Problem:
Each third-party payer has different reimbursement requirements.
Solution:
Dedicate a staff member to each third-party payer to ensure compliance and maximize reimbursement.
Featured Stories
Liberty Center Connections, Inc. in Wooster, Ohio, decreased the claim error rate from 33% to 16% and increased insurance reimbursements from 10% to 17% of total charges. They have dedicated personnel specifically to work on insurance. An understanding of contract stipulations allowed them to follow more efficient procedures to obtain the authorizations in advance and ensure that they met requirements. They also created a checklist with information needed to collect from insurance companies when calling to verify coverage, as well as a list of insurance providers and the credentials required for reimbursement of services provided. They also worked with the insurance clearing house on why they had claims errors, how to fix the errors, and how to resubmit the corrected claim.
Quest Recovery & Prevention Services in Canton, Ohio, increased revenue by placing one person in charge of the third-party billing process. They designed a tracking spreadsheet with denials and reasons, and reviewed it weekly. Quest improved the intake process to identify third-party clients earlier in the process, which allowed them to complete pre-certifications and match assessment and potential treatment with the right license.
Lessons Learned
- Assign a specific staff person to each insurance company. (The same person may be responsible for more than one payer.)
- Create a list of third-party payers and their requirements.
- Assign an appropriately licensed counselor to each client, based on reimbursement requirements.
- Schedule services to match reimbursement requirements; this may mean scheduling only one service each day.
- Negotiate with the third-party payer for exceptions or special circumstances.
- Establish medical necessity.
- Hire employees with backgrounds and experience in finance, health care and insurance.
Tracking Measures
| Cycle Measure | Data Collection Form |
|---|---|
| Denial rate = Total Number of Denied Claims/Total Number of Claims Submitted | None |
| $ of revenue from third-party payers | Revenue by Payer Worksheet |
ActionSteps
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