BETTER INTAKE Make sure staff handling pre-op paperwork is trained to avoid mistakes that could hurt your revenue cycle down the line.

One of 3 things will happen when you submit a claim: It may be paid correctly, partially paid and, of course, it may be denied altogether. It's the seemingly little things that can trip you up. Around one-third of claims are denied due to minor errors in coding, registration or billing. And it costs an average of $25 to rework a denied claim. Here are 6 strategies to get more of your claims paid correctly the first time.

Code it right the first time
The most obvious way to keep denied claims below the MGMA benchmark of 4% is to send out a clean claim on the first attempt. Easier said than done, right? This requires having properly trained coders in the right positions. Coding is comprehensive and layered, so while all coders must comply with the same set of general guidelines, each specialty also has its own set of rules. To simplify the process, start by understanding the coding requirements of your organization's top 5 payers, and remember, Medicare sets the standard. Communication among departments can also affect the volume and frequency of coding-related denials. When surgeons' offices, coders, the front desk and the business office communicate clearly and regularly, claims are submitted correctly and paid more quickly, more often.

Triage denial trends
When a systemic problem with denials exists, try triage. Identify the barriers to claims processing and prioritize them. Here are a few common trends and solutions to look out for:

• If several claims are held or denied for registration issues such as incorrect ID, eligibility, coverage termination or group number, then more instruction must be given to your staff responsible for intake.
• If claims are rejected for modifier usage, specificity or sequencing, then it's your coding department that needs additional training.
• If denials occur for failure to pre-certify or pre-authorize, fee schedule issues or duplicate claims, alert your accounting office.

Reimbursement Roundup

• ASCs to MedPAC: Thanks for nothing. The Medicare Payment Advisory Commission (MedPAC) thinks that Medicare payments to ambulatory surgical centers should stay flat next year. MedPAC's reasoning: More patients are having surgery at ASCs, so this should help offset any financial hardships caused by the stagnant payments. This isn't a new recommendation from MedPAC, which has unsuccessfully recommended eliminating the ASC payment update for several years, including in 2015 and 2016. The current recommendation is not binding, and instead MedPAC will present their comments to Congress in March, with the payment update finalized this fall. Meanwhile, MedPAC recommends a 1.65% payment increase in hospital inpatient and outpatient services in 2017.
• Site-neutral payments coming in 2017. Certain off-campus hospital outpatient departments may face lower reimbursements starting in 2017. As part of the latest budget deal from Congress, new physician-based centers located off of the main campus of a hospital will receive reimbursement rates based on the ambulatory surgical center prospective payment system or the Medicare physician fee schedule. The change affects those facilities established after Nov. 1, 2015, and located more than 250 yards from the hospital's main campus. HOPDs established before the November cutoff date will be grandfathered in and continue to be reimbursed according to the Medicare outpatient prospective payment system (OPPS) schedule. The move is meant to curtail the practice of hospitals acquiring physician offices and outpatient facilities, and then billing under the higher-rate hospital OPPS. While the government says that the move will save Medicare millions, the American Hospital Association said in a statement that the site-neutral payments "may endanger patient access to care, especially among patients who are sicker, the poor, minorities and seniors who often receive care in hospital outpatient departments." The new rule is scheduled to take effect Jan. 1, 2017.

— Kendal Gapinski

Train, train, train
Failure to keep up with training will result in reduction of revenue, penalties for noncompliance, and pre-payment and post-payment audits. That is why credentialed coders are critical to every team, regardless of size and scope.

Only half of the medical billers and coders in the field are certified, according to one recent survey. However — considering the increasing competition and coding regulations — certification is expected to become a necessity by 2020. If your coders are not certified, consider sending them to programs hosted by the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA), 2 groups that are nationally recognized and considered the standard for coding.

Don't make careless mistakes
To minimize avoidable denials and improve turnaround time, focus on eliminating small mistakes. Coders must be trained to understand the importance of correctly entering patient data into the system and how to troubleshoot when problems arise. Transposing a number when entering a date of birth or insurance ID causes claim rejection just as easily as using the wrong modifier or ICD-10 code.

Pre-certification by the insurer is another small step in a larger process that can have a detrimental effect on your accounts receivable. Most managed care organizations require approval for certain procedures and admissions; without it, payment will be denied. Educate your intake staff on these requirements to ensure all patients receive clearance before they're scheduled for surgery.

Expect denials
Denials will occur no matter how diligent you are. One of the most common reasons for denial is the dreaded "not medically necessary." Appeal these rejections as they occur, but don't waste your staffers' time. File the appeal only after you have verified that the coding is correct, the documentation is adequate and the medical decision-making is appropriate. Supply the appropriate medical records and, if possible, include articles, images and a letter from the provider to support the reason for the service.

Attack your backlog now
If you're drowning in coding-related denials, attack them now because they can quickly bring in revenue that would otherwise be lost. Paying attention to corrected claim timeframes and appeals deadlines keeps denials moving toward the overall goal: payment. Try these tactics to force coding denials appeals back to the top of your to-do list: Block out time daily to work backlogs, break down the volume of coding denials into manageable chunks to make the task easier and measure results at the bottom line. If you track the payments received as a result of working through coding denials, it'll be easy to make this tough task a priority. OSM