A/R PROCESS
Turning over accounts receivable into cash
requires a systematic, planned and focused approach.
Each effort must be aimed at eliminating or
resolving the problem instead of merely gathering
information. Documentation of the findings is
critical as it helps as a reference tool for the
future.
Accounts Receivable Workflow
Evolving Benchmarks by Payers:
The first step in understanding the different
payers is to establish benchmarks for their
processing. This is usually obtained from historical
information like the earlier paid EOB’s (Explanation
of Benefits), Denials mails, Manuals and
Newsletters. The benchmark should address:
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• Time frame to process the claim by the
carrier.
• Requirements such as provider number, tax
ID number, pay to address etc.
• Check lists for the requirement of the
carrier for all blocks in the CMS-1500
(HCFA-1500) claim form.
• Attachments, referrals and additional
documentation.
• Different plans deployed by the payer and
card copies of the plans. |
Identification of Claims Outside Benchmark:
Once the benchmarks are established, it is
essential to identify medical claims falling outside
the benchmark on a weekly basis to quantify the
volume and value of such claims. This can establish
and identify a global pattern, which may affect the
majority of claims.
Prioritize Medical Claims to Work On:
Once the medical claims outside the benchmark
have been identified, the next step is to identify
the claims to work on. This is done with the help of
reports of claims by payer type and can then be
prioritized and resolved. While prioritizing the
medical claims, the fillings limits by the carrier
will have to be considered which is very important.
Identifying of Problems:
This is the most important step. The problems
and resolutions to the various scenarios are
analyzed, understood and documented on paper.
Because of the complex regulations governing the
medical insurance business, Insurance companies have
devised various complex rules before paying a claim.
The problem could be an internal data entry error,
incorrect information on the claim, non-covered
benefit, unauthorized procedures and services,
procedure or service not medical necessity,
pre-existing condition, termination of coverage,
failure to obtain preauthorization, out-of-network
provider used, lower level of care could have been
provided etc.
When the problems are researched for solutions we
document the sources of information. It is also
essential for resolved problems to be applied to
other claims pending to the carrier to ensure that
the same problem does not recur.
Prepare an Action Plan:
As soon as we identify the problem, the next step is
to confirm the findings. This is done by giving it
to the calling team who will confirm the
understanding of the problem and gather additional
information on the reasons that have caused the
medical claims to get rejected.
Preparing an action plan will involve deciding
the ways to get the claims paid faster. An action
plan will decide the steps to be taken, including
sending physicians enrollment forms, change of
address letters, additional documentation, and
corrected claims.
Implement the Solution to All Outstanding
Claims:
Once the action plan has been drafted and
confirmed the next step is to implement the solution
to all the outstanding claims that fit the criteria
for such action. This is vital since problems
falling into the same category are fixed at one go.
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