Execuve Summary - HRCS · 2019. 7. 17. · The Business Side, Inc. 6835 Olney Laytonsville Rd...

The Business Side, Inc.

6835 Olney Laytonsville Rd

Laytonsville, MD 20882

Phone: 301-519-9200 x1071

Fax: 301-330-6300

Email: [email protected]

Executive Summary

This report prepared for Clients sorts 835 denial data into the four sections required to allow claim payments*. These

sections are categorized as: Clean Claims, Patient Eligibility, Covered Services and Medical Necessity. By

sorting, analyzing and providing Clients with this information sorted by departments, actionable feedback will allow

management to focus on the best opportunities to increase reimbursements:

Key Recommendations:

�Clean Claims – DC Medicaid will not pay for a Psychologists to treat patients. Psychologists are treating patients

and the claims are being denied. In addition, all coding denials were shared with the coding department.

�Patient Eligibility - A process should be set up to verify eligibility for all hospital services prior to submitting the

charge to the carrier.

�Covered Services – 25% of all covered services denials are from Trusted. Suggest a meeting with Trusted

management team to improve processing.

� Medical Necessity – 34% of authorization denials were from Trusted. Also a person should be assigned to work

with the hospital authorization office to ensure all services provided in the Hospital by Clients physicians are

authorized.

* This report is limited to denials received from available 835 files (Electronic EOB’s).




Phone: 301-519-9200 x1071

Fax: 301-330-6300


2%4%

5%

9%

7%

12%

7%

8%

8%

12%

12%

14%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Initial Denials by Month

- Increase of 2% compared to July is due to DC Medicaid ERA files now being downloaded and included on this

report. 36% of August denials are from DC Medicaid. Because of this high denial rate a meeting will be scheduled

with DC Medicaid representatives to review issues.

$-

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

Top 5 - Carriers (ERA Denials)

DC MEDICAID MEDICARE

BCBS MARYLAND MEDICAL CARE PROGRAM

UNITED HEALTHCARE INSURANCE COMPANY




Phone: 301-519-9200 x1071

Fax: 301-330-6300


$-

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

June-14 July-14 Aug-14

90 Day Denial Trend by Category – Clean Claims,

Patient Eligibility, Covered Service and Medical

Necessity

Covered Service Clean Claim

Patient Eligibility Medical Necessity

Denials are sorted into the following four categories to allow management

to focus on problem areas and lower denials and increase payments.

CLEAN CLAIMS - Provider/Billing office

Claims must be complete and properly filled out to be paid.

Claims must be submitted to the correct carrier, listing the correct patient and

coded correctly.

• Carrier, correct patient and correct coding come from the Provider and/or

the coding office

• Clearinghouse denials are handled by the billing office to ensure claims clear

all edits and are accepted by

the carrier.

PATIENT ELIGIBILITY – Office

If claims are not filed to the correct carrier, it is consider a Patient Eligibility error.

These include not filing the claim to the correct MCO/HMO or filing a claim to

a health insurance when it should be WC. There is a good process in place for

clinic services, but not hospital services - see results.

COVERED SERVICE – Office/Credentialing

Office must verify that specific patient is covered for specific provider for

specific procedure. See pre-existing condition clause or waiting period clause, etc.

MEDICAL NECESSITY – Office

The authorization or referral must be obtained prior to services rendered.

The carrier must agree in advance that the service is necessary, not just the provider.




Phone: 301-519-9200 x1071

Fax: 301-330-6300


Services rendered at a Clients Hospital location continue to have the highest denial rate.

Hospital surgical procedures(surgeries) and Hospital procedures and visits (minor procedures and E&M codes provided in/out patient

hospital) are separated from cost centers here to highlight the denials and differences between clinic and hospital services.

$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

$180,000

DENIALS BY DEPARTMENT JUNE THRU AUG





Phone: 301-519-9200 x1071

Fax: 301-330-6300


CLEAN CLAIMS

ACTION PLAN

There were 300 coding denials in August. 65% of the

denials were from DC Medicaid.

The major issues from DC Medicaid were psychologists are still treating

patients (65 denials) and claims lack information for adjudication (these

are mostly for secondary claims)

Other denials were for new patient qualifications not met, services

rendered by another physician and diagnosis code not valid.

The actual denials were shared and reviewed with the coding

department.

$-

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

90 day Denial Trend by Department by Category

Category - Clean Claims


Department-3

$79,353

59%

Department-2

$31,002

23%

Department-23

$23,457

18%




Phone: 301-519-9200 x1071

Fax: 301-330-6300


CLEAN CLAIMS

Top 5 Payers

Top 5 Providers

DC MEDICAID

$102,484

39%

MEDICARE

$57,979

22%

MARYLAND

MEDICAL

CARE PROGRAM

$40,547

15%

BCBS

$14,270

5%

UNITED

HEALTHCARE

INSURANCE

COMPANY

$10,038

4%

Misc.

$39,398

15%

Provider-7

$26,540

10%

Provider-8

$13,695

5%

Provider-9

$13,420

5%

Provider-1

$12,866

5%

Provider-6

$8,918

3%

Misc.

$189,276

72%

Top 5 Payers

Payers No # of Claims Amount

DC MEDICAID 465 $ 102,484

MEDICARE 199 $ 57,979

MARYLAND MEDICAL

CARE PROGRAM 143 $ 40,547

BCBS 40 $ 14,270

UNITED HEALTHCARE

INSURANCE COMPANY 60 $ 10,038

Misc. 188 $ 39,398

Top 5 Providers

Provider No # of Claims Amount

Provider-7 118 $ 26,540

Provider-8 7 $ 13,695

Provider-9 15 $ 13,420

Provider-1 3 $ 12,866

Provider-6 8 $ 8,918

Misc. 944 $ 189,276




Phone: 301-519-9200 x1071

Fax: 301-330-6300


PATIENT ELIGIBILITY

ACTION PLAN

224 out of 741 eligibility denials were from services

rendered at Clients Hospital. A process should be set up to

verify eligibility for all hospital services.

Example: Patient is enrolled in a Medicare HMO

Example: Patient is enrolled in a Medicaid MCO

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000


Category - Patient Eligibility


Department-24

$24,044

40%

Department-2

$23,806

40%

Department-9

$12,133

20%




Phone: 301-519-9200 x1071

Fax: 301-330-6300


COVERED SERVICE

ACTION PLAN

25% of all covered services denials were from Trusted Health. Suggest meeting with

Trusted management to improve processing reliability. Schedule in-service with Trusted

and Clients offices for training.

If the patient has Trusted Health Plan, deliveries are covered. However, if the patient has

Trusted Health Plan Alliance the delivery is not a covered benefit.

There has been an increase in services not covered due to patients not responding to

carrier questionnaires regarding other health insurance.

$-

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000


Category - Covered Service


Department-3

$54,870

64%

Department-16

$15,949

19%

Department-24

$15,055

17%




Phone: 301-519-9200 x1071

Fax: 301-330-6300


COVERED SERVICE

Top 5 Providers

Top 5 Payers

Provider-7

$29,338

18%

Provider-1

$17,040

10%

Provider-13

$12,728

8%

Provider-12

$9,261

6%

Provider-4

$5,916

3%

Misc.

$92,572

55%

BCBS

$60,784

36%

TRUSTED DC

ALLIANCE

$33,247

20%MEDICARE

$26,130

16%

TRUSTED DC

HEALTHY

FAMILY

$12,635

8%

UNITED

HEALTHCARE

INSURANCE

COMPANY

$12,330

7%

Misc.

$21,729

13%

Top 5 Providers


Provider-7 112 $ 29,338

Provider-1 4 $ 17,040

Provider-13 51 $ 12,728

Provider-12 3 $ 9,261


Misc. 439 $ 92,572

Top 5 Payers


BCBS 168 $ 60,784

TRUSTED DC ALLIANCE 102 $ 33,247

MEDICARE 121 $ 26,130

TRUSTED DC HEALTHY

FAMILY 51 $ 12,635

UNITED HEALTHCARE


Misc. 144 $ 21,729




Phone: 301-519-9200 x1071

Fax: 301-330-6300


MEDICAL NECESSITY

ACTION PLAN

73 out of 214 authorization denials were from Trusted. An appeal of all

authorization denials was sent to Trusted to reverse as promised.

A person should be assigned to work with the hospital authorization office

to ensure that all services provided in the Hospital by Clients physicians are

authorized. If an authorization is not obtained, the physician must be

notified so he/she can assist in the appeal process for an authorization.

Sending medical records alone may not be sufficient to have denials

overturned.

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000


Category - Medical Necessity


Department-3

$27,261

58%

Department-23

$11,286

24%

Department-19

$8,281

18%




Phone: 301-519-9200 x1071

Fax: 301-330-6300


MEDICAL NECESSITY

Top 5 Providers

Top 5 Payers

Provider-4

$14,590

19%

Provider-8

$9,334

12%

Provider-7

$7,799

10%

Provider-14

$3,307

4%

Provider-3

$3,268

4%

Misc.

$40,223

51%

DC MEDICAID

$38,382

49%

TRUSTED DC

HEALTHY FAMILY

$11,916

15%

BCBS

$8,063

10%

UNITED

HEALTHCARE

INSURANCE

COMPANY

$5,887

8%

MARYLAND

MEDICAL CARE

PROGRAM

$3,819

5%

Misc.

$10,454

13%Top 5 Payers


DC MEDICAID 67 $ 38,382

TRUSTED DC HEALTHY FAMILY 73 $ 11,916

BCBS 9 $ 8,063

UNITED HEALTHCARE


MARYLAND MEDICAL CARE

PROGRAM 12 $ 3,819

Misc. 40 $ 10,454

Top 5 Providers


Provider-4 11 $ 14,590


Provider-7 19 $ 7,799

Provider-14 5 $ 3,307


Misc. 175 $ 40,223




Phone: 301-519-9200 x1071

Fax: 301-330-6300


DENIALS BY DEPARTMENT JUNE THRU AUG

Facility June-14 July-14 Aug-14

Department-3 $ 126,201 $ 151,718 $ 164,694

Department-23 $ 163,888 $ 43,746 $ 55,870

Department-2 $ 56,744 $ 31,399 $ 70,812

Department-24 $ 38,473 $ 53,074 $ 64,693

Department-22 $ 21,395 $ 40,418 $ 30,414

Department-19 $ 19,637 $ 35,392 $ 49,151

Department-16 $ 12,532 $ 36,514 $ 31,609

Department-9 $ 22,578 $ 25,923 $ 48,313

Department-6 $ 11,259 $ 35,946 $ 17,441

Department-21 $ 13,609 $ 21,767 $ 10,908

Department-5 $ 13,299 $ 13,571 $ 19,939

Department-8 $ 7,685 $ 8,885 $ 12,208

Department-15 $ 11,560 $ 8,567 $ 7,820

Department-11 $ 3,755 $ 16,885 $ 19,620

Department-17 $ 4,876 $ 8,903 $ 9,347

Department-18 $ 5,113 $ 4,539 $ 6,872

Department-14 $ 5,335 $ 4,511 $ 7,319

Department-1 $ 3,798 $ 4,179 $ 6,145

Department-4 $ 2,837 $ 2,829 $ 7,423

Department-10 $ 2,991 $ 3,872 $ 15,805

Department-7 $ 1,478 $ 2,819 $ 3,537

Department-12 $ 1,829 $ 1,744 $ 1,821

Department-20 $ 1,446 $ 1,856 $ 5,580

Department-13 $ 1,268 $ 2,162 $ 1,334




Phone: 301-519-9200 x1071

Fax: 301-330-6300



Category - Clean Claims


Department-3 $ 21,064 $ 39,986 $ 79,353

Department-16 $ 2,973 $ 11,776 $ 4,740

Department-24 $ 5,518 $ 5,705 $ 21,078

Department-9 $ 5,394 $ 8,281 $ 18,705

Department-11 $ - $ - $ 4,224

Department-23 $ 85,218 $ 5,135 $ 23,457

Department-2 $ 20,836 $ 7,099 $ 31,002

Department-22 $ 12,388 $ 7,156 $ 11,389

Department-19 $ 5,131 $ 11,632 $ 23,456

Department-21 $ 2,536 $ 7,421 $ 4,284

Department-8 $ 1,688 $ 886 $ 4,309

Department-14 $ 2,442 $ 1,530 $ 1,383

Department-10 $ 1,555 $ 1,420 $ 844

Department-17 $ 1,789 $ 3,422 $ 2,860

Department-5 $ 1,202 $ 1,979 $ 9,872

Department-4 $ 698 $ 335 $ 1,956

Department-18 $ 954 $ 1,152 $ 1,730

Department-7 $ 647 $ 73 $ 368

Department-20 $ - $ - $ 2,261

Department-15 $ 5,707 $ 854 $ 3,411

Department-6 $ 5,382 $ 31,552 $ 11,987

Department-1 $ 1,771 $ 936 $ 1,424

Department-13 $ 483 $ 820 $ 529

Department-12 $ 379 $ 545 $ 94




Phone: 301-519-9200 x1071

Fax: 301-330-6300


DATA CURRENT MONTH DENIAL CATEGORY – CLEAN CLAIMS

Department-3

Denial Amount

The benefit for this service is included in the payment/allowance for another

service/procedure that has already been adjudicated. $ 17,638

This (these) diagnosis(es) is (are) not covered. $ 17,040

Claim/service lacks information or has submission/billing error(s) which is needed

for adjudication. $ 14,908

Department-2

Denial Amount

Claim/service lacks information or has submission/billing error(s) which is needed

for adjudication. $ 16,188

The procedure/revenue code is inconsistent with the patient's age. $ 4,212

Procedure code was invalid on the date of service. $ 3,792

Department-23

Denial Amount

Prior processing information appears incorrect. $ 9,783

The procedure code is inconsistent with the provider type/specialty (taxonomy). $ 8,200

Multiple physicians/assistants are not covered in this case. $ 2,328




Phone: 301-519-9200 x1071

Fax: 301-330-6300



Category - Patient Eligibility


Department-3 $ 40,692 $ 24,081 $ 3,210

Department-24 $ 21,817 $ 26,546 $ 24,044

Department-2 $ 27,173 $ 15,747 $ 23,806

Department-23 $ 19,442 $ 7,118 $ 10,011

Department-22 $ 3,961 $ 16,189 $ 10,087

Department-5 $ 9,643 $ 9,580 $ 8,127

Department-19 $ 6,517 $ 10,444 $ 11,127

Department-9 $ 8,635 $ 6,797 $ 12,133

Department-21 $ 8,264 $ 6,274 $ 1,199

Department-8 $ 3,706 $ 2,831 $ 3,953

Department-6 $ 5,067 $ 3,591 $ 3,211

Department-16 $ 1,706 $ 4,718 $ 8,183

Department-15 $ 3,263 $ 3,495 $ 1,225

Department-1 $ 1,377 $ 3,126 $ 4,264

Department-18 $ 2,034 $ 1,816 $ 3,609

Department-17 $ 1,205 $ 2,377 $ 4,329

Department-10 $ 662 $ 1,619 $ 11,464

Department-7 $ 490 $ 2,590 $ 2,349

Department-14 $ 1,805 $ 1,039 $ 3,280

Department-20 $ 393 $ 1,856 $ 2,007

Department-4 $ 1,014 $ 819 $ 3,009

Department-13 $ 527 $ 706 $ 339

Department-12 $ 672 $ 568 $ 950

Department-11 $ - $ 459 $ 2,668




Phone: 301-519-9200 x1071

Fax: 301-330-6300


Department-24

Denial Amount

Claim/service not covered by this payer/contractor. You must send the

claim/service to the correct payer/contractor. $ 10,002

Expenses incurred after coverage terminated. $ 4,026

Patient cannot be identified as our insured. $ 2,735

Department-2

Denial Amount



Patient/Insured health identification number and name do not match. $ 4,274

Charges are covered under a capitation agreement/managed care plan. $ 3,483

Department-9

Denial Amount

Charges are covered under a capitation agreement/managed care plan. $ 6,243



Our records indicate that this dependent is not an eligible dependent as

defined. $ 1,212

DATA CURRENT MONTH DENIALS CATEGORY – PATIENT ELIGIBILITY




Phone: 301-519-9200 x1071

Fax: 301-330-6300



Category - Covered Service


Department-3 $ 34,510 $ 63,513 $ 54,870

Department-23 $ 38,561 $ 25,304 $ 11,116

Department-24 $ 10,826 $ 20,611 $ 15,055

Department-16 $ 6,421 $ 16,108 $ 15,949

Department-22 $ 3,602 $ 15,345 $ 8,216

Department-19 $ 5,202 $ 6,807 $ 6,287

Department-11 $ 3,755 $ 14,434 $ 12,728

Department-9 $ 4,881 $ 8,274 $ 14,834

Department-21 $ 1,745 $ 8,072 $ 3,680

Department-2 $ 4,721 $ 5,780 $ 9,615

Department-8 $ 1,342 $ 4,207 $ 2,418

Department-5 $ 2,084 $ 1,777 $ 1,217

Department-17 $ 1,374 $ 2,268 $ 1,332

Department-18 $ 1,255 $ 748 $ 1,012

Department-14 $ 768 $ 1,106 $ 2,361

Department-4 $ 160 $ 153 $ 1,208

Department-10 $ 746 $ 805 $ 1,645

Department-15 $ 970 $ 233 $ 490

Department-6 $ 675 $ 226 $ 469

Department-1 $ 353 $ 117 $ 457

Department-12 $ 53 $ 396 $ 182

Department-7 $ 341 $ 147 $ 726

Department-13 $ 98 $ 238 $ 306

Department-20 $ 428 $ - $ 682




Phone: 301-519-9200 x1071

Fax: 301-330-6300


Department-3

Denial Amount

This service/equipment/drug is not covered under the patient’s current benefit

plan. $ 16,209

These are non-covered services because this is not deemed a 'medical necessity'

by the payer. $ 15,440

Plan procedures not followed. $ 12,780

Department-16

Denial Amount

Non-covered charge(s). $ 11,724

This provider was not certified/eligible to be paid for this procedure/service on

this date of service. $ 3,426

Plan procedures not followed. $ 705

Department-24

Denial Amount

This service/equipment/drug is not covered under the patient’s current benefit

plan. $ 9,141

Non-covered charge(s). $ 2,259

These are non-covered services because this is not deemed a 'medical necessity'

by the payer. $ 1,472

DATA CURRENT MONTH DENIALS CATEGORY- COVERED

SERVICES




Phone: 301-519-9200 x1071

Fax: 301-330-6300



Category - Medical Necessity


Department-3 $ 29,935 $ 24,138 $ 27,261

Department-23 $ 20,667 $ 6,189 $ 11,286

Department-19 $ 2,787 $ 6,509 $ 8,281

Department-16 $ 1,432 $ 3,912 $ 2,737

Department-2 $ 4,014 $ 2,773 $ 6,389

Department-9 $ 3,668 $ 2,571 $ 2,641

Department-22 $ 1,444 $ 1,728 $ 722

Department-15 $ 1,620 $ 3,985 $ 2,694

Department-4 $ 965 $ 1,522 $ 1,250

Department-8 $ 949 $ 961 $ 1,528

Department-18 $ 870 $ 823 $ 521

Department-17 $ 508 $ 836 $ 826

Department-12 $ 725 $ 235 $ 595

Department-5 $ 370 $ 235 $ 724

Department-14 $ 320 $ 836 $ 295

Department-21 $ 1,064 $ - $ 1,745

Department-13 $ 160 $ 398 $ 160

Department-6 $ 135 $ 577 $ 1,774

Department-20 $ 625 $ - $ 630

Department-24 $ 312 $ 212 $ 4,516

Department-10 $ 28 $ 28 $ 1,852

Department-7 $ - $ 9 $ 94




Phone: 301-519-9200 x1071

Fax: 301-330-6300


Department-3

Denial Amount

Precertification/authorization/notification absent. $ 19,034

An attachment/other documentation is required to adjudicate this

claim/service. $ 6,810

Payment adjusted because the payer deems the information submitted does not

support this many/frequency of services. $ 718

Department-23

Denial Amount

Coverage/program guidelines were not met or were exceeded. $ 7,691

Information requested from the Billing/Rendering Provider was not provided or

not provided timely or was insufficient/incomplete. $ 2,520

The authorization number is missing, invalid, or does not apply to the billed

services or provider. $ 1,075

Department-19

Denial Amount

The authorization number is missing, invalid, or does not apply to the billed

services or provider. $ 4,651

Referral absent or exceeded. $ 1,431

Payment adjusted because the payer deems the information submitted does not

support this many/frequency of services. $ 1,254

DATA CURRENT MONTH DENIALS CATEGORY – MEDICAL NECESSITY

Execuve Summary - HRCS · 2019. 7. 17. · The Business Side, Inc. 6835 Olney Laytonsville Rd...

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Transcript of Execuve Summary - HRCS · 2019. 7. 17. · The Business Side, Inc. 6835 Olney Laytonsville Rd...