Bus Stop #1: Credentialing
The first stop along the Pathway to Payment is to ensure that your providers are credentialed and participating with multiple payors. Becoming a participating provider (“PAR”) with an insurance has its perks and patients generally are fearful of the terms “out of network” when they are selecting which providers they want to use.
The credentialing process may seem daunting at first - especially with the different forms, applications, provider numbers, and licensure documentation you have to provide, not to mention the processing time for your application. But, this is arguably the most important stop on a long road to getting paid.
If you have multiple locations within your practice, each one needs to be credentialed with each insurance you want to be a participating provider with. Each individual provider within your practice should also be credentialed with those insurances to avoid delays in completing documentation due to needing a co-signature.
Bus Stop #2: Insurance Verifications and Benefits
Once your practice becomes a participating provider with these insurances you can start accepting patients with those insurances. One of the perks of being PAR with these payors is that you can have access to online portals that are available. These portals are extremely convenient and give you access to a multitude of resources - benefit information being one of them.
Many of these insurances can be found on hub portals such as Availity, but other insurances have their own portals such as state Medicaid programs and Medicare. Setting up these portals is generally a simple process where you have to register your NPIs and TINs for each location, create a user login and password, then verify your information.
One of the resources on these portals lets you check benefit information for policyholders. This will help your practice as well as the patient have a better understanding of patient responsibility and cost-share amounts for the services you are providing. The most important items to confirm while checking benefits are:
Authorization requirements (be sure to confirm if this is handled by a third party vendor rather than the insurance)
Copays
Coinsurance
Deductible
Out of pocket expenses
Visit limits (this is not the same as authorized visits)
After you have verified the benefits and confirmed accumulations for each cost-share item, provide this information to the patient prior to him/her starting treatment. This is best done by completing a financial responsibility sheet or insurance benefits information sheet to include in the patient’s intake paperwork. The patient should attest to the benefits information and acknowledge that he/she is aware of the potential patient responsibility throughout the course of treatment.
This ensures there are no surprises to the patient or to your practice once the claims process. If the patient has a copay, you will be aware of that and can collect the copayment at each visit, rather than waiting to collect it once the claims process and your chances of collecting are significantly reduced once the patient leaves your clinic.
Bus Stop #3: Authorizations
Some insurance plans require authorization - and depending on the insurance this may be referred to as clinical submissions, precert, medical necessity review, etc. - so it’s important to understand each payor and the terminology they use when requiring an authorization. If this information is not on the portals then someone must call the insurance to confirm the authorization requirements. During a time where technology has consumed almost every aspect of society, a good old fashioned phone call to speak to a representative about the authorization is always worth making.
Online Portals / Requesting Authorizations
This information should be collected during the benefits check back at Bus Stop #2. The process for obtaining authorization should also be obtained during the benefits check. This is also a feature on some online portals where the benefits information is located, however, if the authorization is handled by a third party vendor, then you need to contact that vendor to have your processes in place for submitting these authorizations. These third party vendors often also have online portals to submit and check the status of authorizations.
Tracking System
There needs to be a diligent system in place to track and monitor your patients who require authorization. If the authorization is required before the eval, then your team needs to ensure the necessary steps are being taken to get the auth requested prior to eval date. There are several nuisances about authorizations that are imperative that you are aware of and you should always confirm which CPT codes require authorization.
Tracking and submitting authorizations will avoid losing reimbursement for services rendered due to missing authorizations. Your entire team should be involved in this process so they understand the “why” behind the importance of diligent tracking and requesting authorizations when they are needed. Once the authorization is approved and can be tracked in your billing software your team should be able to run reports and view patient charts to see when the authorization expires/the patient needs more visits.
Retroactive Authorizations
If an authorization is missed the next option is to attempt a retroactive request for authorization. Many insurances do not allow retroactive authorizations, but again, this information should be obtained during the initial benefits verification. If the retroactive authorization is denied, the final resort is appealing for medical necessity.
Bus Stop #4: Submitting Claims
This stop is one of the most satisfying stops along the Pathway to Payment. It combines all of your efforts from the previous stops and sends them off to the insurance for processing. This stop is also the intermission stop where we wait for the connecting bus to take us to the next stop.
Many payors have transitioned to electronic submissions of claims. Every billing software should have the option to physically print these claim forms and mail to the insurances as well as an option to set up EDI for electronic submissions for quicker turnaround times for claims processing.
The two key focuses at this stop are 1) ensure each payor is set up correctly and 2) be aware of timely filing deadlines.
When the payor settings are incorrect or do not coincide with the information the payor has on file for your location is when you run into denial issues which ultimately put you at a race against the clock to have claims resubmitted. Getting claims out the door is at its core the purpose of the revenue cycle, but getting claims out the door correctly the first time is what the focus should be on.
Common issues with claim submissions include submitting claims to the wrong physical address, having the wrong EDI set up for electronic claims, missing information on the claim forms, and missing timely filing deadlines. All of this information is easily attainable and should receive a high level of attention from the beginning. Once these payors are set up in the billing software you will likely not have to edit them again.
Take time to refine your process and ensure everything in your billing software is set up correctly before mass submitting claims. Once the claims are out the door - we wait.
Bus Stop #5: Accounts Receivable
At this point, we are about 30-45 days out from the first time a patient entered your practice for services. This stop is also very satisfying because you see the hard work from Stops #1-5 pay off - literally.
Overall, you should have a processed mapped out and strategy in place on how you will handle these sets of aged claims. The AR Team needs to be aware of nuisances across insurances as well as timely filing deadlines.
These items should be tracked and handled in an efficient and timely manner.
0-30 Days Aged
Aging reports for claims should be run in a timely manner starting with claims that are 0-30 days aged. Many of these claims will still be processing but it is important to keep track of them because 30 days quickly turns into 90 days if you are not conscientious of the aging process and running the aging reports.
30-60 Days Aged
Claims that have aged 30-60 days should be a primary focus since this is where you will catch any denials or rejections from either the clearinghouse (if claims were submitted electronically) or the insurance company for invalid/incorrect/missing information on the claim forms. This is a crucial bump in the road that can be remedied and the potential to collect on these claims is highly likely since this is usually still within most insurances’ timely filing limits.
60-90 Days Aged
This aging bucket is where you should be concerned with the reason for these claims aging out this far. Did the insurance pay and now you are waiting for the patient to pay? Did you miss a denial? What next steps need to be taken to resolve these claims?
90-120 Days Aged
This group of aged claims should sound the alarm for your AR Team. These claims either fell through the cracks of the previous aging buckets or you are waiting for payments from patients. At this point, all hands should be on deck to get claims reprocessed at the insurances - if timely filing limits allow this - or patients need to be called about their outstanding balances.
120+ Days Aged
Any claims outstanding at insurances at this stage should be addressed immediately to resolve the issues. If there is no other remedy for the claim, it will likely result in a write off.
Any patient balances that have aged this far should also be addressed immediately by making final calls to collect on the outstanding balances before they are sent to collections.
Bus Stop #6: Denials and Appeals
The final stop on the Pathway to Payment is addressing any denials that are discovered in the AR process at Stop #5. Common denials include missing authorizations, invalid member ID, missing provider information, and missing clinical documentation. Each of these can be easily avoided at their respective stops along the Pathway, which is why it is important to take your time at each stop to ensure everything is handled correctly before going to the next stop.
If the claims are returned for denials, some of the issues can be resolved by resubmitting the claims with corrected information and/or documentation.
Other claims may require additional work such as filing an appeal if they are denied for medical necessity or missing authorization. The appeals process for each insurance is different in that some require forms to be completed while others allow for a more informal request for appeal.
Either way, all insurances have timely filing deadlines for these appeals and they should be strictly abided by. This is your last chance to get paid on claims.