Briefing: Tips for Avoiding Denials Date: 21 March 2007 Time: 1010 - 1100

1. Briefing: Tips for Avoiding Denials Date: 21 March 2007 Time: 1010 - 1100

2. Objectives • To provide information to the attendees that will allow you to reduce the number of denials you now receive from insurance plans/payers and pharmacy benefit plan managers/PBM’s

3. Preventing Denials • It’s a Team Effort throughout the MTF • Gathering of Patient Demographics • CHCS Data Entry • Provider Chart Documentation • Record Coding General – Data Quality • Ancillary Services Coding – Data Quality • Coding Audits • Provider Table Accuracy • NDC Code Accuracy

4. Preventing Denials • Gathering of Patient Demographics • Patient Name • Patient Date of Birth • Patient Address • Copy of Patient Insurance ID CARD – COPY Front and Back • Insured Individual Name • Effective Dates – Term Date

5. Preventing Denials • Coverage Through? Employer/Retiree Plan • Insurance Company Name • Subscriber/Patient ---ID!!! • Many are not SS# any longer – HIPAA & many have a distinct number after for each individual covered by the policy • Plan Code • Group # • RX BIN # • CLAIMS Filing Address – RX vs. Medical

6. Preventing Denials • CHCS Data Entry • Verified Information only • OHI/SIT new Classifications accurately entered • Occupational Visits – not billable –special MEPRS • Accident Case – Now - Block 11 of DD Form 2569 • New DD Form 2569 this block will no longer be present

7. Preventing Denials • Documentation – clinical • Provider documentation of ALL services rendered • Coding Audits – Pre-Billing • Statistical reports • Education and Training

8. Preventing Denials • Coding – General • Code only what is documented • Audit and Educate • 24 hour stays • Inpatient/outpatient overlaps

9. Preventing Denials • Coding – Ancillary Services • Be Specific • Utilize data from Civilian Ordering Physician • Request it if not provided • Reflect actual service not general • CPT Code Book • Annually update deletions and additions

10. Preventing Denials • Provider Tables • Specialty • Non Privileged Provider vs. Privileged Provider • DEA Codes • License #’s • HIPAA Taxonomy • NPI #’s

11. Preventing Denials • NDC Items • Frequency of Updates • Ownership of Updates • Expired items – Zero $’s – NO RATE • Days Supply and Quantity • CHCS Conversion table issues

12. Preventing Denials • Most Frequent Denials • Non Participating Provider • Medicare EOB Required • Unable to identify patient as subscriber • Duplicate Claim • Ancillary care not linked can cause this

13. Preventing Denials • Front End Impact on Back End A/R Functions • Incorrect data • Cause payer denials • Cause claim rejections • Cause slow down in payment • Cause payers to question credibility of future claims

14. Preventing Denials • Front End Impact on Back End A/R Functions (Cont’d) • Insufficient data • Cause payer denials • Cause claim rejections • Cause slow down in payment • Cause payers to question credibility of future claims • Staff frustrations • Leadership questions

15. Preventing Denials • Communicate and educate your partners • Leadership of MTF • Providers • Check-In Personnel • Coders • UBO/PAD Office • Payers & PBM’s (Pharmacy Benefits Managers)

16. Preventing Denials • Communicate and educate your partners (Cont’d) • Make suggestions • Partner with your TPC/OHI staff • Provide Briefings on outcomes and impacts • Monitor when changes are to be made • Provide Feedback on weakness and SUCCESS

17. In Summary • T = Top down support needed for best outcomes to be achieved • E = Everyone has a part in providing data for claims submitted • A = A/R overall is affected by the accuracy of claims data • M = Money in the bank with less denials and more claims paid as submitted

18. Quiz • Who owns accuracy of Data on claim? • One of the most common reason for denials? • Reason for performing pre-billing coding audit? • Monitor out comes and statistics, why? • Share the success with whom?