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Routing claims or, in particular, some remittances that come back from insurance companies are just for payment posting. Some may be denials. Some may include information about contractual allowances or patients. There’s a whole range of information that may come back.
Create an optimized process for routing remittances
A large portion of these that need to be routed to different places in the organization consists of denials, but they don’t go to the same site. One of the challenges that many billing departments or billing companies may face is that you would write off some of them. Maybe, you know you can’t appeal those denials, and you have some information to say, “We’ve never been able to get this particular type of claim paid for this payer.” You want to do an auto write-off. You don’t want to go through the work of trying to fight it over and over again, knowing that there’s nowhere to go with it. In those situations, it goes directly to payment posting, and it should be written off.
Understand how to manage denials effectively
Some of the denials that come back may require eligibility or benefits checking or something from that particular department. Some denials may require appeals, or you would want them to be appealed because you should have gotten paid for it. It would be best if you got paid for it. Some of them require additional documentation, medical necessity, those sort of things that may go to a records department. The ones that need appeal may go to collectors. They may go to a specific level or a sub-department of collectors like a level three. If you’ve got lower-level collectors, it’s maybe people that check the status. And the highest level perhaps do appeals.
Some of the denials that come back may need to go to a coding department to have it re-coded or to have something validated that’s coming back from the insurance company to make sure that’s correct. Other ones may even need to have some research done. Maybe, they go to collectors. On the other hand, they go to a different department that’s more involved in payer policies and documenting those business rules.
Choose the right billing system
I’m not sure I’ve seen a billing system that can handle complex denials management. Typically, you’re not going to see a situation where they can automatically route those to different places in your organization. Still, it is possible to set up a relatively simple analysis to do this with a set of rules. So if X denial code is received, it goes to department Y. The output is that every day when the series of remittances come in, they get output, and the list is created that goes to each separate department with, “These are the claims that came in, and they need to be worked by that particular department.”
This is either going to save your collectors and your employees a ton of time weeding through all the various remittances and claims that come in in worklist queues. Or it’s going to save a manager, typically, much work where they don’t have to filter through. They also have to figure out which ones go to which departments and which ones need more work. Some of these can be pretty complex where, for example, a specific set of codes, CPT codes, in combination with a certain set of denial codes from a certain set of payers. In addition, maybe some combination of all of those factors, get routed to this department. In short, this action needs to be taken, or the balance gets transferred over to the patient. We write off the claim or something similar.
Automate your remittance workflows
That’s hard to manage manually, and it’s hard to work that even in an Excel spreadsheet. It is possible to do, but those are the types of things that you can set up so that instead of somebody manually routing all of this or people wasting tons of employee resources. For instance, they’re going into worklist queues that don’t apply to them, and then they reroute them, reassign them to different departments.
What’s the solution?
Simple analysis or setting up an analytics template can do all of the things for you and save a ton of manual labor.