Despite every practice’s best efforts and best practices, not every claim is 100% clean of errors when it is first submitted – and that is OK because an effective and efficient clearinghouse should be able to help you catch many of these errors before the claim is ever sent to the payer.

Even if your clearinghouse catches a majority of errors, it is essential for all practices to know if a claim was rejected by the clearinghouse’s edits or by the payer’s edits. This knowledge is important to a healthy bottom line because rejections slow down revenue.

Given the choice between the two types of rejections, I always think that it is preferred to have your clearinghouse catch claim errors rather than the payer. At this point, people often ask me why one type of rejection is better than any other. The answer is simple – time. If you submit a bad claim to a clearinghouse – a good vendor will edit it and, if there are any edit errors, they will let you know very quickly—within minutes. Otherwise, it will take some time (possibly days or weeks) for the claim to go out to the payer, fail payer edits, and then return to you for your review. All of these steps take time, which slows down your revenue stream.

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Keeping track of prior authorization policies is difficult. Each health plan has its own set of requirements, which often change with regularity. Some Medicaid payers, for instance, want one “blanket” referral authorization before patients see certain specialists; the specialist isn’t required to obtain prior authorizations for every procedure. Other plans are much more restrictive, approving prior authorizations for specified procedures only when certain criteria/diagnosis’ are met.

The problem, of course, is that failure to obtain proper authorizations can have a drastic affect on practice income. The bottom line is simple: no authorization, no payment. Insurers won’t pay for procedures if the correct prior authorization isn’t received, and most contracts restrict you from billing the patient as well.

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Thank you to everyone who attended our March 24 webinar, ICD-10 and 5010 – Understanding the Challenge at Hand. In this one hour event, industry expert, Kim Reid, CPC, approved PMCC instructor for the American Academy of Professional Coders and Northeast Regional Director for AAPC Physician Services, highlighted the distinctions between 5010 and ICD-10; potential challenges practices would face during both transitions; and key steps practices should be taking right now to prepare.

Click here to download this free webinar to learn more about the ICD-10 and 5010 changes and how they will impact your practice.

Earn 1.0 Continuing Education Unit (CEU) from the American Academy of Professional Coders (AAPC) by viewing this webinar.

We are happy to announce the launch of a new website – ICD-10 Hub – which is part of a new partnership between Navicure and AAPC. The purpose of the site is to provide all medical practices with helpful information and in-depth resources to assist with the 5010 and ICD-10 transitions. ICD-10 Hub will compliment and bolster the practice management information you already receive on this blog.

Devoted to helping every practice successfully move to 5010 and ICD-10, ICD-10 Hub allows you to download webinars, read blogs and catch up on the latest news the industry has to offer. Some of the content currently available includes:

• 5010 Timeline – This one-page overview details what steps you and your technology vendors should be taking, plus when to successfully transition to 5010.
• ICD-9 to ICD-10 Mapping – This reference sheet lays out how ICD-9 codes translate to ICD-10 codes.
• 5010 Payer Announcement Updates – This “living” document relays the steps each individual payer has taken and is planning to take in the near future to ensure their preparedness for 5010. This information will be updated frequently with the latest information you need to know.
• Recorded Webinars – Multiple webinars, which each focus on a different aspect of the transitions, are available for free download from the site.

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Most practices diligently track denied claims because of the impact they have on revenue; however there are other types of denials – hidden ones – that often fly under the radar while slowly draining revenue. In this complimentary webinar learn how to maximize your reimbursement by identifying and tracking these “hidden denials.”

Join us on Wednesday, April 20 at 1:00 pm EDT, for a free webinar: Hidden Denials and Appeal Letters: Tips and Tricks to Maximizing Your Reimbursement.

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The organization I work with, Pocono Health System is made up of several components, including the Pocono Medical Center, the Pocono Health Foundation, and Pocono Healthcare Management (PHM). As manager of PHM—the management services organization that supports Pocono’s 82 providers—I recently had the opportunity to help guide our implementation of a new clearinghouse, which was done to help improve our revenue cycle.

When PHM opened its doors in 2003, it chose to use a practice management system that came with its own clearinghouse solution. While that might sound ideal from an integration standpoint, the software itself was not proactive and client support was practically non-existent. In fact, as often as not, we informed the clearinghouse about critical changes to claims edits! Most of our suggestions fell on deaf ears.

In a way, the first lesson PHM learned from its new clearinghouse implementation came before we even selected a different system. Our experience with our original system taught us to place “client support” high on the list of search criteria. We didn’t want our financial viability to be at the mercy of a non-supportive vendor again, so we chose a solution partly on the strength of its guarantee that every call will be answered by live support staff. (I have to admit I was skeptical about that guarantee, but the clearinghouse has lived up to its promise.)

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With 5010 and ICD-10 looming on the horizon, now is the time for practices to begin safeguarding against spikes in rejections and denials. Rejections and denials are, obviously, important barometers of financial health that must be tracked at all times. But accurate tracking becomes even more important during times of change.

In my opinion, practices should begin considering periods of transition as “the new normal.” After all, fresh legislative mandates seem to be hitting the healthcare industry with increasing regularity. It might be wise to invest a little time in developing policies and processes to monitor key practice indicators during times of upheaval.

Rejections and denials offer the perfect place to start. Right now is a good time to begin establishing benchmarks for these numbers in your practice. Don’t wait until December 31 to determine your average rejection and denial levels—do this in the months prior to the 5010 conversion on January 1, 2012. That way, you have an accurate yardstick against which to measure your post-conversion rejections and denials.

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Practices are well aware of the pending changes stemming from the transition to the new ICD-10 coding set that will occur on October 1, 2013, and many already are in the midst of making sure that they are fully prepared for this shift. Some steps that practices are taking right now include: developing committees to assess what software and IT upgrades need to be made; finalizing internal staff training plans; and creating implementation plans to ensure readiness by all staff.

Although these steps are exactly what practices should be doing to prepare for ICD-10, many people are still wondering if the compliance deadline will be extended—and what penalties they will face if their practices are not prepared when that deadline rolls around.

First, I am confident in saying that ICD-10 has a hard cut-over date of October 1, 2013. The Centers for Medicare and Medicaid Services (CMS) feels like it already has granted practices a two-year “extension” of sorts by pushing back its originally proposed 2011 implementation date.

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Cross-training staff is a time-intensive endeavor, especially if you do it correctly. That’s why many practices hesitate to make it a routine part of their operations. But properly cross-trained staff bring more to a practice than the ability to “cover” for one another during illnesses or vacations—they help improve the bottom line.

Thoroughness is the key to a good cross-training program. Offering front-desk staff only a high-level view of back-office operations, for instance, is not enough. Instead, solid cross-training should reveal in real detail how front-desk tasks affect the back-end, and vice versa.

The goal is to encourage a collective mindset by making all staff aware of the true effect their actions have on both patient care and the revenue cycle. An effective program must:

• be well-planned;
• engage your most experienced individuals in the “teaching” roles;
• map out specific learning objectives for each staff member; and
• ensure the learning objectives are met.

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After much anticipation and preparation, another annual HIMSS conference is now a mere memory. But last week’s gathering at the Orange County Convention Center in Orlando, Fla., clearly engaged a diverse cross-section of the healthcare industry. This year, three themes really took center stage among those I spoke with: accountable care organizations (ACOs), 5010/ICD-10 and social media. Each of those issues, if you think about it, plays a distinctive role in reaching “meaningful use” goals.

It’s hard to believe the difference just a year can make in regard to “meaningful use.” It was certainly the hot topic at last year’s HIMSS conference in Atlanta. Since at the time little was set in stone about the regulations, there was a lot of talk and little action. Healthcare organizations were biding their time, hesitant to purchase IT systems before knowing the exact “meaningful use” requirements.

This year, by contrast, people were actively shopping for those systems. In fact, I saw a few EHR vendors actually taking contracts on the exhibit hall floor! The writing is on the wall; clearly, the industry is beginning to move past the theory behind “meaningful use” and toward the practical applications to support it.

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