Best Practices for Updating Claim Workflow

  • Updated

The use of Queues, Statues, and Issues (QSIs) is a crucial part of the claim workflow and the RCM best practices. In addition to QSIs, users should take copious notes and assign follow-up dates to ensure each claim is being reviewed, processed, and paid on time.

  • Queues are important because they can help organize your claims into different action categories. This makes it easier for the management team to know who on their team should be assigned to which queues based on skills or role.
  • Statuses are important because they tell you where the claim is in its lifecycle. This can help the management team coach their team on which statuses to tag for certain scenarios to ensure easy follow-up on claims without having to dig through claim notes.
  • Issue tagging is important because issues can show where pain points are in the organization and determine the current issues delaying reimbursement. The A/R Waterfall Report will help the management team track pain points and will help you track your team's collections efficiency by tracking the reimbursement percentages throughout the year.
  • Taking notes is important because they help teams easily determine the history of what has been done on each claim. A claim note must be added each time a claim is called on, checked in a portal, or received payer letters. This ensures that nothing is missed on the way to claim adjudication. A uniform note-taking structure across the board is equally as important, the management team can QA claim notes to ensure their team is following proper note-taking structure.
  • Setting follow-up dates is important because the Work Center shows which claims are due for follow-up based on this date. If the date is never updated, the claim will stay overdue in the Work Center list, which may confuse or slow down the team if it's already been checked on recently.

    Typically, you should be calling on claims 20-30 days following claim submission depending on whether a payer portal is available to the team. Some payers will not give claim updates until the claim has been in processing for 30 days. 

Effective Claim Follow-Up

By properly managing QSIs, teams can improve claim follow-up efficiency, track reimbursement trends, and ensure timely and accurate payment processing. There are five important steps to take when managing a claim, let's review each step and why it's a critical part of the revenue cycle. 

  • Billing teams should use payer portals for claim follow-ups whenever possible. Train team members to check the relevant payer portals (like Availity) twice before calling insurance companies for updates.

    The main goal of the first few claim checks is to confirm that the payer is handling the claims you submitted. If team members cannot verify processing through the payer portals, they should contact the payer directly.

    However, payer portals can sometimes have issues. Claims might not appear in the portal, or the claim details may differ from what was originally submitted. For example, a payer might split claims based on treatment, leading to differences in the claim data. In these situations, add a note about the insufficient data from the portal and follow up with the payer by phone within 1-2 business days to ensure proper processing. You want to avoid any timely filing issues due to rejected or withdrawn claims.
  • Since talking to insurance companies is an important part of the medical billing field, knowing what to say and how to say it is pivotal to making the most out of these conversations.  

    In other words, effective team members learn to talk the talk before they walk the walk. 

    Generally speaking, you will need to speak to a live representative to confirm claim statuses and any other reviews that your team has requested. Do not be shy - tell the representative what you need and why.

    We like to refer to this first step as "setting the table," meaning that you are letting the representative know why you are calling, what the issue is and what you are expecting to happen.  For example, your first call to a payer will either be your first time confirming claim status or you are following up on portal check information.  Therefore, you will "set the table" and let the live representative know that: 

    1. You are calling to confirm that the claim was received. Or you will let the representative know that you have already confirmed claim status via the portal. 

    2. Your issue is that the claim has not been finalized yet and the claim was submitted 20-30 days ago. Or your issue might be with the processing details on the payer portal. 

    3. You are expecting the claim to be processing or finalized with the payer or you need an additional review based on the information disclosed in the portal. 

    Depending on the reason for making the call you will want to enable team members to set their tables accordingly. 

  • There are three parts to the note-taking process:   

    1. Entering the templated note into the RCM. 

    2. Adjusting the queue, status, and issue tag to reflect current processing progress and correct claim allocation. 

    3. Setting the next follow-up date.

    Payer portal notes should always include the claim number and any additional information stated in the payer portal. This means that you will want to include processing details and/or payment details if the claim has processed.  

    Portal Check Notes: 

    "Per [PORTAL NAME], claim # [PAYER CLAIM NUMBER] is.."   

    Then, we require our team to include all details included on the portal.  If the claim is still processing then your note would look like this: 

    "Per Availity, claim # 714650V65970X00 is in process. 
    Allowing additional time for processing."

    If a claim finalized and denied, a good note would look like this: 

    "Per Availity, claim# 7254506286J0X00 denied on 09/13/2017 and the denial msg as "Withdrawn - Need claim level information". 
    Contacting payer at next follow up for clarification on withdrawal." 

    In a perfect world, team members would check payer portals and find claims were processed and paid.  If a team member confirms that a claim was processed and paid via the payer portal, their note would read: 

    "Per Availity, claim #7116502008L0X00 processed 05/06/17 and paid $399 to provider on check #E8571346 issued 05/08/17. 
    No patient responsibility. Remaining balance is provider write off."   

    Payer portals often do not include all the payment information that is recommended for accurate payment posting.  We advise requiring billing collectors to confirm the following information when a claim has been reimbursed: 

    • ​Claim # 

    • Paid amount 

    • Check # 

    • Check date 

    • To whom the claim paid 

    • Total amount of check 

    • Check status (Did the check clear?) 

    • Member share within the allowed amount (Co-insurance, Deductible, Co-pay, etc.) 

    • Non-allowed amount and responsibility (either balance billed to the patient or provider write-off, depending on contracting with payer) 

    • Copy of EOB or claim summary​ 

    Payer Call Notes

    PC (Phone call) to [NAME OF PAYER] [PHONE NUMBER DIALED]
    T/T (talked to) [NAME OF REP] [CALL REFERENCE NUMBER]. 

    From there, we expect the team member to state what happened on the call without stating any assumptions.  This means that we only want to include actual information that occurred during the call.  You can always include what you tried to accomplish on the call or any other pertinent details that will help the team understand the current claim status.  Additionally, the best notes include applicable next steps to finalize claim processing. 

    Here are a few examples of claim notes that utilize the Call Queue Note-taking Template: 

    "PC to BCBS TX 800-528-7264 T/T Dina R#1-10481792351. Advised rep of the authorization on file. 
    Rep advised this is a Blue Advantage HMO. Rep advised provider is not in network for Blue Advantage HMO and would require a referral to be processed in-network.
    Rep advised referral must be called in by PCP Chad Weldon who can be contacted at 817-579-3999. Moved to practice queue for follow up." 
    "PC to BCBS CO 888-817-3717 T/T Gill R#2017213060924. 
    Per rep, claim #2017150CE6347 was pended 06/23/17 requesting complete medical records.
    Moved to admin queue for follow up."   
    "PC to BCBS TX 800-528-7264 T/T Joyal, Call Ref# 1-10558339151, Claim# 7254506286J0X, 
    Per Rep, stated that they need a corrected claim with appropriate revenue codes to send this claim back for reprocess.
    Rep refused to take it for further review on call. Need to refile this claim." 
  • Although templated notes are incredibly helpful, the real beauty of the note-taking system lies in the issue-tagging and status-updating because that data will produce accurate reporting that your team can manipulate to predict trends and forecasts.   

    The goal is to be able to determine the current processing stage and the current issues delaying reimbursement without needing to dig through claim notes.  The correct combination of statuses and tags should help your manager answer questions on reimbursement issues as well as help your manager determine processing trends.

    Here are a few examples of potential status/issue tag combinations for common claim processing scenarios: 

    Scenario 

    Status 

    Source/Tag 

    Claim is still processing, but it has been processing for over 30 days without any resubmissions and the payer cannot confirm why processing is delayed. 

    Payer - Original Claim Processing 

    Payer - Delayed Processing - Payer Did Not Specify Reason                 

    Claim processed but rejected because incorrect code set was used 

    Billing – Resubmit Needed 

    Billing - Incorrect Coding Used – CPT/HCPC 

    Claims processors are requesting medical records for review and you need to get them from the provider for submission. 

    Practice - Payer Needs Information/Documentation         

    Payer – Medical Records Requested 

    Claim denied for non-specific payer error, this needs to be escalated to a different team member for review. 

    Research - Issue Not Clear         

    Payer - Delayed Processing – Payer System Issue 

    Again, you always want to keep your status and issue tags simple and specific so that all team members can quickly determine the most accurate combinations for their notes.   

  • Following the first call, we advise setting the follow-up date for subsequent follow-up calls no more than seven business days after the previous call. This lets you ensure that the payer is reprocessing the claim as you requested and/or that the payer is following through on a commitment previously made to you.

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