Best Practices for Billing Managers

As a billing team lead or manager, your primary goals are to eliminate obstacles that hinder processes, mentor and develop your team’s skills, and ensure that daily activities remain aligned with departmental objectives and the company's overall goals.

Audience

• 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 RCM configuration based on their own experiences and the experiences of their team. 
• Billing Managers make sure billing processes and best practices are clearly defined, the right people are working on claims based on their skill and experience, and ensure the RCM configuration supports your processes.

Process Overview

Billing Managers following the RCM best practices will organize their daily, weekly, and monthly activities into three categories: Audit, Analyze, and Act.

Role	Weekly	Monthly
Billing Manager	Audit Billing Agent Activity Report Dashboard Tiles Management Center Dashboard Tiles Analyze Payer Mix using Claim Payments Report	Act Update processes as necessary based on root cause analysis and staff feedback. A highly effective method for root cause analysis is the Fishbone Diagram technique.  Optimize the RCM (Revenue Cycle Management) configuration according to your analytics and to incorporate new scenarios that should be reflected in Queues, Statuses, and Issues.  Regularly retire, update, or add new QSIs (Quality Standards Indicators) to ensure they are user-friendly, which will facilitate successful process adoption. Analyze Forecasting/Cash Claim Payments Report Claims Submission Report Payer Mix Analyze Team and Payer Performance A/R Insurance Report Using Groups for Issue Source, Type and Patient Claims Submission Report Claim Payments Report Dashboard Tiles

Building Your Team

Billing Managers make sure that the right people are working on claims based on their skill and experience. Divide the claim follow-up team into two tiers based on experience and types of calls. More complicated issues that arise during these calls should be escalated to the Tier 2 billers, who are more capable of troubleshooting these claim problems over the phone.

• • Portal Checks
  • Initial Claim Calls
  • Confirming status of additional inquiries or reviews
  • Requesting EOB's or reimbursement data
• • Prior Authorization discrepancies
  • Inconsistent reimbursement rates and pricing issues
  • Payer system issues
  • Benefits misquote
  • Contracting discrepancies

Billing Manager's Weekly Tasks

 The Billing Manager's weekly tasks will fall into two categories: Audit and Analyze.

• The Billing Agent Activity Report analyzes the production of individual users across several categories, including the total number of claim notes written daily, the total claims closed, and the number of payments posted. Most intermediate-level collectors should aim to write around 45 claim notes per day, depending on the complexity of the tasks associated with those notes.
  
  For instance, a team member handling Tier 1 claim follow-up is likely to complete more claim notes than someone engaged in Tier 2 heavy research on denial trends, which may require extensive time on the phone. Consequently, it is advisable to remain flexible with individual production expectations.

• You can use the built-in Dashboard tiles to get a pulse on performance metrics such as Clean Claim Rate and Collection Rates.

  The organization dashboard is a powerful tool for managing your team against key performance indicators. It follows the entire revenue cycle of a behavioral health claim and highlights the most common problem areas.

• The organization dashboard is a powerful tool for managing your team against key performance indicators. It follows the entire revenue cycle of a behavioral health claim and highlights the most common problem areas. Every tile on the dashboard has a purpose and was selected based on real-life billing experience to help behavioral health billing teams run at optimum performance. You don’t need to waste time learning what you should be tracking daily - it’s all there.
  
  We recommend the team be working those tiles to zero, daily. A team lead is reviewing the dashboard multiple times a day, as well as a billing manager if you’re on a smaller team and holding both roles. This dashboard encompasses the daily activities your team should be doing every day and it’s the traffic control center of your billing operations.
• The Organization Dashboard gives a clear overview of daily activities in the revenue cycle but isn’t ideal for analyzing trends or understanding underlying reasons. It’s best for managing day-to-day operations, while reporting is more effective for tracking performance and addressing issues.

• • As a billing team, one of your main goals is to decrease the time to the first payment, and leaving your attendance unsubmitted will work against that goal so this tile helps you keep that on track.
    
  • First, you’ll want to ensure you’re working this tile down to zero as quickly as possible to catch billing errors. If any information in a patient’s profile, service configuration, or claim rule has been updated since a claim was submitted, corrections may be prompted and shown in the Patients with Claim Corrections Pending tile.
    
    Clicking into this tile will show what claim contents differ so the user can make the choice to correct the claim or ignore the correction attempt. You’ll want to monitor the types of corrections that are being made on a regular basis to determine if you have an upstream issue in patient intake that’s prompting corrections down the line.

  • After claims are submitted to the clearinghouse, if they are rejected, they will show in the Claims Rejected Pending Review tile. Clicking into this will redirect you to the Work Center > Insurance Claims > Currently Rejected/Held section to review claims that have a rejected status.

    If the claim is being processed with the payer without issue, you can edit the payer status to Accepted. If the claim needs to be corrected and resubmitted, it will be removed from the list after resubmission. To identify the reason for rejection, click the claim ID and read the processing events. 

    See a list of common rejection reasons here. 

    Helpful Hints for Troubleshooting:

    • Use the Claim Status Report by Claim to get a picture overall of the main reasons why claims are being rejected. You’ll want to filter by Queue “Payer” and then create a pivot table to get a count by claim issue.

    • Check-in with your team on a monthly to quarterly basis to discuss your QSIs and ensure they have the appropriate options for their current scenarios. The data will not be useful for you if it’s not accurate. The best way to encourage this is to have meetings where the data is being reviewed by the team and they are involved in the process of troubleshooting. Incorporating some type of weekly scorecard for the department and a weekly meeting to review can help discuss trends related to current issues.
      

  • This tile helps you monitor all claims that are queuing for submission, not just new claims. Clicking the tile will take you to Work Center > Insurance Claims > Submit Claims where you can preview the individual claims.
    
  • Electronic enrollments allow the RCM to do a lot of the work for you, however, when an ERA is downloaded and unable to automatically match to a claim, it will show in this tile. This revenue isn’t fully realized until it is matched to a claim and it will reflect in your reporting. It’s important to implement discipline and timeliness on your team related to payment matching.
    
    Maintaining this tile should be a payment poster's priority for each day’s posting. Clicking into this tab will show all ERAs that need to be matched to claims. If the ERA is for a claim submitted outside of the RCM, you can Mark as Legacy to remove it from the list. Those payments can be found in the Records Center again at any time. Choose the Resolve link to match it to the correct claim and patient.

    Helpful Hints for Troubleshooting

    • Filter the Claim Payments Report by Payment Matching Status: Unmatched Payments for any date range to get summary totals or details. This could be helpful to understand the dollar value and impact of unmatched payments as well as identify any trends across payers, service types, dates submitted, etc.
      

  • Reviewing and resolving payment collections that are potential duplicates or mis-posted help streamline recognized revenue. This tile will take you directly to the payments needing attention and we provide the reason in the list so you can get a better understanding of the types of issues you see there. For example, billed amounts and paid amounts mismatched for the line item vs the payment totals are usually flagged for review
    

  • Claims gather here when the balance on a posted claim is more than the charged amount or patient responsibility exceeds the billed charges. This happens when the payer sends multiple ERAs for the same claim without sending offsetting ERAs, which accounts for the charges and adjustments numerous times.  Learn more in this article.

    Best practices for your processes:

    • For more details, click on the check number. Do this before applying a reversal if it is at all unclear which remit should be reversed.

    • Address imbalances only after all postings have been made to a claim. Before correcting for a balance issue, ensure no payments are waiting to be matched to the claim.

    • Do not apply a reversal if the payer is sending a recoup. Wait to receive and post the recoup.

    • Do not apply reversals in anticipation of a future decision. Wait for the claim to be fully processed with all remits received.

      
  • As a team lead, you’ll know the team isn’t following the best practices of updating their follow-up dates diligently if claims are piling up on this tile. It’s really important to establish good habits in this area because even if the claim volume seems manageable today, there’s always tomorrow.

    You need to establish habits that gear you up for growth and keep you organized. This can be a challenging concept when you first adopt the RCM - because your manual processes were holding you back from scaling with your growth but they were comfortable. With the RCM, you’ll be able to process more claims than you could before and the way you manage the increased capacity is to use the tools (such as bulk update and follow-up dates) to radically prioritize the claims that require your attention now.
    

Billing Manager's Monthly Tasks 

The billing manager's monthly tasks will fall into the following categories: Act and Analyze.

• Use the Fishbone Diagram to quickly and effectively determine the root cause of an issue. Once identified, use the analysis to update processes and provide staff feedback.
• Use your analytics to optimize your RCM configuration based on the scenarios you've encountered by managing your QSI's.

Analyze With Reporting

The Reports in RCM provide data that can be used for a variety of purposes in a treatment center and within revenue cycle teams. The suggestions below focus primarily on using these reports for monitoring and analyzing the effectiveness of the best practices, however, these suggestions don’t accurately reflect all objectives and options of these particular reports.

• The Claims Submission Report will help you understand claim submission trends at a deeper level than the dashboards. The options with this report vary widely depending on the performance metrics you’re looking to capture. However, some suggestions would be:

  • Expected Allowed Amount by Payer so you can forecast cash flow

  • Claim Count by Payer compared to average weekly claim submission just to understand if there are any variances in submission

  • Add a calculated field for Service End Date minus Claim Submission date to better understand your cross-team collaboration and how much time is being lost between when a patient receives a service and when the claim is billed

  • Claim Count by Method to understand if there’s been an increase in paper claims submitted. If so, you’ll want to review those claims to see if there are electronic enrollment issues, or perhaps team members are dropping to paper as a workaround for a recurring issue you’re not aware of

  • Running the Claim Submission report showing all instances will help you understand how frequently you’re resubmitting claims

• This report breaks down individual user production into several categories including total claim notes written daily, total claims closed, and the number of payments posted.  Most intermediate-level collectors should be averaging around 45 claim notes daily depending on the actions required for those notes. 
  
  For example, a team member who is doing Tier 1 claim follow-up should be able to complete more claim notes than someone who is doing Tier 2 heavy research on denial trends where extensive time on the phone might be warranted.  Therefore, it's a good idea to be flexible with individual production expectations. 

• The Claim Status Reports will likely be your go-to for various analytics. We’d recommend customizing various report outputs and saving them as templates so you can easily run them weekly and monthly. What makes the Claim Status Reports valuable for evaluating payer mix and net collection ratio is that it’s based on claim or service but includes the payment data (whereas with the Claim Payments Report, you are only getting payment data for claims paid so it’s not a full picture).

  You’ll also find this report useful for analyzing team performance since it includes the queues, status, and Last Action Date.

  Key metrics:

  • Net Collection Ratio

  • Payer Mix

• The Claim Payments Report tracks reimbursements through the current month via electronic EOB or manual posting, and it can also pull previous payment data that's been uploaded to the system.  With the Claim Payments Report, you’re looking to see if your team's efforts is paying off as expected.
  
  Your team isn’t the only performance you want to monitor - we know you’re looking at payers too. Since your top payers are responsible for much of your practice revenue, monitor them for underpayments monthly by reviewing payments routinely and tracking how much you collect from each payer.

  We recommend running this report at least once a week to determine the status of your team's collections and re-allocate team priorities as needed. 

  • Unmatched Payments

  • Paper to Electronic EOB

• If you’ve implemented the RCM Best Practices and the team has developed good habits of using notes, queues, statuses, and issues - A/R reporting will illustrate exactly where collections are delayed in the reimbursement process and the blockers causing collections obstacles. Based on the data you enter with your notes, the A/R Report can be grouped by claim status, claim issues, or claim queue to pinpoint reimbursement problems and processing trends.

  For example, if you run an A/R report based on issue tag, you can figure out which issues are slowing down reimbursements such as COB issues, authorization problems, or medical necessity disputes.  Additionally, you can use this report to pivot your team to tackle problems such as inconsistent pricing or delayed processing based on priority or provider request. 

  By entering detailed notes, you can group the A/R report by claim status, claim issues, or claim queue to identify reimbursement problems and processing trends. Additionally, you can customize the report to display your accounts receivable data based on payer, facility, or practice. Effectively utilizing this report, along with customizing your tags and statuses, can guide your team towards specific reimbursement projects, such as end-of-the-month payment posting or payer-specific documentation requests.

  With the RCM, you can obtain detailed information about your outstanding A/R in just minutes. While other systems may inform you that you’re not receiving payments, using RCM Best Practices will help you understand the reasons behind those delays.
  

• Monitor your team's collections efficiency by tracking reimbursement percentages throughout the year. The A/R Waterfall report provides a detailed breakdown of collection percentage totals by payer, treatment, and practice, allowing for month-by-month comparisons. This tool is valuable for ensuring that your team is performing consistently over the year and for identifying any significant reimbursement delays. Additionally, this report can be an effective resource when addressing payers that are not providing consistent rates for the same services.