ERA Posting Improves Practice Efficiecy draft 022714

ERA Posting Improves Practice Efficiency

Jerrie K. Weith, FHFMA, CMPEChastity D. Werner, RHIT, CMPE, NCP

Anders Health Care Services Webinar SeriesMarch 19th, 2014

Learning Objectives

Background and benefits

Creating a plan

Set-up

The process

Reconciliation that works

Automation opportunities

Resources

Background & Benefits

Source: The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, ed. 2, Walker-Keegan, Woodcock, Larch.

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.

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: www.caqh.org

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)

Background & Benefits

Reference: www.caqh.org

Background & Benefits

Payment Posting

46% 51%

• 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: 2012

$300 billion is spent annually on manual and paper intensive processes to

disburse payments from payers to providers.

Background & Benefits

Increased efficiency!

Faster payments!

Increased time with patients!

Interface with clearinghouse

Direct via payer website or clearinghouse

Click icon to add picture

Reference: http://www.aetna.com/provider/medical/service_med/electronic_med/edi_calculator/EDI_Savings_Calc.html

Background & Benefits

Reference: http://www.ama-assn.org/resources/doc/psa/eft-getting-started.pdf

Case Study

Background & Benefits

FTEs 3

Hours designated to posting payments 1,456Rate $16.25Total $70,980

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

FTEs 1

Hours designated to posting payments 1,456Rate $16.25Total $23,660

Manual Posting

Electronic Posting

CREATING A PLAN

Creating a Plan

Current process• Steps taken• Physical storage versus electronic

Creating a Plan

Who’s involved• Internally• Externally

Magnum PI

Timeline

Test 1-2-3

Tweak

SET-UP

Set-Up

Perform payer analysis

Enroll with payers (direct or via

clearinghouse)

System set-uppayer profiles

Payer ProfilesSet-up according to

payerERA payer ID

Remittance libraryReason code set-up

Automation according to reason code

Create a path between practice & clearinghouse/payer

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

http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/payer-specific-information.page?

Set-Up

Payer profile• ERA Payer ID• Reason Code

Library• Remittance

Profile Library

Set-Up

Reason Code Library• Add code• Skip Adjustment Code• Transaction Detail Status

What are your numbers?

“On the fly”

Reason Code Library www.wpc-edi.com/reference/codelists/healthcare

Set-Up

Remittance Profile Library

Set-Up

Automation• Now or later?• Tasking by reason

Invalid ID - Front desk Medical necessity - Coding/billing

• Tasking by post date

THE PROCESS

Process

Utilize a clearinghouse

Download remit

Upload to system

Review and correct issues

Post to system

Process

System• Process

Import remittance Create a batch name

– Payer name_deposit date_amount Process date versus post date Reason codes again

RECONCILIATION THAT WORKS

Reconciliation That Works

Payment posting• Contractual • Non-contractual• Post all zero pays• Reconciliation

Click icon to add pictureReconciliation Process:1) Separate deposits2) One batch per deposit 3) Uniform batch description

(i.e. Anthem 03/19/2014 $34,584.03 )4) Match to bank deposits to system

(i.e. download bank report & system report to Excel then sort data accordingly)

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

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% = 132

132 X $100.00 (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.

$158,400 annually

Resources

www.caqh.org

http://www.caqh.org/Host/CORE/EFT-ERA/EFT-ERA_Rules_Overview.pdf

www.availity.net

www.navinet.com

www.ama-assn.org• Payer policies• Toolkits

Anders Webinar Series

• Credentialing Doesn’t Have to be Hard!• June 18

• Effective Technology Will Elevate Your Practice• September 17

• 2015 – Here We Come!• November 19

http://anderscpa.com/webinar-series/

Questions

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

314-655-5558

jweith@anderscpa.com

Chastity D. Werner, RHIT, CMPE, NCP

314-655-5561

cwerner@anderscpa.com

Anders Health Care Services

Brian McCook bmccook@anderscpa.com

John McGuire jmcguire@anderscpa.com

Brian Meyers bmeyers@anderscpa.com

Jerrie Weith jweith@anderscpa.com

Chastity Werner cwerner@anderscpa.com

314-655-5500

www.andershealthcare.com