“Claiming” what is ours…by Shannon Browder
August 25, 2022 | Uncategorized
Operators in post-acute care know that timely and accurately documenting and billing for care and services delivered is critical to a sound business model. However, without a robust appeals and denial management program on the back-end, many providers are left with deficits that erode the bottom line time and time again.
While we would like to believe that all payers are advocating for accurate and timely payment to providers, there is an abundance of evidence to the contrary. We can all agree it is necessary to have a checks and balance system to spot check claims and ensure that what is billed is appropriate. When this is done fairly and consistently across all payers, operators can participate fully and expect appropriate outcomes. The current atmosphere for payment, especially by managed payers, has really taken a turn to “deny first and pay later.”
Fortunately, our Nexion Health Accounts Receivable and Appeals team are in it to win it! “Claiming” what is ours is the number one goal, even if it requires appealing to the final available level of appeals. Payment in full for accurate and efficiently billed claims has become the expected outcome because of a strong, methodical, and consistent approach to gaps in processes and diligence in appeal timelines.
Generally, our attitude is to expect the additional documentation requests (ADR) or the Pre or Post Pay Probes to come and respond the same way every time, building a solid response system. As we begin to see the last of the aged ALJs from the early Medicare Part B pre-auth fiasco come to an end, we see the continued growth of the Managed Medicare claim reviews multiply tenfold. As a trend, managed claim appeals are taking to the second and third level to win, but every level is worth the fight as it sets precedent for appropriate arguments for inappropriate denial trends.
Our teams are rooted in the RAI manual as well are our documentation processes are rooted in defending our claims. We set ourselves up for sustained success through these actions and more:
- Gaps are identified easily and quickly leading to appropriate training; documentation set ups revised; and/or audit systems deployed to head off future claim issues.
- Education to managed care companies via the appeals process is done boldly by our team members often quoting various resources used for CMS coding guidelines when denial reasons are not supported.
- Strong internal and external communication systems to ensure timely flow of claims information, appeal timelines and rapport established.
- Pursuing the appeal as far as it can be pursued realizing that at each level is a new opportunity to make the case for payment with a new reviewing audience.
At the end of the day, well, at the end of the appeals process, there is nothing more rewarding than to see the “paid in full” notification that reflects the entire team’s efforts to get paid for the care and services we carefully delivered and rightfully billed for. Virtual high fives and shouts of “another one!” make each day worth the fight!
Shannon Browder, RN/RAC-CT/RAC-CTA is the Director of Appeals and Denials Management for Nexion Health.