Author Archive for PARC Editor

EMTALA in Georgia

We know the EMTALA guidelines for the ER log book. I’m looking for the State of Georgia guidelines. Can anyone help me?

Marianne Addison
Patient Access Supervisor
BJC Medical Center
Commerce, GA

Accurate edits return $$$

By Vince Arencibia and Julie Souder

Many companies offer various services and ideas on how to improve revenue. Most, if not all, concentrate their efforts on the front-end registration process, dealing with eligibility, making sure the patients have enough insurance coverage, collection of co-pays, etc. All these procedures are important, good practices to follow and are essential to a good revenue cycle program.

One vital step in the revenue cycle program tends to be ignored or is inadequate – proper setup and use of a scrubbing system. In order to have a clean claim, there are a few components dealing with systems and personnel that need to exist. A good, reliable scrubber system needs to be in place, the billers need to know how to use it, understand the information the scrubber provides, and, most of all, know how to resolve claims issues presented by the scrubber.

Companies spend hours on research and development concentrating on how well the electronic file is built so the insurance company will accept it. However, even though it is an important step as part of claim submission, how accurate is the information within the file? What if you do not have electronic file submission established for all the carriers, and paper claim submissions need to a review?

In addition to a good scrubbing system, there needs to be a good revenue integrity person at your facility keeping up with all the various scenarios relating to reimbursement. The revenue integrity person needs to understand the types of contracts the hospital has with a particular insurance company. 

Your facility needs to have solid background on what insurance companies look for and what the best practices are in the billing and coding arena. In our experience with many clients over the years, we have determined that in order to have a good revenue cycle program, there needs to be a synergy between revenue integrity, medical records, coding, billing, and compliance. A good “scrubber” system can help to ensure you receive the most appropriate reimbursement for the services you provide. 

Besides the front-end eligibility and compliance on file structure, what are the claims issues at a hospital? There are three components:

• Compliance
• Lost charges
• Payer-specific issues

There also needs to be a good understanding on how to build edits on your scrubber to look for certain edits dealing with areas such as:

• Outpatient Medicare
• Carve out
• Interventional radiology
• Drug administration
• User-defined

The question is – do you have a person in-house dedicated to reviewing claims before or after they are billed? Are you relying on the scrubbing system to do just that? Does your scrubber perform to your expectations?  Systems are supposed to be automatic, but we know in the healthcare environment, there are too many variations for a system to automatically pick up most coding errors.

There needs to be someone or some system in place to review particular claims either right before you bill them, and/or shortly thereafter.

Only with the synergy mentioned above, will your facility experience the expedience and accuracy of claims processing and reimbursement it deserves.

Vicente Arencibia is a chief information officer with Omega Technology Solutions. Arencibia leads a team providing all aspects of electronic technologies, including compliance, claim submission and revenue management. Arencibia is a qualified manager and holds a B.S. in management and marketing degrees from Florida Atlantic University.

Julie K. Souder, CPC, CPC-H, CPATI, is a business analyst for Omega Technology Solutions with more than 22 years in the healthcare industry. Her experiences have taken her everywhere from working on systems to collect patient information during emergency situations, to patient billing, to medical record audits. Previous positions have included the business office management of what was the largest private ambulance company in South Florida, to owning her own medical collections agency. Today, she is involved in research and development of claims edit systems that report compliance issues as well as alerts for potential lost charges/revenue. She is also involved in the charge description master products provided by OTS.

Questions for new OB unit

The hospital that I work at will be opening an OB unit this fall. I am trying to compile a list of questions because many of the managers here do not have experience with labor & delivery.

Does anyone have a list of important questions to ask or know where I can find one? (I’m thinking things like who handles the birth certificates, how are charges billed, etc.)

I’d also like to know if anyone has suggestions about processes that have worked well for them.

Brianna Walter

Pre-registration supervisor

Baltimore Washington Medical Center

Standing order labs

How do your facilities handle registration of “standing order labs”? I am looking for a process that will streamline the patients rather than having to stop at registration each time.

Liz Kucharczyk
ER Registration Supervisor
Hilton Head Hospital
Hilton Head, SC

Billing post-denials

A patient came into the office and gave us Anthem Blue Cross and Blue Shield insurance card, so we billed that insurance. Blue Cross denied stating that the patient wasn’t eligible then we billed the patient. The patient comes back after a year later and says, “Oh, by the way I had Cigna insurance.”

So, we bill Cigna insurance, and we get denials stating that it is past timely filing, which we knew would happen.

My question: Is it legal to bill the patient after receiving these denials from Cigna and make them responsible for paying us services rendered? Or, is there a law that forbids us from doing so?

Danielle Bryant

Medical biller

Newington Internal Medicine Primary Care, LLP

Newington, CT

Bad debt in a shifting economy

As more Americans become unemployed and potentially also become uninsured or underinsured, a new challenge is being added to the patient financial counselor’s responsibilities.

Add to this the continued increase in high deductible health plans, and providers are starting to see increases in the self pay dollars owed for services.

We are also seeing software tools being used which provide a propensity to pay score for self pay patients or patients with a self pay balance.

My question is this — what impacts on bad debts are you seeing both because of the shifting economy and because of the new technology being deployed?

Editor’s note: This post was provided by Sandra J. Wolfskill, FHFMA, president of Wolfskill & Associates, Inc., in Chardon, OH.

Medicare co-insurance collection

I am looking for hospitals who have been successful in collecting Medicare co-insurance to network with.

Stephanie Smithson, CHAM

Director of Patient Accounts

Dunn Memorial Hospital

Bedford, IN

Benchmarks — eligibility preauthorization

I managed a centralized pre-registration department for outpatient services. Are there benchmarks per shift for eligibility preauthorization? 

Tashema  Cook
Manager, patient access/patient financial services
Office of Physician Services
Danbury (CT) Hospital

Benchmark — upfront collections

Does anyone have any benchmarking on collections up front? We currently collect in the ER, outpatient and inpatient departments.

Antionette G. Anderson
Director, patient access
Skaggs Community Health Center
Branson, MO

Benchmark — registrations per hour

What is the benchmark for number of registrations per hour? For outpatient services, do the registrars order the diagnostic test?

Kelly Isidore, CHAA, CHAM
Manager of Patient Access
Bay Medical Center
Panama City, FL