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Dedicate a Staff Member to Each Payer

Problem:

Each third-party payer may have different requirements for reimbursement.

Solution:

Dedicate a staff member to know what the requirements are for 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 $18,900. They placed one person in charge of the third-party billing process. They designed a tracking spreadsheet with denials and reasons, and reviewed them weekly as opposed to having a more casual approach. They 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. Customers were asked to pay 100% up front when they had insurance and were informed that they would be reimbursed. They check insurance benefits initially and explain to the client how their benefits will apply.

Lessons Learned

  • Assign a specific staff person to specialize in 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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