The Avea Way: Best Practices for Billing Managers

  • Updated

Objective

As a billing team lead or manager, your goals are focused on removing roadblocks that impede processes, mentoring & up-skilling your team, and ensuring the daily activities are on track to help the departments, and ultimately the company, achieve their goals.

Responsible

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 AveaOffice configuration supports your processes.

Team Leads typically balance serving as subject matter experts in their particular department/area, ensuring process adherence while also doing a portion of the daily activities. Team leads should be 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.

 

Team Leads and Managers following the Avea Way will organize their daily, weekly, and monthly activities into three categories Audit, Analyze, Act.

 

Daily

Weekly

Monthly

Team Lead

Act

Work the Management Center Dashboard Tiles to green every day

 

Generally, team leads are following this on a daily basis and checking in with individuals as needed.

Audit

Audit claims for various team members and various queues using random sampling to verify queues, status and issues are used and notes are diligently kept and provide quality information.

Analyze

Act

Continuously train and re-train staff on proper processes and weak areas identified during claim audits

Analyze

Billing Manager

 

Audit

 

Analyze

 

Act

Update processes as needed based on root cause analysis and staff feedback.

A great method for root cause analysis is called Fishbone Root Cause Analysis.

Optimize AveaOffice configuration based on your analytics and new scenarios that should be represented in Queues, Statuses and Issues.

Retire, Update or Add new QSIs regularly so they are easy to use which will make process adoption successful.

Analyze Forecasting/Cash

Analyze Team and Payer Performance

 
 

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.

Tier 1

Tier 2

Portal Checks 

Prior Authorization discrepancies 

Initial Claim Calls 

Inconsistent reimbursement rates and pricing issues 

Confirming status of additional inquiries or reviews  

Payer system issues 

Requesting EOB's or reimbursement data 

Benefits misquotes 

 

Contracting discrepancies

 
 

The Management Center

Location: Navigation Menu > Management Center

Organization Dashboard

The organization dashboard is a powerful tool to help you manage your team to key performance indicators because the dashboard follows the entire revenue cycle of a behavioral health claim and surfaces 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 day to day - it’s all there.

We recommend the team be working those tiles to zero on a daily basis. 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.

Patients With New Claims Pending

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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.

Patients with Claim Corrections Pending

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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 be monitoring 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.

Claims Rejected - Pending Review

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After claims are submitted to the clearinghouse, if they are rejected, they will show in the “Claims Rejected Pending Review” tile. Clicking into this tile shows all claims that have a rejected status. If the claim is actually processing with the payer just fine, you can edit the payer status to Accepted. If the claim needs to be corrected and resubmitted, it will remove 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

Tips 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 be helpful for discussing trends related to current issues.

Claims Ready for Review/Submit

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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 > Submit Claims where you can preview the individual claims.

Insurance Payments in Review

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Electronic enrollments allow AveaOffice 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 prior to AveaOffice, 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. 

Tips for Troubleshooting:

  • Filter the Claim Payments Report by Payment Matching Status “Unmatched Payments” for any date range to get summary totals or detail. 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.

Insurance Payment Collection in Review

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Reviewing and resolving payment collections that are potential duplicates or misposted 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 amount mismatches for the line-item vs the payment totals are usually flagged for review

Insurance Claims Out of Balance

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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 detail, 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 there are no payments 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.

Claims Follow-Up Overdue & Claims Follow-up Today

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As a team lead, you’ll know the team isn’t following the Avea Way 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 AveaOffice - because your manual processes were holding you back from scaling with your growth but they were comfortable. With Avea, 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.

Organization Dashboard vs Reporting

The Organization Dashboard is great for telling you what’s happening and where in the revenue cycle, however, it’s not going to be the best way to analyze why it’s happening or help you understand trends. The Organization Dashboard is more of a day-to-day activities management tool whereas reporting is for the pulse and for problem-solving issues at their source.

Dashboard Tiles

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

Reporting

The Reports in AveaOffice 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 Avea Way, however, these suggestions don’t accurately reflect all objectives and options of these particular reports.

Claim Submission Report

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

Billing Agent Activity Report

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. 

Claim Status Report

The Claim Status Report 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 Report 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

Claim Payments Report

This 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 the outcome of your team's efforts are 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.

Avea recommends 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

A/R Insurance Report

If you’ve implemented the Avea Way 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 can 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. 

Also, you can adjust the report to show your accounts receivable data based on the payer, facility, or practice.  Utilizing this report and customizing your tags and statuses effectively can help you pivot your team to specific reimbursement projects such as end-of-the-month payment posting or payer-specific documentation requests.  

Other systems tell you that you’re not getting paid, but using the Avea Way, you’ll know why you’re not getting paid.

With AveaOffice, you can get this specific information around your outstanding A/R within minutes.

 

A/R Waterfall Report

Track your team's collections efficiency by tracking the reimbursement percentages throughout the year. The A/R Waterfall report breaks down the collection percentage totals per payer, per treatment, and per practice to give you a month-by-month comparison.  This is a handy way to ensure that your team is performing consistently across the year and hasn't run into any major reimbursement hold-ups. This report is also a great tool to use against payers that are not paying consistent rates for the same services! 

 

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