In this episode, we are joined by BESLER’s Olga Barone-Allan and Roseline Guillaume to discuss how Medicare return to provider can improve a hospital’s accounts receivable
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Highlights of this episode include:
- What is “return to provider” and why is it significant?
- Key terms to understand when evaluating the return to provider
- Status and locations codes to be concerned about
- Recommendations for providers who are working with the return to provider file
Mike Passanante: Hi, this is Mike Passanante. And welcome back to the Hospital Finance Podcast.
Now, on today’s show, we are going to be discussing how Medicare return to provider can improve a hospital’s accounts receivable. And to do that, I am joined by Roseline Guillaume who is a Claims Processing Supervisor here at BESLER. And once again, I’m also joined by Olga Barone-Allan who is a Client Relations Manager.
Ladies, welcome to the show!
Roseline Guillaume: Thank you
Olga Barone-Allan: Hi!
Mike: So first, for those in our audience who may not be familiar with the term “return to provider,” can you briefly explain what that means and why it’s significant?
Olga: Return to provider is a functionality and/or an option in the Medicare system, this system, that will allow providers the opportunity to adjust a claim, edit it. It usually is like a placeholder. So after you submit your claims electronically for billing purposes, Medicare will allow you a certain amount of days based on the MAC within the jurisdiction to fix a claim that might be missing some kind of code, modifier, if the total charges don’t match up. And that allows the provider to expedite the claims without them being denied.
Mike: Got it! And how does that return to provider file help improve accounts receivable at a high level. We’ll get into some detail here, but at a high level, how does that help?
Olga: What it does is it helps the revenue team, and in particular Patient Financial Services, to avoid denials, first of all. It allows an opportunity for billers to assess the claim without it being processed and rejected. So they have that window of opportunity to go in and fix the edit on the claim that Medicare is scrubbing.
So it’s similar to a billing scrubber, but this is on the Medicare end that it scrubs the claim for the provider. It allows an opportunity based on number of days.
What it does also is it allows a manager or a director of the PFS area to provide feedback to other department or within its department to implement some process improvements. It allows also to add those processes to increase a clean claim rate. And a clean claim rate is a claim that is processed without any edits at all. And the turnaround rate is very important for the billing office. The higher clean claim rate is, the best practice is monitored based on that. So that allows the processes within the department to get quicker cash, decrease in AR days definitely, and it helps lessen the burden on the staff to have to rework claims multiple times, the same claims. So that is the purpose of the return to provider.
Mike: And then, you mentioned the idea of going in and sort of working that file. And to do that, there are a few key terms that are probably important for us to understand when you’re evaluating the return to provider file. Can you explain those to us?
Olga: The one in particular is the TB999 status location. I’ll let Roseline speak further into this. But this is the area where the billers can run reports and then get into the detail of those claims and work them on a regular basis.
It’s very key to work these on a regular basis because, after a certain period of time, the Medicare or the MAC will purge these claims. So, it can create a black hole that where the account on your receivable is aging, and you’re assuming that Medicare is processing the claim, in fact, Medicare has purged that account because you didn’t work it timely within the RTP status.
But to explain a little bit further about the TB status location, I will hand it over to Roseline.
Roseline: One of the key component to RTP’s which is a term that most account receivable that worked your trial balances are familiar with is with Medicare’s RTPs, they do follow a hierarchy of error reason codes. And every time you touch a claim, and you make a correction, the clock starts over. So it is important to have those errors looked at every day because when you have a MAC that can pay you within 7 days or 14 days, the longer you take to correct that claim, the longer that payment is going to take for the facility to collect on it.
So, the status locations are very important to monitor. And when you understand the process of the claim moving through the RTP, you will know which areas you’re most vulnerable in terms of keeping track of and documenting what you’re finding in terms of the RTPs themselves.
And it’s important to be familiar with the error reason codes themselves. They’re a narrative which is given by Medicare. And also, you can factor on trends also allowing you to improve your accounts receivable.
Mike: What are some of the status and location codes to be concerned about?
Roseline: Typically, as an account receivable person, you would want to make sure that you’re keeping track and be very aware of where your claims are moving. When they go into one of the status locations that are all alpha characters, those are typically comparable to a work list so to speak, or a work queue, that an individual has to manually look at those claims, review the errors, and then force them along through the system.
So, with every denial, if someone has a queue, you don’t know how large that queue is. Your claims are sitting there, and you really don’t have a clue to how long they’ve been there, they can get lost, like Olga mentioned, to a black hole. They can go into a black hole. And typically, those claims will require that you make a phone call. And Medicare will have to physically go in there and look at them and tell you, “Yes, we’ve seen some movement” even though you, on the other end as a provider, you may not see that the claims got moved.
So, the locations with all alpha characters are definitely very important to monitor.
Mike: I believe you have a few recommendations for providers around working with the return to provider file. Could you walk us through them?
Olga: Definitely! The recommendations that we’ve experienced in the past in our various roles previous to BESLER is setting up a report or a spreadsheet and monitoring the trends as Roseline mentioned. It’s important to understand the trends and the different status location and the movement because it does allow you to give feedback to other departments of registration, HIM case management, lab, of the various reasons why these claims do end up in an RTP status.
And the more you provide that feedback, that circle back, you’re helping your overall process to improve certain areas that you may not even be aware of. The key is not to get any claims RTP’d is to make sure to get the claims process in a clean status, meaning that you want the claim, as you submit it, to go through as a clean claim. And that is the ultimate goal.
Even though the RTP is a great opportunity that’s given to the providers, the ultimate goal is to get your clean claim rate as high as possible.
So, the trends that it allows you to track and compare can help you with that feedback to the various department.
What it also will do is the more you work these claims, the less likely your Medicare AR days will increase because you’re constantly working these accounts, and you’re making sure that they’re going through the process that you’re identifying.
Also, what we would recommend is occasionally, maybe quarterly, to take your ATB detail from our Medicare population and match it up. Make sure that you’re accounting for every single account so that if any account did get purged by the MAC, you know right away, and you’re not risking timely filing.
The worst thing is when your staff is assuming that all the claims were submitted to Medicare or in the Medicare system, Medicare goes ahead and purges those accounts, and your receivable is increasing in days because those claims are not being worked.
And it’s no fault of anyone because of the sheer volume. Outpatient or inpatient, it’s very hard to get a handle on that.
So, we recommend that working the RTP on a regular basis, keeping track of the status locations even if it’s a weekly tracking tool, understanding more of the education and understanding the various status location and how each status location is impacted by a previous status location, and just the overall reconciliation of your Medicare ATB for your Medicare claims against the Medicare system and making sure that all your claims are accounted for.
Roseline, do you have anything else to add?
Roseline: Yes. I just wanted to add in… one of the benefits of tracking your status locations via the Claim Summary Totals Inquiry is the fact that it’s an excellent tool for the provider to predict the monies that’s coming, number one.
And also, from experience, I can say you may be able to catch technical errors on the Medicare—you know, this is just a system. It’s automated in, but it can break down at any given point. And claims can get hung in those status locations. You’re anticipating this money, and it just never comes.
So, when you’re tracking the movement of those status locations, if there’s a technical issue to why your checks are not coming through as expected, then you’re able to call Medicare on it. They’ll take a look at it, and they’ll let you know whether you have issues. And it’s a good way of knowing whether there’s going to be any withholdings on your money. And you can see that. You expected $3 million, and then you only get $400,000. You have a way of addressing that issue and get an answer from Medicare.
Mike: Olga and Roseline, thank you for coming by the show today and helping us all understand more about Medicare return to provider.
Olga: Thank you Mike.
Roseline: Thank you Mike.