The Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative

1. The Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative A project of the Network of Behavioral Health Providers (NBHP) in collaboration with Mental Health America of Greater Houston (MHA) Thanks to the generosity of our funders, Houston Endowment Inc., The Meadows Foundation and United Way of Greater Houston Community Response Fund, this event is offered at no cost. NBHP Network of Behavioral Health Providers

2. Your Biggest Pain in the Neck—Claims Denials: How to Reduce Them Presented by: Mandie Eichenlaub Director, Managed Care MHMRA of Harris County May 23, 2014

3. Overview • Revenue Cycle Management • Before you can start you have to know where you are: • Data analytics • Understanding your patient population • Knowing your payor mix • How is your payment data currently tracked • From where can data be extracted • Analysis is important • Relationships are key • Set priorities based on the above

4. Revenue Cycle Management • Insurance verification • Should occur prior to the patient’s arrival. • Have online and electronic forms available – even if it’s just via e-mail – and ask for those forms prior to the appointment • Prior preparation speeds up the registration process • Ask questions of the insurance company before the appointment: • Is patient information correct? • Are prior authorizations necessary? • Verify covered services and CPT codes • Obtain information about co-pays, coinsurance and deductibles • Collect patient responsibility up front (if you have done proper insurance verification, this should be easy) • Notify patients ahead of time what their responsibility will be (and if payment plans are available, etc.)

5. Revenue Cycle Management (cont’d) • Clean claims • Know the codes, modifiers and other information required • Payor specific coding requirements lead most often to underpayments • Promptly handle denials (we will talk about this later) • Review payments for accuracy (underpayments can eat your lunch!)

6. Claims Follow Up • Essential to make sure you are paid timely • Some issues that require follow-up: • The claim was never received • The claim has been denied • The claim is pending information from the member • Do you need better training for front office staff? They are your first line of defense! • Do you understand your contract or the out of network benefits available to the patient?

7. Appealing Denied Claims • Follow up on claims 10 business days after electronic claims are billed and 15 days after paper bills to ensure the claim was received • Set a dollar threshold – when does it cost more in manpower to appeal a claim than you would recover in an appeal? • Review the denial reason – was it you or was it the company • Do not delay – stay on top of issues so they do not snowball • Get the patient’s help – especially for commercial insurance • Know your contract – understand Covered Services and Compensation

8. Be Efficient in Following Up • Be well prepared prior to your initial contact • NPI • TPI • Member information: name, DOB, policy number • Date(s) of service • Ask for the insurance representative’s information including direct call back information if available. • Get a call reference number

9. Be Efficient in Following Up (cont’d) • Ask lots of questions: • What is the status of the claim? • When is the claim scheduled for payment? • Where in the payment process is the claim? • What is the amount of the payment? • What is the check number? • Why is the claim taking so long to process? • Why is the claim pending or under review? • Where do I need to send medical records? • Who can I speak with to get this claim paid faster? • Why is the claim not being paid according to contract?

10. Be Efficient in Following Up (cont’d) • Be assertive and take appropriate action • Make sure your staff knows how to handle each of the denial reasons listed in slide 11 • Have appropriate policies in place that spell out how to talk to the insurance company about each one of these issues • Involve the patient but only as a last resort • Send a bill • Contact the patient by phone • Initiate a conference call with the insurer and the patient

11. Top Reasons Claims are Denied • FOR GROUPS: Roster not loaded properly • No claim on file • No referral on file • Missing or invalid CPT or HCPCS code • Timely filing • Member information is incorrect • Need primary insurance information/coordination of benefits • Information needed from the member • Service required prior authorization or precertification • Services not covered • No medical necessity • Medical records requested to pay the claim • Coverage has terminated • Accident details required (rarely for BH services)

12. Claims and Clinical Issue Resolution • Review outstanding accounts receivable (see spreadsheet) • Analyze claims data to identify issues • Work with contracted payors to resolve root cause claims issues • Identify new and existing issues with coding, billing and payment

13. When talking doesn’t work • Escalate within the payor organization • Demand letters to compliance and legal departments • Issue resolution with industry groups • Complaints to HHSC, TDI and CMS

14. Understanding Where You Are • Patient Population: • MHMRA Harris as an example: • 25,000 patients with open cases • 8,700 patients (approx 35%) have some form of third party coverage

15. Payor Blend amongst the 8700 • Amerigroup (30%) • United Behavioral Health (Optum) (23%) • Texas Children’s Health Plan (13%) • Community Health Choice (7%) • Molina (6%) • Blue Cross Blue Shield (5%) • Aetna (3%) • Superior (2%) • United (Commercial) (2%) • Cigna (2%) • Others (4.5%)

16. Patient Appointment Process, Impacts of CPT Code Changes MH Division

17. MHMRA Revenue Management Participants • Front Office Staff (at each of ~10 clinics – typically 1 Business Office Supervisor and 1-2 Business Office Specialist(s) in addition to reception staff, etc.) • Director, Managed Care • Payor relations, strategic development, contracting, high level issue resolution • Director, Revenue Management • Assistant Director • 3 staff - Billing/Claims Submission • 1 staff - Business Office Support • Manager, Payments • 4 staff - receipt of payments, financial reporting • Manager, Appeals • 4 staff - follow up on all denials, rejections, etc.

18. Discussion