Billing Specialists Get The Job Done
By Lisa Bargmann
Wednesday, August 02, 2006
Reimbursement Specialists Get the Job Done
By Lisa Bargmann
Getting paid for home infusion services requires organization, accountability, special skills and follow-through. Often reimbursement teams are doomed to failure from the outset because key responsibilities are not being performed, are performed by the wrong people or are not integrated into an overall process. Four primary positions are listed below.
- CMN / Authorization Specialist: This specialist is responsible for generating the forms and cover letters to send to the physicians while double-checking that the patient will qualify based upon the information gathered. A follow up process is required since they will also be responsible to call physicians and send subsequent requests when documents are not returned timely. Once documents are returned, they are reviewed to assure qualifications are met. If met, the documents are logged to allow for claims to release. If the documents do not qualify, the CMN Specialist works with the physician’s office to see if there was an error made or if not, works with the Operations staff to determine if the patient should be billed or the service terminated. Most importantly, the CMN / authorization specialist is responsible for tracking when CMN’s and authorizations expire to prevent unauthorized services from being provided. If this function is part of the intake department it should still be managed as a part of the overall reimbursement process.
- Billing Specialist: A Billing Specialist takes responsibility to generate the appropriate paper or electronic claim for all delivered services and unbilled charges. They work closely with the person responsible for insurance and contract setup to eliminate as much manual effort (calculating units, grouping products, recurring rentals, etc.) from the billing process. With proper system set up, there should not be a need to review hard-copy claims for accuracy. This specialist mails hard copy claims with the proper attachments and submits electronic claim files and monitors acceptance reports. Most electronic claim front-end edit denials are demographic in nature, and this person is responsible to fix the errors and flag to transmit again. You should have fewer billing specialists if they perform these functions described, and more staff focused on collections.
The Billing Specialist is responsible to match up the denials from primary insurances to the ultimate payer. Specifically when a primary, such as Medicare, does not pay because they don't offer benefit on the therapy it is important to file the claim with that denial. The denial must be appropriate, in that specifically a PR (patient responsibility) is needed. It is important for the Cash Application Specialist to identify these denials needed for claims processing and forward to the Billing Specialist ASAP.
- Collection Specialist : The collections process should be what 70-80% of your reimbursement staff spends their time on. The collection specialist ensures that every claim submitted is resolved as quickly as possible. A report or computer queue of accounts is worked by either calling or utilizing an online system to insurance companies. Also included are working denials, calling and sending letters and statements to patients who owe either primary amounts or deductible/co-pays. At a minimum, a collection specialist has to understand the intricacies of the various payer medical necessity criteria, what information each payer wants to see on their claim forms, what needs attached to claims, how to read their explanation of benefits, and have excellent phone skills. Beyond that, and most importantly, they require “sleuthing” skills. They need to be able to look at a claim and determine what is wrong with it, and if they cannot, they need to know how to seek out the information and then turn that information into a payment. This means asking the right questions and in many cases negotiating. Anything that can be done to allow this staff to be more productive in their collection efforts is extremely critical to their success and cash flow to your business. You may also elect for them to review an edit list of claims that will be generated to assure clean claims. The collector should be a more senior level position, with the Billing Specialists functioning as more of an assistant to them.
- Cash Application Specialist: Another roll that needs fulfilled is the cash application specialist. This position is responsible for proper posting of payments, transferring amounts to secondary payers, pushing of co-pay/deductibles, balancing to deposits and possibly keying your approved adjustments and write-offs. They provide critical continuity between the billing and collection process.
Take some time to review your reimbursement department and identify who is handling each of these functions and whether they are accomplished in a smooth and coordinated effort. Identify gaps between intake, billing, collections and posting that are causing inefficiencies. If you are not meeting your financial goals consider having someone from the outside helping you refine your process and get your results back on track.