Importance of Periodic Reporting for Efficiency in Claims Management

Effective claims management is crucial for any organization involved in the healthcare industry. Periodic reporting allows you to monitor trends, identify issues, and implement improvements, thereby enhancing the efficiency of the claims process. Two key types of reports that can greatly assist in this process are Billing by Procedure and Claims Corrections reports.

Billing by Procedure Report:

What is a Billing by Procedure Report?

A Billing by Procedure Report provides an overview of claims submitted to insurance companies, categorized by the specific medical procedures performed grouped by their HCPCS/CPT code. This report helps in analyzing which procedures are frequently billed and the corresponding revenue generated.

How to run the Billing by Procedure report:

1. Click on Reporting on the left-hand navigation menu.
2. If you have not already generated a report, a Generate Report box will appear immediately. 
3. In the Generate Report window, set the following:
   1. Report: Billed Charges by Procedure 
   2. Claim Group: All (This can be changed to a specified claim group)
   3. Time Frame: Past 30 Days
   4. Select by: Last Transmit
4. Once the criteria is selected, click the Generate button to generate the report.
5. To create a new report, simply click  New Report  on the top of the screen.

Why Run Billing by Procedure Reports Periodically?

1. Identify Revenue Trends:
   • Running these reports periodically (weekly or monthly) helps billers identify trends in billing by procedure, indicating which services are in high demand and which might be declining.
2. Revenue Optimization:
   • By understanding billing trends, the provider can allocate resources more effectively, focusing on procedures that generate higher revenue, and ensuring proper coding and documentation for these procedures.
3.  Cost Control:
   • By monitoring billing by procedure, providers can control costs by identifying procedures that may be costly to perform but are not generating sufficient revenue.
   • Running these reports periodically (weekly or monthly) helps identify trends in billing by procedure, indicating which services are in high demand and which might be declining.

Analysis of the Billing by Procedure Report:

• In the last 30 days, there have been a total of 32 instances of procedure code 99213, with a cumulative billing amount of $2,257.25.
• The total billing for all procedures during this period is $4,998.15.

Percentage of Total Billing Represented by Procedure 99213:

To find the percentage of the total billing represented by procedure 99213:

(Procedure 99213 Amount / Total Billing Amount) * 100

= ($2,257.25 / $4,998.15) * 100

= 45.15%

Interpretations and Considerations:

• Procedure Contribution: Procedure 99213 represents 45.15% of the total billing for the last 30 days. This indicates that it is a significant contributor to the healthcare facility's revenue during this period.
• Revenue Stream Analysis: The data suggests that procedure 99213 is a vital revenue stream. Understanding this can help in budget planning, ensuring that resources and staffing levels are allocated appropriately to handle this high-volume procedure efficiently.
• Coding and Documentation: Since procedure 99213 is a substantial portion of the total billing, it's crucial to ensure accurate coding and proper documentation for these claims. Any errors or discrepancies in billing this procedure can have a significant financial impact.
• Financial Forecasting: This data can be used for financial forecasting. Knowing that 99213 represents nearly half of the total billing, the organization can project its revenue and allocate resources accordingly.
• Budget Allocation: In budget planning, it's essential to allocate funds for resources, training, and technology improvements that support the efficient processing of procedure 99213 claims. A large percentage of the budget may need to be dedicated to this area.
• Quality Assurance: Given the financial importance of 99213, quality assurance measures should be in place to ensure that the documentation and coding meet all necessary criteria. This can help prevent claim rejections and denials.
• Staffing: Depending on the volume of 99213 procedures, staffing levels in the billing and coding departments may need to be adjusted to handle the workload effectively.

In summary, procedure 99213 represents a significant portion of the total billing, and this information is vital for budget planning, resource allocation, quality control, and overall financial management. Careful attention to this high-billing procedure is essential to maintain revenue stability and efficiency in claims management.

Claims Corrections Report:

What is a Claims Corrections Report?

A Claims Corrections Report provides details of claims that required corrections due to errors or discrepancies. It helps in tracking the number of claims that needed adjustments, the reasons behind these corrections, and their financial impact.

How to run a Claims Corrections Report:

1. Click on Reporting on the left-hand navigation menu.
2. If you have not already generated a report, a Generate Report box will appear immediately. 
3. In the Generate Report box, set the following:
   1. Report: Claims Corrections
   2. User: All
   3. Claim Group: All (This can be changed to a specified claim group)
   4. Time Frame: Past 30 Days
4. Once the criteria is selected, click the Generate button to generate the report.
5. To create a new report, simply click  New Report  on the top of the screen.

Why Run Claims Corrections Reports Periodically?

1. Identification of Error Trends: 
   • By analyzing the Claims Corrections report, you can identify common types of errors that require corrections. This retrospective view can help you understand where the issues lie, allowing you to implement preventive measures to reduce future occurrences of those specific errors.
2. Process Improvement: 
   • When you identify recurring errors through the Claims Corrections report, you can focus on improving the claims submission and processing processes. This, in turn, can reduce the likelihood of errors in the future.
3. Training and Education: 
   • The report can also guide you in providing targeted training and education to your staff or providers who may be making consistent errors. This proactive approach can help prevent errors from happening in the first place.

Analysis of the Claims Corrections Report:

In the Claims Corrections Report, there were a total of twelve claims corrections. The two largest correction categories were:

• Document Attachments Errors (3 Claims): These corrections were related to not attaching the required documents, even though the attachment dropdown indicated the need for documents in the claim.
• Payer Name Errors (2 Claims): These corrections were associated with entering the wrong payer name in the field for the patient's insurance.

Interpretations and Considerations:

Document Handling and Workflow:

• Document attachment errors may indicate a need for better workflow procedures or staff training in claims processing. Ensuring that the attachment dropdown accurately reflects the requirements and that staff members are well-versed in attaching the necessary documents can prevent delays and corrections.

Compliance and Documentation Control:

• The recurring document attachment issues suggest that there might be a need for better control and compliance measures related to documentation. Improved oversight and adherence to documentation requirements can reduce errors and improve claims processing efficiency.

Payer Information Accuracy:

• Errors in payer name entries are critical, as they can lead to misdirected claims. These errors may indicate a need for staff training on the importance of accurate data entry in patient insurance information fields.

Quality Assurance and Training:

• To prevent payer name errors, investing in quality assurance measures and ongoing staff training is crucial. This can help ensure that patient insurance information is consistently and accurately recorded.

Resource Allocation:

• Budget planning should consider allocating resources for training and quality control measures to reduce errors. Reducing errors can lead to fewer corrections, quicker claims processing, and improved cash flow.

Efficiency and Productivity:

• Reducing corrections related to document attachments and payer information can significantly enhance the efficiency of the claims processing workflow. This, in turn, can help improve the overall productivity of the claims management department.

Claim Reimbursement Time:

• Minimizing errors and corrections can lead to quicker claim reimbursement. This can be especially important for maintaining consistent cash flow and financial stability.

In summary, the Claims Corrections Report highlights specific areas that require attention for improved claims processing efficiency, compliance, and accuracy. Budget planning should consider investments in staff training, quality control measures, and workflow improvements to reduce errors and corrections, ultimately enhancing the financial health of the healthcare organization.