The Avea Way: Best Practices for Updating Claim Workflow

Importance Of QSIs

Queues, Statues and Issues (QSIs) are a crucial part of the claim workflow and the Avea Way.  

Step

Importance

Queues

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

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.

Issues

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.

Notes

Notes are important because they help teams easily determine the history of what has been done on each claim. It is important that a claim note be added each time a claim is called on, checked in a portal, or received payer letters for. 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.

Follow-Up Date

Follow-up dates are 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 processing for 30 days.

 

Step 1: Payer Portal Checks

Efficient billing teams utilize payer portals for claim follow-ups as much as they can.  Coach team members to check the applicable payer portals (Availity, etc.) twice before calling insurance companies directly for status checks.

Since the goal of the first few claim checks is to ensure that the payer is processing the claims that you submitted, it is a good idea to contact the payer if your team is unable to confirm processing via the payer portals.  

However, portals are not always helpful for processing verification and details. Sometimes claims simply will not show up in the payer portal or the claim data might differ from what was initially submitted.  For example, a payer might decide to split claims up based on the treatment that will not match the claim data submitted for processing. In these situations, Avea recommends adding a claim note regarding insufficient portal data and following up with the payer via phone within 1-2 business days to ensure processing. The last thing you need is a timely filing issue because of a rejected or withdrawn claim. 

Step 2: Calling the Payer/"Setting the Table"

Since talking to insurance companies is an important part of the medical billing field, knowing what to say and how to say it are 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 are going to 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. 

Step 3: Take Great Notes

There are three parts to the note-taking process:   

  1. Entering the templated note into AveaOffice. 

  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 that claims processed and paid.  If a team member confirms that a claim 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." 

Step 4: Updating Status and Issues

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.   

Step 5: Update Claim Follow-Up Date

Following that 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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