Recipe for timely managed care payments

Technology, meeting payer requirements essential

(Editor’s note: This is the second of a two-part series on speeding payment for private duty services from managed care organizations. Last month, Private Duty Homecare outlined steps to improve managed care communication and convenience. This month, we give tips for meeting payer billing requirements and the use of available technology to help speed payments.)

Providers can tighten their typically slow managed care reimbursement cycle by streamlining communication and effectively documenting and coordinating agency efforts prior to opening a case. Other actions that occur after service begins, can also accelerate payment. Experts provide these tips:

Follow payer billing requirements.

"Abiding by payer rules" is the first thing Stephen Flannery, reimbursement director for Bayada Nurses in Moorestown, NJ, mentions when asked how to speed up managed care payments. Once a claim is denied, he adds, "getting paid is almost a miracle."

Joyce Beseke, home care provider services representative for Blue Cross Blue Shield of the National Capital Area in Washington, DC, says she is "in awe" of home care billers who must keep track of a slew of payers, each with different billing standards. Flannery hires billers with experience and trains them to "give the insurance company what it wants, not what we can provide them."

To better meet each payer’s billing requirements, Bayada billers now concentrate their efforts by payer, not Bayada service office, as they did previously. In addition, billers use a contract book that outlines contracted payers’ billing requirements, including the types of documentation that must be submitted with each bill. The company will also soon implement QudraMed ClaimStar software, that maps downloaded bills against managed care organization requirements and flags missing elements. Flannery expects this to significantly improve Bayada’s ability to generate clean claims during the first billing cycle.

It’s all in the attachments

Beseke often sees situations in which providers submit bills either without corresponding nurses notes, plan of treatments, other necessary documentation, or with documentation from other billing cycles. Providers also commonly mismatch code descriptions and frequencies. For example, extended and regular home infusion visits are coded differently. Beseke says these issues may result from late nurses notes.

Bayada service office nurse managers enforce the company’s note submission policy. Individual field staff members’ payroll is not processed until notes are received. Compliance is still an issue, however, and Bayada has taken other steps such as increasing the full-time to per diem employee ratio and providing fax machines to employees with heavy caseloads.

Once documentation arrives, matching it with corresponding bills is another issue. For Bayada, receiving notes from each of its 29 service offices complicates the entire process. Flannery recently created a new position to sort these remotely-received documents so billers can more readily match attachments with corresponding billing periods. Still, billers spend almost as much time matching attachments with bills as they do verifying and completing other aspects of each claim.

Use available technology.

To speed up payments, Blue Cross offers electronic claims submissions to providers for a monthly access fee. According to Beseke, most home care companies do not take advantage of the service because they find the cost in relation to their volume prohibitive. Bayada has invested in such technology with key payers. Flannery estimates that it shaves almost a month from Bayada’s accounts receivables with those organizations.

Flannery sees technology as the key to shorter payment cycles. He notes that providers and payers face common claims processing problems, including entry-level employees, complicated policy terms, and voluminous information required to process claims. The amount of information required to process each claim has only increased, and with already low margins and further payment reductions anticipated, efficiencies will not come from adding staff.

Technological improvements: The way to go

Flannery says improved technology is the only way providers and payers can process claims more efficiently and cheaply. He looks forward to the day when computer-generated claims and computer-scanned patient care documents are matched, mapped to payer-specific billing requirements, flagged for errors and missing data elements, and electronically submitted and paid, all without human intervention.

Talk with payers.

Flannery meets regularly with payers to understand their billing requirements and address issues before they mushroom into major payment problems. From such a meeting, he recently learned that the admitting diagnosis field on all Bayada bills to a certain payer was blank. As home care admitting and discharge diagnoses are almost always the same, Bayada staff did not note the omission. But for this payer, whose home care billing system is drawn from hospital parameters where admitting and discharge diagnoses are often different, the blank field meant automatically rejected claims.

That error was readily correctable, but Flannery is ever-vigilant for the ones that aren’t. Claims with problems, he adds, take on lives of their own.