Mastering Claim.MD Reports: A Guide to Informed Billing Management

All the reports listed below are found in the Reporting page which is located in the left navigation menu. 

Billed Charges by Payer:

Why Run this Report:

• Monitor revenue distribution: Gain insights into how your revenue is distributed among different payers.
• Identify high-paying payers: Discover which payers contribute the most to your revenue and focus on building stronger relationships with them.
• Detect underperforming payers: Identify payers with lower billed charges and explore opportunities to improve reimbursement rates or negotiate better contracts.

Analysis:

Higher Valued Payers:

Aetna:

• Quantity: 14 claims
• Billed Amount: $1,350.00
• Percentage of Total Billed Charges: 27.01%

Humana:

• Quantity: 6 claims
• Billed Amount: $877.00
• Percentage of Total Billed Charges: 17.55%

Analysis:  These payers account for a significant portion of the billed charges in the last thirty days.

Medium Valued Payers:

CIGNA:

• Quantity: 8 claims
• Billed Amount: $813.00
• Percentage of Total Billed Charges: 16.27%

TX Medicare Part B:

• Quantity: 10 claims
• Billed Amount: $738.15
• Percentage of Total Billed Charges: 14.77%

United Health Care:

• Quantity: 7 claims
• Billed Amount: $620.00
• Percentage of Total Billed Charges: 12.41%

Analysis:  These payers represent a substantial percentage of the billed charges in the last thirty days.

Lower Valued Payers:

TX BCBS:

• Quantity: 3 claims
• Billed Amount: $355.00
• Percentage of Total Billed Charges: 7.10%

UMR - Wausau:

• Quantity: 1 claim
• Billed Amount: $145.00
• Percentage of Total Billed Charges: 2.90%

ANTHEM_CA:

• Quantity: 1 claim
• Billed Amount: $100.00
• Percentage of Total Billed Charges: 2.00%

Analysis: These payers collectively contribute a smaller percentage of the total billed charges but still play a role in maintaining a comprehensive revenue stream. Efficient management of claims and adherence to payer-specific requirements remains essential to optimize revenue from all sources.

Implications:

• Revenue Dependency: Large payers like Aetna contribute significantly to billed charges. Cultivating strong relationships with them is critical to ensure prompt payments and a stable revenue stream.
• Diverse Payer Portfolio: Medium-valued payers, including CIGNA, TX Medicare Part B, and United Health Care, offer revenue diversification. Effective management of claims submitted to these payers is essential for consistent income.

Considerations:

• Building Strong Relations: Develop and maintain strong, proactive relationships with large and medium payers. Establish direct communication channels and address their specific needs promptly.
• Training and Compliance: Ensure your billing team is well-versed in payer-specific requirements and coding procedures for large and medium payers. Provide training to reduce claim rejections.
• Revenue Diversification: Explore strategies to diversify payer sources to reduce dependency on a single or a few high-valued payers, ensuring more financial stability.

Billed Charges by Billing Provider:

Why Run this Report:

• Assess provider productivity: Evaluate the billing performance of individual providers in your practice.
• Identify top performers: Recognize which providers are generating the most revenue and potentially share best practices among the team.
• Address underperformers: Identify providers with lower billed charges and provide additional training or support to improve their billing efficiency.

Payer Modified CPT/HCPC:

Why Run this Report:

• Maintain coding accuracy: Ensure that your claims match the CPT/HCPC codes specified by payers to prevent claim denials.
• Detect discrepancies: Identify instances where payers have modified the codes, enabling you to reconcile and resubmit claims correctly.
• Reduce claim rejections: By aligning your billing codes with payer-specific requirements, you can minimize claim rejections and improve reimbursement rates.

Transmits:

Why Run this Report:

• Track claim submission status: Monitor the status of claims submitted to payers, including those that have been accepted, rejected, or are still pending.
• Identify issues early: Early detection of claim rejections allows for quick resolution and resubmission, minimizing revenue delays.
• Improve claims management: Analyze patterns in claim status to refine your billing processes and reduce rejections.

Analysis:

• Over the past month, claim transmissions have generally proceeded smoothly, reflecting a consistent workflow.
• However, a notable deviation occurred on November 1st, marked by a sudden surge in re-transmitted claims.
• The spike suggests a specific issue or bottleneck on that particular date, warranting a closer examination of the underlying causes.

Implications:

• Increased Workload: The surge in re-transmitted claims indicates an additional workload for the team, potentially affecting efficiency.
• System Glitch: The concentrated spike may be indicative of a system glitch or error on November 1st, demanding immediate attention to prevent future disruptions.
• Financial Impact: The delay and reprocessing of claims can have financial implications, necessitating a review of potential revenue loss or delayed reimbursements.

Considerations:

• Root Cause Analysis: Conduct a thorough investigation into the specific reasons behind the spike on November 1st to address the root cause effectively.
• Process Optimization: Identify areas in the claims transmission process that may require optimization or additional resources to prevent similar spikes in the future.
• Communication Plan: Develop a communication plan to inform stakeholders about the temporary disruption and the steps being taken to resolve the issue, ensuring transparency and managing expectations.

Top Rejections:

Why Run this Report:

• Address common denials: Identify the most frequent reasons for claim rejections and take proactive steps to rectify these issues.
• Minimize revenue loss: By addressing common rejections, you can reduce the financial impact of denied claims and optimize revenue.
• Enhance claim accuracy: Implement corrective measures to ensure that claims are error-free and compliant with payer requirements.

Analysis:

• The largest portion of rejections is due to the "Attachment Type [AM]" where no pages have been uploaded, constituting 3 out of the total rejections. This indicates a recurring issue that needs immediate attention.
• Other notable rejections include "Invalid Patient State," "Diagnoses [T1490] valid but not for this date," and "ERA DENIAL - Claim not covered by this payer/contractor." While these have a smaller quantity, they represent different challenges in data accuracy and payer-specific issues.

Implications:

Operational Delays and Revenue Impact:

• The frequent rejection related to "Attachment Type [AM]" suggests potential operational delays and impacts on revenue due to incomplete documentation.
• Inaccuracies such as "Invalid Patient State" and "Diagnoses [T1490] valid but not for this date" may lead to prolonged claims processing, affecting revenue cycles.

Contractual and Compliance Risks:

• The "ERA DENIAL - Claim not covered by this payer/contractor" rejection indicates potential risks to contractual agreements with payers. Non-compliance may lead to revenue loss and strained payer relationships.

Data Accuracy Challenges:

• Various rejection reasons, including "Invalid Patient State" and "Tax ID must be 9 digits," point to challenges in maintaining accurate patient and financial information.
• Addressing data accuracy is crucial for reducing rejections, ensuring timely reimbursements, and mitigating compliance risks.

Considerations:

Enhanced Attachment Management:

• Implement a systematic approach to ensure all claims requiring attachments have the necessary documentation uploaded.
• Develop training programs for staff to emphasize the importance of complete documentation for claims submission.

Data Validation and Training:

• Enhance data validation processes to reduce errors in patient state, diagnoses, and other critical fields.
• Provide ongoing training to staff on accurate data entry practices, focusing on key areas leading to rejection.

Payer-Specific Compliance Measures:

• Regularly update and educate staff on payer-specific requirements to address issues like "ERA DENIAL" and other payer-related rejections.
• Establish a proactive communication channel with payers to resolve disputes and align claims submissions with their expectations.

Age of Billing:

Why Run this Report:

• Monitor claim aging: Keep track of how long claims have been outstanding to prevent overdue claims from affecting your revenue cycle.
• Prioritize collections: Focus on collecting older claims first, as they are more likely to face denials or payment delays.
• Optimize workflow: Use aging data to refine your billing processes and reduce the time it takes to receive payments.

Analysis:

Service Dates and Claim Aging:

• Most claims have service dates from October 2022.
• Over 50 claims are over a year old, which is notably high but explained by the presence of older data in the demo database.

Implications:

Delayed Revenue Recognition:

• Claims with service dates from October 2022 indicate a billing period well over a year ago, leading to delayed revenue recognition.
• Over 50 claims aged over a year suggest potential delays in reimbursement and a backlog in revenue realization.

Data Accuracy and Clean-up:

• Service dates from October 2022 suggest outdated billing practices, emphasizing the need for data accuracy and clean-up.
• Aged claims may significantly impact financial reporting accuracy and should be prioritized for resolution to ensure a clear financial picture.

Operational Efficiency Challenges:

• Older claims may indicate inefficiencies in the revenue cycle or challenges in follow-up processes over an extended period.
• Streamlining operations and implementing proactive follow-up strategies are crucial to enhance efficiency and reduce the backlog of aged claims.

Considerations:

Urgent Claim Audits:

• Conduct urgent audits of claims to identify and address the backlog of aged claims promptly.
• Establish a focused effort to clean up and resolve older claims, ensuring accurate financial reporting despite the delayed processing.

Rapid Follow-up Procedures:

• Implement expedited follow-up procedures for aged claims, including systematic reviews and timely resubmissions.
• Provide immediate training or allocate additional resources to staff involved in follow-up activities to address the urgency of aged claims.

Data Cleanup Protocols:

• Develop urgent protocols for ongoing data cleanup to rectify the outdated information in the database promptly.
• Regularly review and update billing practices, placing a special emphasis on resolving the accumulation of aged claims to prevent such delays in the future.

Payment / Adjustments:

Why Run this Report:

• Financial visibility: Gain a clear understanding of how much revenue you've earned and the amount that has been adjusted.
• Budget and plan: Use payment and adjustment data to budget and plan for your practice's financial needs.
• Identify discrepancies: Detect any inconsistencies in payments or adjustments and take action to reconcile and correct them.

Analysis Summary:

Amount Paid: $1782.40 (Paid):

The total payment received for the claim is $1782.40.

Charge exceeds fee schedule / maximum allowable or contracted/legislated fee arrangement: $570.60 (CO-45):

The claim has a payment adjustment of $570.60 due to the billed charge exceeding the fee schedule or contracted/legislated fee arrangement.

Coinsurance Amount (PR-2): $340.00:

The patient is responsible for a coinsurance amount of $340.00 as part of their cost-sharing.

Co-payment Amount (PR-3): $160.00:

The patient is also responsible for a co-payment amount of $160.00.

Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor (OA-109): $48.00:

The claim is not covered by the current payer/contractor, and there is an additional adjustment of $48.00. The claim must be sent to the correct payer/contractor for processing.

Implications:

Payment Discrepancy:

• The payment of $1782.40 indicates the amount reimbursed by the payer.
• The payment adjustment of $570.60 suggests that the billed charge exceeded the allowed amount, impacting the overall reimbursement.

Patient Financial Responsibility:

• The patient has a combined financial responsibility of $500.00, consisting of a $340.00 coinsurance amount and a $160.00 co-payment amount.

Claim Routing Issue:

• The additional adjustment of $48.00 indicates that the claim was not covered by the current payer/contractor, emphasizing a potential issue with claim routing or payer identification.

Considerations:

Review Fee Schedule and Contracts:

• Evaluate the fee schedule and contracts with the payer to understand why the billed charge exceeded the allowed amount.
• Consider renegotiating contracts if necessary or addressing any discrepancies in fee schedules.

Patient Communication:

• Clearly communicate the coinsurance and co-payment amounts to the patient, providing transparent information about their financial responsibility.
• Implement processes to verify and educate patients on their financial obligations before services are rendered.

Claim Routing Process:

• Investigate the reason for the claim not being covered by the current payer/contractor.
• Review and enhance the claim routing process to ensure accurate identification of the correct payer/contractor and minimize such issues in the future.

Revenue Cycle Management:

• Continuously monitor and analyze payment and adjustment patterns to identify opportunities for optimizing the revenue cycle.
• Implement strategies to minimize payment adjustments due to exceeding fee schedules, ensuring accurate billing and reimbursement.

Time till payment:

Why Run this Report:

• Manage cash flow: Understand the time it takes to receive payments after claim submission to optimize your practice's cash flow.
• Identify slow payers: Recognize payers that have longer payment cycles and consider renegotiating contracts or pursuing alternative payment options.
• Improve financial planning: Use payment time data to better forecast and plan for your practice's financial needs.

Patient Demographics:

Why Run this Report:

• Obtain a comprehensive overview of the patient population through demographic insights.
• Leverage demographic data to tailor healthcare strategies and improve patient care and engagement.
• Ensure compliance with regulatory requirements by maintaining accurate patient demographic information.

Claim Activity:

Why Run this Report:

• Evaluate claims processing efficiency by tracking statuses, including approvals, deletions, archiving, and rejections.
• Monitor claim statuses to assess financial health, identifying potential revenue loss from rejected or deleted claims.
• Conduct audits and ensure compliance with claims processing protocols.

In the Claims Activity Report, "deleted" claims pertain to those never transmitted and subsequently archived, including rejected claims. In contrast, "archived" claims are those successfully transmitted and acknowledged by the payer. This report serves as an efficient tool to manage and access archived claims without navigating to the Search page, streamlining the process of identifying valid and acknowledged claims for analysis or reference. Understanding this distinction enhances the overall efficiency of claims management.

Analysis of Claims Activity Report:

High Approval Rate:

• The significant quantity of 51 claims marked as "Transmit Approved" indicates a high success rate in claim transmissions, showcasing an efficient and effective submission process.

Low Rejection Rate:

• The low quantity of 1 claim marked as "Rejected" suggests a robust claims validation process, resulting in minimal rejections and potential revenue loss.

Limited Deletions and Archiving:

• The low quantities of 3 claims marked as "Deleted" and 1 as "Archived" indicate a minimal number of claims either not transmitted or rejected and subsequently archived. This highlights a streamlined approach to managing rejected claims.

Implications:

Operational Efficiency:

• The high approval rate implies a well-organized and efficient claims submission process, contributing to operational efficiency and potentially faster reimbursement cycles.

Cost Savings:

• Low rejection rates minimize the need for extensive appeals or re-submissions, contributing to cost savings in terms of time and resources.

Data Integrity and Compliance:

• The limited number of deleted and archived claims indicates a focus on data integrity and compliance, ensuring that only valid and acknowledged claims are retained.

Considerations:

Continuous Process Improvement:

• Despite a high approval rate, ongoing evaluation of the claims submission process is crucial to identify areas for improvement and maintain efficiency.

Enhanced Rejection Analysis:

• Investigate the cause of the rejected claim to address potential patterns or issues affecting submission success.

Training and Communication:

• Ensure staff is well-trained on claims submission procedures to maintain the high approval rate and minimize errors leading to rejections or deletions.

Average Payment Comparison by Procedure:

Why Run this Report:

• Benchmark average payment and billing amounts for procedures against global and internal averages.
• Analyze average payment and billing data to optimize the revenue cycle.
• Gain insights into payer negotiations by comparing average payments across procedures.

Analysis (only Procedure 93000):

Significant Discrepancy in Global Averages:

• The average paid amount for Procedure 93000 is notably higher at $53.19 compared to the global average paid of $15.83. This substantial difference raises questions about potential negotiation opportunities with payers to align the procedure's reimbursement more closely with the global average.

Higher Average Billed Than Global Average:

• The average billed amount for Procedure 93000 is $71.84, exceeding the global average billed of $63.96. While the higher billing amount might indicate revenue optimization, it also suggests the importance of evaluating the impact on reimbursement rates and potential payer negotiations.

Efficiency Gap Between Average Billed and Average Paid:

• The gap between the average billed and average paid amounts for Procedure 93000 is significant ($71.84 billed vs. $53.19 paid). This highlights a potential area for optimizing revenue cycle management, emphasizing the need for strategies to bridge this efficiency gap.

Implications:

Negotiation Opportunities:

• The substantial difference between the average paid and global average paid suggests a potential opportunity for negotiation with payers to bring the reimbursement rates for Procedure 93000 more in line with the global average.

Billing Strategy Impact on Reimbursement:

• The higher average billed amount implies a revenue optimization strategy, but its impact on reimbursement rates should be carefully evaluated. Considerations should be given to potential effects on payer relationships and reimbursement negotiations.

Revenue Cycle Efficiency Enhancement:

• The efficiency gap between average billed and average paid indicates a potential area for revenue cycle optimization. Enhancing processes to narrow this gap can lead to more accurate reimbursement and improved financial performance.

Considerations:

Payer Communication and Contract Review:

• Initiate communication with payers to discuss and negotiate reimbursement rates for Procedure 93000. A comprehensive review of contracts can identify opportunities to align payments more closely with the global average.

Billing Strategy Alignment:

• Evaluate the impact of the higher average billed amount on the overall revenue strategy. Ensure that the billing strategy aligns with organizational goals and consider adjustments if necessary.

Efficiency Measures Implementation:

• Implement measures to enhance the efficiency of the revenue cycle, specifically focusing on reducing the gap between average billed and average paid amounts for Procedure 93000. This may involve process improvements, staff training, or technology enhancements.

Appeal Activity (Faxed Appeals, Mailed Appeals, Electronic Appeals, Downloaded Appeals):

Why Run this Report:

• Assess the efficiency of the appeal process by tracking volume and method of appeals.
• Analyze appeal types (faxed, mailed, electronic, downloaded) and their success rates.
• Explore opportunities to enhance technology integration for appeals, considering the volume of electronic and downloaded appeals.