ERA Posting Improves. Learning Objectives 3/20/2014. Creating a plan Set-up The process Reconciliation that works. Resources

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1 ERA Posting Improves Practice Efficiency Anders Health Care Services Webinar Series March 19 th, 2014 Jerrie K. Weith, FHFMA, CMPE Chastity D. Werner, RHIT, CMPE, NCP Learning Objectives Background and benefits Background and benefits Creating a plan Set-up The process Reconciliation that works Automation opportunities Automation opportunities Resources 1

2 Background & Benefits More efficient, saves time, saves money Old process: opening mail, logging in payments, stamping checks for deposit, preparing the deposit and courier EFT: payer directly transmits the funds it owes a medical practice to the medical practice s bank account. ERA is forwarded to practice with payment details. Source: The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, ed. 2, Walker-Keegan, Woodcock, Larch. Background & Benefits CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule - Problem Addressed & Key Impact Problem addressed by the rule: Providers do not receive uniform code combinations for same or similar business scenarios from all health plans; as a result, are unable to automatically post claim payment adjustments and denials accurately and consistently Focus on minimum business scenarios with maximum set of code combinations targeting 80% of major provider usage problems/high volume code combinations Without business scenarios and maximum set of code combinations, there are over 800 RARCs, approximately 200 CARCs and 4 CAGCs resulting in thousands of possible code combinations for review by providers Reference: 2

3 Background & Benefits Key impact: Begins to address a significant industry challenge by addressing high-volume issues Providers can more effectively use ERA data when definitions for claim payment adjustments or denials are consistent across all health plans, resulting in better revenue cycle and cash flow management Providers can more effectively obtain payment from patients, more quickly generate cross-over claims to other payers, and reduce open accounts receivable Requires more focus on the use of standard codes (not proprietary codes) Reference: Background & Benefits 46% 51% $300 billion is spent annually on manual and paper intensive processes to disburse payments from payers to providers. Transaction count of payer payments disbursed via EFT 5% increase over 2 year period PPACA mandate effective date 1/1/2014 Reference: InstaMed Trends in Healthcare Payments Annual Report:

4 Background & Benefits Increased efficiency! Faster payments! Increased time with patients! Interface with clearinghouse Direct via payer website or clearinghouse Reference: Background & Benefits Reference: 4

5 Background & Benefits Manual Posting FTEs 3 Hours designated to posting payments 1,456 Rate $16.25 Total $70,980 Electronic Posting FTEs 1 Hours designated to posting payments 1,456 Rate $16.25 Total $23,660 3 FTEs devote 70% of their time to posting payments/30% to following up on accounts 2,080 x.70=1456 hours Average wages $13 hour + benefits = $16.25 CREATING A PLAN 5

6 Creating a Plan Current process Steps taken Physical storage versus electronic Creating a Plan Who s involved Internally Externally Magnum PI Timeline Test Tweak 6

7 SET-UP Set-Up Perform payer analysis Enroll with payers (direct or via clearinghouse) System set-up payer profiles Payer Profiles Set-up according to payer ERA payer ID Remittance library Reason code set-up Automation according to reason code Create a path between practice & clearinghouse/payer 7

8 Set-Up Clearinghouse ERA/EFT set-up Internal set-up Set paths for communication Perform payer/era analysis Payers Direct ERA enrollment More complex EFT enrollment Set-Up Payer profile Payer profile ERA Payer ID Reason Code Library Remittance Profile Library 8

9 Set-Up Reason Code Library Add code Skip Adjustment Code Transaction Detail Status What are your numbers? On the fly Reason Code Library Set-Up Remittance Profile Library 9

10 Set-Up Automation Now or later? Tasking by reason Invalid ID - Front desk Medical necessity - Coding/billing Tasking by post date THE PROCESS 10

11 Process Utilize a clearinghouse Review and correct issues Download remit Post to system Upload to system Process System Process Import remittance Create a batch name Payer name_deposit date_amount Process date versus post date Reason codes again 11

12 RECONCILIATION THAT WORKS Reconciliation That Works Payment posting Contractual Non-contractual Post all zero pays Reconciliation Reconciliation Process: 1) Separate deposits 2) One batch per deposit 3) Uniform batch description (i.e. Anthem 03/19/2014 $34, ) 4) Match to bank deposits to system (i.e. download bank report & system report to Excel then sort data accordingly) 12

13 AUTOMATION OPPORTUNITIES Automation Opportunities Real time edits Task PMS claim edits GIGO or Clean claims out=$$$ Electronic transactions 837-electronic claims 835-remittance advice 270/271-elibility benefit inquiry and response 276/277-claim status inquiry and response 13

14 Automation Opportunities 100 claims per day X 20 days a month 2,000 claims 20% denial rate 2,000 claims X 20% = 400 claims 33% of denials are never recovered 400 X 33% = X $ (average reimbursement) = $13,200 monthly Source: The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, ed. 2, Walker-Keegan, Woodcock, Larch. Resources www caqh ERA_Rules_Overview.pdf Payer policies Toolkits 14

15 Anders Webinar Series Credentialing Doesn t Have to be Hard! June 18 Effective Technology Will Elevate Your Practice September Here We Come! November 19 Questions 15

16 Anders Health Care Services Anders Health Care Services optimizes staff, resources and revenue for hospitals and physicians by offering solutions and direction to complex practice management issues. We provide an integrated approach from the financial, operational, compliance and strategic perspectives. Anders Health Care Services Jerrie K. Weith, FHFMA, CMPE Chastity D. Werner, RHIT, CMPE, NCP Chastity D. Werner, RHIT, CMPE, NCP

17 Anders Health Care Services Brian McCook John McGuire Brian Meyers Jerrie Weith Chastity Werner