The Avea Way: Best Practices for Billing Team Leads

Objective

As a billing team lead, your goals are focused on keeping the workflow processes in place and removing the confusion that impedes processes, mentoring & upskilling your team, and ensuring the daily activities are on track to help the departments, and ultimately the company, achieve their goals.

Responsible

Billing Team Leads are responsible for selecting the appropriate treatments for claim creation, ensuring the quality of the data on new and corrected claims before submitting claims for processing to the payer, and supporting your team with admin-level configuration changes.

Team Leads will also serve as subject matter experts in their particular department/area and ensure process adherence, working closely with the Billing Managers to surface day-to-day challenges and suggest modifications to the Avea configuration based on their own experiences and the experiences of their team. 

 

Note: Steps for claim creation, claim QA, claim submission and admin-level configuration may be performed by the same individual(s), depending on the organization of your team and user permissions.

Process Overview

  

Daily 

Weekly

Billers

Kicking off the billing cycle

 

Working Rejections and Corrections

  • Reviewing and managing claim rejections
  • Reviewing and resolving claim corrections

Pushing new services toward claim creation

  • Submitting Treatments to Billing

Billing Team Leads

Review Management Center Claim Submission tiles

  • Patients with Claim Corrections Pending

  • Claims Rejected - Pending Review

  • Claims Ready for Review/Submit

 

Resolving and Submitting Corrected Claims

  • Aiding your Billers with configuration changes to generate corrections

  • Reviewing corrected claims in the Submit queue

  • Submitting corrected claims

New Claim Creation and Submission

  • Review Patients with New Claims Pending tile

  • QA unsubmitted treatments

  • Creating claims from submitted treatments

  • Reviewing and Submitting new claims

Productivity

  • Ensuring Management Center Claim Submission Tiles are regularly worked to green

  • Weekly Retrospective Meeting of Rejections and Denials

  • Claim Submission Report

 

Billing Team Leads

Daily Task: Reviewing Management Center Claim Submission Tiles

As a Lead, start each day reviewing the Management Center’s Claim Submission tiles and organize yourself and your team to first pay special attention to the Claims Rejected - Pending Review. Changes to claim billing processes are usually found by troubleshooting rejections when unknown payer and clearinghouse requirements for clean claim submission are revealed.

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Members of your billing team will need to address the Claims Rejected - Pending Review tile daily and may require your assistance with admin-level changes in order to be successful in creating the appropriate corrections to resubmit clean claims.

Ensure that your team is digging into the details of a claim rejection by following the steps and tips outlined in The Avea Way: Best Practices for Billers and are quickly escalating rejection types that require admin-level permissions to you or another Lead.

Admin-level changes needed can include:

  • Service Billing Profile updates (revenue, bill type, place of service, procedure code, bundling, etc.,)

  • Claim Rules management

  • Claim form or method changes

  • Issue troubleshooting

Daily Task: Resolving and Submitting Corrected Claims

Claim corrections are generated by AveaOffice after changes in the account are made to update incorrect data on a previously submitted claim in an effort to address a rejection or denial. Billers will resolve corrections daily and push them to the Submit queue for Leads to review prior to submission.

Ensuring corrections are resolved and submitted accurately and quickly will prevent delays in claim follow-up, extensions in time to reimbursement, and lend to preserving the accuracy of revenue projections for the month.

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The Patients With Claim Corrections Pending tile is a count of patients with pending claim corrections.

  • Any claims impacted by a change in the account will be generated by a user or AveaOffice and queued in the Create Corrected Claims sub-tab of the Insurance Claims tab in the Work Center.

  • This tile should be worked to green and display 0 by the end of the day. If a number lingers in this tile, your team may need help with confirming the accuracy of the intended changes.

The Claims Ready For Review/Submit tile is a count of claims currently queued for submission for all practices under your organization’s account. This will include both new and corrected claims.

  • Any resolved claim corrections are completed by a Biller and queued in the Submit Claims sub-tab of the Insurance Claims tab in the Work Center.

  • As a Lead, you should review the Submit list daily to push claim corrections along quickly. Follow the steps and tips below to expedite the corrections review and submission process.

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Step

Action

Tips and Notes

View Resolved Corrections

Go to Work Center > Insurance Claims > Submit Claims, then select the Practice.

or

Click on the Claims Ready For Review/Submit tile, then select the Practice.

  • Sort the list by the Context column to group all Corrections at the top of the list.

Review/QA the Corrected Claim Data

  1. Read the information displayed in the table for the claim.

  2. Click on the View link on each claim line labeled with a context of Correction.

  3. Scroll through the list to ensure billing data is accurate.

  • Use the View link to review a list of all data intended to send to the clearinghouse in the EDI file.
    (The Preview claim form PDF may not include all the data included in the EDI file due to the limitations of image files.)
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  • No matter the method (electronic or paper), the View list will return the list of claim fields set to go out for the claim.

  • Double-check the updates your billers approved for the correction by clicking on the patient’s name to open a new tab to Insurance Billing > Corrections History.
    Click the View link on the correction line for a summary of updated fields.

Submit Corrected Claims

Click the checkmark box next to each claim line with a context of Correction to only select corrected claims.

  • If claims do not need to be mailed in-house with records or appeals letters, then click Submit.

  • If claims need to be mailed in-house with records or appeals letters, then download the PDF preview to print later and click Mark as Submitted.

  • Mark as Submitted is a useful tool for preserving a record of a claim change, or a follow-up instance, in AveaOffice without sending it through the clearinghouse.
    Aside from in-house mailing, it is also useful for a number of workarounds.

Confirm Batch Processing

After claim submission, refresh the page until batch details display as Submitted.

  • If a batch fails or another issue arises, AveaOffice will display an error and redirect the claims (and you) back to the Submit sub-tab.

 

Error messages displayed on the claim row are a Lead’s responsibility to address prior to submission. Read each error message carefully and follow the directives given to remove the error. Errors in a claim at the Submit stage will prevent submission.

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Weekly Task: New Claim Creation and Submission

As a Lead, you’ll set a day of the week on which your Biller is expected to have completed and submitted new treatments to billing for the previous week. On claim submission day, review the Management Center’s Claim Submission tiles, paying special attention to the Patients with New Claims Pending tile.

After a quality assurance check is complete for all services submitted to billing, you’ll push those treatments to claim creation, then QA the data on new claims and submit for processing.

Working quickly and diligently in this step, like all others, sets the claim follow-up and revenue cadence for your organization.

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The Patients with New Claims Pending tile is a count of patients with treatments ready for claim creation. Each row is a patient and each column is a date of service. Services submitted to billing will display on the patient’s row under the date it was marked in Attendance.

It’s important that you conduct a review of the prior week’s marked treatments to quality assure all treatments that should be billed out are correctly and completely marked.

If treatments are missing in this list, they may be marked but not submitted to billing, or omitted from Attendance. This would be an opportunity to reconnect with your Biller to investigate why this is the case and potentially follow up with the clinician.

Step

Action

Tips and Notes 

QA treatments submitted to billing

Go to Work Center > Insurance Claims > Create New Claims, then select the Practice

or

Click on the Patients with New Claims Pending tile, then select the Practice

Prepare treatments for claim creation

Use the Select None/Select All, Toggle link below the patient’s name, or individual checkmark boxes to ensure all appropriate treatments are selected for claim creation.

  • As an additional QA step, you can use the Eligibility link below each patient’s name to run a quick check for active coverage.

Create new claims

Click Create New Claims for Selected Treatments button.

 

You’ll automatically be navigated to the Submit sub-tab once creation is complete.

  • If an error displays on this screen, move to create claims for treatments by patient or service until the source is identified.

Review/QA the Claim Data

  1. Read the information displayed in the table for the claims.

  2. Click on the View link on claim lines labeled with a context of New, Secondary, or Tertiary.

  3. Scroll through the list to ensure billing data is accurate.

 

If a patient billing solution is implemented for the practice, Private Pay or Guarantor billables will display in this list.

  • Use the Show: dropdown to filter the list to only display Insurance claims only.

  • Sort the list by Created Date to review newest first, or by Payer/Patient to group for review.

  • Use the View link to review a list of all data intended to send to the clearinghouse in the EDI file.
    The Preview claim form PDF may not include all the data included in the EDI file due to the limitations of image files.

    • No matter the method (electronic or paper), the View list will return the list of claim fields set to go out for the claim.

Submit New Claims

Use the Select None/Select All links or click the checkmark box next to each claim line with a context of New, Secondary, or Tertiary to only select corrected claims.

 

Click the Submit Claims button

 

 

Confirm Batch Processing

After claim submission, refresh the page until batch details display completely.

  • If a batch fails or another issue arises, AveaOffice will display an error and redirect the claims (and you) back to the Submit sub-tab.

 
 

Error messages displayed on the claim row are a Lead’s responsibility to address prior to submission. Read each error message carefully and follow the directives given to remove the error. Errors in a claim at the Submit stage will prevent submission.

 

Weekly Task: Productivity

Management Center Claim Submission Tiles

As a Team Lead, your team's efficiency and ability to perform daily tasks are critical to the success of your organization. Ensuring that you and your team have worked each tile to green daily/weekly, is an indicator of organizational health and should be a primary focus.

Weekly Retro on Rejections, Denials, and Configuration

Connecting with your Billers and Billing Manager regularly to review edge-case or recurring rejections, denials, or issues rooted in account or service configuration is a good way to identify areas for improvement in process or account configuration.

  • Consider tracking Time to Bill and Clean Claim Rate as weekly KPIs for your team

  • Review frequency of rejections and corrections week over week to identify trends

  • Discuss recent or needed account configuration changes to regularly achieve KPI goals

  • Identify roadblocks and update team processes

If your organization uses EOS, a regular L10 meeting with Scorecard tracking can help your team quickly escalate and respond to roadblocks and track toward organizational goals.

Claim Submission Report

Use the Claim Submission Report on a weekly basis to review new and corrected submissions for the entire organization or individual practice. This report is useful for reporting billed charges and services to your Billing Manager and/or accounting department as well as digging into a number of trends.

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