INSURANCE BILLING (including EDI) and ACCOUNT MANAGEMENT

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INSURANCE BILLING (including EDI)andACCOUNT
MANAGEMENT

• 12/10/03

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Overview

• axiUm at the University of Michigan
• Account Management - Insurance
• EDI Insurance Billing
• Account Management Patient

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axiUm _at_ Michigan
PROVIDERS COUNT OPERATORIES
Pre-doctoral 421 144 CompCare
Hygiene 95 (included above)
Advanced specialty 120 129
Faculty practice plan 34 14
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axiUm _at_ MichiganFY02-03 Data
CATEGORY COUNT
Procedures 198,400
Appointments 125,500
Active Records 94,440
EDI ins claims 29,400 (w/o Medicaid)
EDI pt statements 15,000/month
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UMSD PAYOR MIX (FY02-03)
DENTAL INSURANCE 43.4
MEDICAL INSURANCE 10.6
TOTAL INSURANCE 54.0
PATIENT PAY 46.0
TOTAL CHARGES 100
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UMSD PAYOR MIX - DETAILS UMSD PAYOR MIX - DETAILS UMSD PAYOR MIX - DETAILS UMSD PAYOR MIX - DETAILS UMSD PAYOR MIX - DETAILS
43.4 DENTAL 10.6 MEDICAL
16.7 Medicaid 3.2 Comm - YES
8.3 MetLife 2.8 BCBS of MI
7.5 Comm - YES 2.6 Medicare
7.1 Delta Dental 1.7 M-Care
2.4 BCBS of MI 0.3 BCare Netwrk
1.4 Comm - NO 0.1 Medicaid
0.012 UMSD research
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axiUm _at_ University of Michigan

• Phase 1 staff entry (complete)
• Phase 2 chair-side entry
• Controlled Pilot (1/04)
• Student on-line scheduling (1/04)
• Full clinic implementation ?????

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What other Schools manage an Insurance Receivable?

• Currently?
• Considering redefining patient/insurance mix in
  the future?
• Doing EDI insurance now?
• Considering EDI insurance in 6-12 months?

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Account Management

• INSURANCE BALANCES

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Life of an Insurance Claim
Adjudication
Addtl Info Submitted
Pre-D Submitted
Lockbox Payments
Insurance Inquiries
Charges Entered
Insurance Refunds
Upfront Adjustments
Carrier Rejection
EDI Rejections
Claim Submitted EDI/HCopy
Open Ins A/R
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Insurance Balances CBO Tasks(Clinic Billing
Office)

• Eligibility verification
• Coverage template verification
• Post upfront adjustments
• Submit EDI claims daily
• Work Future Appt Report weekly
• Handle insurance inquiries

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Insurance Balances CBO Tasks(contd)

• Post insurance rejections
• Post lockbox insurance payments
• Work open insurance A/R reports
• Full A/R follow-up (all of the above)

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Full A/R Follow-up

• Patient Card Review
• Confirm responsibility party for minor
• Verify coverage template is correct
• Add Custom Code County
• Check for unallocated patient payments
• Check for unallocated patient adjustments
• General Tab Review
• Find all open insurance transactions
• Find patient payment over allocations
• Call carrier on claim status/resubmit claims
• THEN, and only then, do task on account

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Tools Used - INSURANCE

• InfoMgr reports
• Bi-weekly ortho billing transaction exports
• Insurance policy look-up
• Claims Not Submitted
• Unallocated payments
• Unallocated adjustments
• Insurance A/R
• Notes
• TRX Notes
• Sticky Notes
• Patient contact notes
• Axium messaging

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Tools Used - INSURANCE

• Dental Informatics reports
• Future appointment reports
• Coverage template reports
• In Dispute reports
• Work In Progress reports (w/pre-auth info)
• Oracle Financial Reporting tool
• Credit balances
• Adjustments
• A/R
• Access Aged A/R Reports

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Claim Cycle - Details
PRE-DETERMINATIONS
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Pre-ds _at_ Michigan

• Minimal use of PreDs at UMSD at this time
• Medicaid of MI Prior Authorizations
• Staff entry of preplanned treatment
• If patient requests, PreD submitted
• Replies usually received in 2 weeks

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Pre-Ds What other Schools use axiUms pre-d
feature?

• How many schools submit pre-ds now?
• Frequency?
• Based on type of carrier?
• Dollar amount of treatment plan?
• Patient request?

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Claim Cycle - Details
CLAIM SUBMISSION
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WebMD EDI Set-up

• Exan Academic - approved WebMD EDI vendor
• Michigan dental submission, 5/01
• Michigan medical submission, 6/03
• Server-to-server ftp submission to WebMD
• Encrypted submission files
• Encrypted claims processing reports
• 98 of Michigans claims are EDI today

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WebMD EDI Enrollment

• Enrollment forms with WebMD
• Complete Batch Claims Provider Set-up Forms
  (attached)
• FAX to WebMD Enrollment
• WebMD processing time 2-3 weeks

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WebMD EDI Set-up (contd)

• Commercial carriers no special forms
• EDI participating (specific NEIC ids)
• EDI non-participating (WebMD drops to paper)
• Refer to Payer Lists _at_ www.envoy.com

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WebMD EDI Set-up (contd)

• Billing Agent Authorization forms
• Submit as directed by WebMD
• Carriers requiring these forms vary by state
• MI required BCBS, Medicaid, Medicare
• Once enrolled, submit test claim batch
• NOW YOURE READY TO ROLL!

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EDI Batch Review

• Sort by date range 2-day hold
• Review practice/provider/discipline combination
• Review carrier/provider name (billing entity
  exceptions)
• Drop to paper Insurance Total 0.00
• Drop to paper all unspecified ADA CPT codes
• Dental EDI and Medical EDI processes separate
• Remove To Paper To Held (easy)
• 30-minute process at tops
• Keep an EDI log of volume statistics

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EDI Batch Submission
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What reports do we receive?

• Immediate -- Submission Confirmation
• Next Day -- Claims Processing Report
• Immediate rejections
• Carrier inquiries
• Carrier rejections

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What reports do we receive? (contd)

• Immediate Rejections WebMD (following day)
• Typical dental rejections
• Missing tooth
• Zero charge claim
• Invalid procedure code not CDT-4 code
• Provider name does not match carrier files
• Typical medical rejections
• Place of service missing or invalid
• Invalid ICD-9 diagnostic code
• Referring physician name missing

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What reports do we receive? (contd)

• Carrier EDI inquiries
• Additional info needed to adjudicate
• Carrier EDI rejections
• SS/employee not found with carrier
• Contract cancelled by policyholder
• End of month statistics

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EDI Resubmissions

• _at_ Michigan rarely need to resubmit file
• Files archived at
• Submitters PC
• Server level
• Submitted Procedures Tab not used
• Needs Claim Format field added

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QUESTIONS?

• EDI

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Claim Cycle - Details
INQUIRIES
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CARRIER INQUIRIES

• EDI Inquiries
• Hard copy inquiries
• Preoperative radiographs required
• Perio charting needed
• Providers treatment notes needed
• _at_ Michigan average 100/week

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Claim Cycle - Details
LOCKBOX PAYMENTS AND POSTING
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LOCKBOX PAYMENTS POSTING

• No live cash received in our office
• Use bank lockbox system
• Insurance payments
• Mail-in patient payments
• All documentation w/o a payment
• Predominantly use PT ALLOCATE button
• Facilitates open insurance A/R follow-up
• 550,000 posted/month in CBO

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Claim Cycle - Details
CARRIER REJECTIONS
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CARRIER REJECTIONS

• Most common rejections we receive
• Service applied to deductible
• Not a covered dental or medical benefit
• Not eligible
• SS invalid
• Maximum benefit reached/year
• Frequency of service allowed exceeded
• Service over age limit of policy
• _at_ Michigan 200/week

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Claim Cycle - Details
OPEN INSURANCE A/R
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OPEN INSURANCE A/R

• ALL staff embracing full A/R follow-up
• Most significant change this past year to our A/R
  follow-up process
• Results are evident
• Increased lockbox payments - staffing challenges
• Increased calls balances after insurance
• Use of Future Appointment Report
• Of course, open A/R reports

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ENHANCEMENTS REQUESTED

• INSURANCE
• RELATED

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• EDI Claims
• Add columns PA box, ICD9 code, POS, and
  Modifiers
• Submitted Procedures tab add Claim Format Field
• Utilities/AutoClaims
• Add ability to select a date range to recreate
  claim and resubmit unpaid insurance claims
• Transaction/Treatment/Medical button
• Add Referring Physician fields (not retained on
  HCFA submit screen)

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• InsPymt Tab
• Ability to sort Posting Date (or Date Range)
• Print Held
• Ability to highlight range of claims to send to
  printer at once
• Insurance table
• Need inactive flag for invalid Companies
• Procedure table
• Need inactive flag for discontinued entry codes

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Other Enhancements Insurance Related?
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QUESTIONS?

• INSURANCE BALANCE
• ACCOUNT MANAGEMENT

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Account Management

• PATIENT
• BALANCES

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Life of an Patient Charge
Credit History Checks
Adjudication
Payment Plan Set-up
Outgoing Collection Calls
Charges Entered
Lockbox Payments
Upfront Adjustments
Incoming Patient Calls
Bad Debt Referral
Patient Refunds
EDI Patient Statements
Open Patient A/R
Returned Pt Stmts
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Patient Balances CBO Tasks

• Work weekly Future Appt Report - Patient
• Patient calls (in/out)
• Establish and update axiUm payment plans
• Submit EDI statements weekly (by cycle)
• Process Returned Patient Statements
• Post lockbox patient payments

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Patient Balances CBO Tasks (contd)

• Credit History Checks
• Refund review
• Refund check writing
• Bad debt referrals to collection agency
• Work open patient A/R reports
• Full A/R follow-up (all of the above)

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Full A/R Follow-up

• Patient Card Review
• Verify patient demographics on phone
• Confirm responsibility party for minor
• Verify coverage template is correct
• Add Custom Code County
• Check for unallocated patient payments
• Check for unallocated patient adjustments
• General Tab Review
• Find all open insurance transactions
• Find patient payment over allocations
• Call carrier on claim status/resubmit claims
• THEN, and only then, do task on account

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Tools Used - PATIENT

• InfoMgr reports
• Weekly patient statement cycle exports
• Unallocated payments
• Unallocated adjustments
• Returned Patient Statements
• Notes
• TRX Notes
• Sticky Notes
• Patient contact notes
• Axium messaging

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Tools Used - PATIENT

• Dental Informatics reports
• Future appointment reports
• In Dispute reports
• Oracle Financial Reporting tool
• Credit balances
• Adjustments
• A/R
• Access Aged A/R Reports

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Patient Balance Cycle - Details
EDI PATIENT STATEMENTS
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EDI PATIENT STATEMENTS

• Weekly EDI submission 15,000/month
• 4 cycle alphabetic splits
• Encrypted ftp file submission
• Use ExpressBill (owned by WebMD)
• Fax confirmation of submission
• Faxback address changes in file
• Working on redesigned patient statement

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RETURNED PATIENT STATEMENT

• Ongoing challenge _at_ Michigan
• Up to 4 of EDI statements returned
• Improving registration verification
• Immediate referral to collection agency
• Collection agency does skip tracing

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Patient Balance Cycle - Details
PATIENT CALLS IN OUT
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PATIENT CALLS IN OUT

• Incoming calls to collectors 250/wk
• Outgoing calls to patients 500/wk
• Voicemails 350/wk
• Email Inquiries 150/wk

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Patient Balance Cycle - Details
CREDIT HISTORY CHECKS
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CREDIT HISTORY CHECKS

• Signed release to check credit history
• Currently ortho clinic only available to all
• Pull TRW reports
• Recommendation to clinic
• To extend payment plan
• To deny payment plan
• Clinic can override recommendation
• YTD 395 pulled 83 approval rate

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Patient Balance Cycle - Details
PAYMENT PLANS
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PAYMENT PLANS

• With axiUm, everyone can see financial
  arrangement
• Excellent for orthodontics
• Challenges
• - Payments not ticked for apply to plan
• - Trx paid/adjusted current solution
• - Statement presentation still an issue

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Patient Balance Cycle - Details
OPEN PATIENT A/R
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OPEN PATIENT A/R

• ALL staff embracing full A/R follow-up
• Most significant change this past year to our A/R
  follow-up process
• Results are evident
• Increased lockbox payments - staffing challenges
• Increased calls balances after insurance
• Use of Future Appointment Report
• Of course, open A/R reports

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Patient Balance Cycle - Details
REFUNDS INSURANCE PATIENT
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REFUNDS INSURANCE/PATIENT

• Refund check writing authority to 1,500
• Priorities
• Insurance overpayment requests
• Patient overpayment requests
• Processed weekly
• Avg 6,000/month refunds

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ENHANCEMENTS REQUESTED

• PATIENT
• RELATED

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Enhancements Requested - Patient

• Testing Claims Owing Patient Statement
• Patient Bad Debt Management
• Ability to automate referrals to external
  collection agencies

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Other Enhancements Patient Related?
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QUESTIONS?

• PATIENT BALANCE
• ACCT MANAGEMENT