre-verification, authorization and billing turnaround resulted in TFL-related and authority-related claims reduced.