Ensure clean claims for maximum payment

Wrong code. Out-of-date referral. Inaccurate patient information. All three of these items are simple pieces of information that can cause big problems for your same-day surgery program because they all lead to denials of your claims.

While correction of these simple mistakes and resubmitting the claim might result in a payment, the extra staff time and delay of payment affect the financial success of your program by increasing employee costs and reducing cash flow, says Amy Mowles, president and chief executive officer of Mowles Medical Practice Management, a consulting firm in Edgewater, MD, and a speaker at the most recent annual meeting of the Federated Ambulatory Surgery Association. "Every same-day surgery program must implement a system that ensures the filing of clean claims the first time," she says.

One of the first steps to avoiding denials is to know upfront what your payers will cover, says Mowles. "The best way to stay up to date on this information is to designate an employee, usually the billing manager, as your expert," she suggests. This employee will be responsible for reading payer newsletters and update notices and educating other staff members about changes, she says.

One of Mowles’ clients uses the staff lounge bulletin board as an education center. "She reviews the payer newsletters, highlights the information that is important to her billing and collections staff members, and posts the newsletters on a bulletin board in the breakroom," she says. The bulletin board is divided into sections based on payers with the updated information posted by date so the latest news is easy to spot. "At staff meetings, billing and collections employees are quizzed on the information," she adds.

Because proper coding is essential to filing a clean claim, be sure your staff members understand the importance of modifiers, Mowles notes. "Be sure that the modifier is accurate and presents a clear picture of the services the patient received," she says. (See list.)

Another key is to monitor denials and payments, says Mowles. Don’t just post a payment when it arrives, she advises. "Have someone responsible for reviewing the payment to make sure that the amount paid is correct according to the contracted amount and that the payment reflects all multiple or bundled services correctly," Mowles adds. "If there is a difference between what you expected to receive and what you received, follow up with the carrier immediately."

Monitor your denials with a log that lists denials by payer and procedure, and review it regularly, suggests Christine Yoder, RN, director of nursing at Wyomissing (PA) Surgical Services. The log gives you a chance to identify trends in denials.

"We noticed that we were getting prior approval for specific pain management procedures, then the surgeons would perform a different procedure on the day of surgery," she adds. "These claims were denied because the procedures weren’t approved."

After investigating the reason for the change in procedure, Yoder’s staff discovered patients were seeing physician assistants (PA) in the surgeons’ offices prior to surgery rather than the surgeon. "The PA would order a specific procedure, but the surgeon would not be involved in the decision," she says. Now, when the surgeon’s office calls the surgery program to schedule a procedure, the scheduling staff remind the caller that the surgeon needs to sign off on the procedure.

"If the patient is in our center when the physician decides to perform a different procedure, we delay the procedure to try to obtain approval. If the approval cannot be obtained quickly, we reschedule for another day," she says. Physicians are more aware of the need for preapproval now, and Yoder reports that she is seeing fewer changes in procedure on the day of surgery.

Tracy Odom, RN, administrator of Pain Consultants of South Mississippi in Hattiesburg, obtains preapprovals in writing. While preapproval does not guarantee payment if the payer representative makes a mistake, the documentation is essential to your appeal, she adds.

"If the payer can’t or won’t fax a preapproval, my staff members write the name of the person who gave the approval, the time and day of the conversation, and the name of the procedure that was approved," she says. This documentation is essential if the claim is denied, Odom adds.

"I will even check denial reports on certain procedures," she notes. "I look at the procedure by payer to see if there are any trends that require my follow up with my staff or the payer."

While coding and understanding the payers’ requirements is important to filing timely, accurate claims, gathering correct information early in the scheduling and pre-admission process also is key, Odom says. "I only have six people who handle admissions, billing, and coding, but I find it helpful to cross-train them so that they see how their primary job responsibilities affect the other areas," she says. While Odom doesn’t expect her front-desk employee to take over the billing employee’s job, the cross-training did reap advantages, she adds.

"When she sat with the billing employee to learn some of the basic duties, she made the comment that she now understands why certain pieces of information are important to collect," Odom says. "Cross-training gives everyone a chance to see how a simple mistake at any point can grow into a major problem." She also recommends same-day surgery staff establish a relationship with key contact people for each payer. "It’s much easier to resolve problems when you know whom you are calling," Odom explains. She also suggests being prepared and staying calm.

"I’ve learned that no matter how mad you might be that a claim was denied, you need to be nice and understand that the payer has a job to do, and that job involves denying claims," she says. "If you have your documentation and your facts ready when you contact the payer, and you present the information calmly, you are more likely to resolve the problem."


For more about avoiding claim denials, contact:

  • Amy Mowles, President and Chief Executive Officer, Mowles Medical Practice Management, 447 Penwood Drive, Edgewater, MD 21037. Phone: (410) 956-1907. Fax: (443) 782-2386. Web: www.mowles.com.
  • Tracy Odom, RN, Administrator, Pain Consultants of South Mississippi, 106 Asbury Circle, Hattiesburg, MS 39402. Phone: (601) 268-8698.
  • Christine Yoder, RN, Director of Nursing, Wyomissing Surgical Services, 1235 Penn Ave., Suite 100, Wyomissing, PA 19610. Phone: (610) 373-3715.