Using case management to improve claims payment - patient account management

Healthcare Financial Management, May, 1995 by Julie A. Micheletti, Steve Mevert, Thomas J. Shlala

Whenever healthcare professionals contemplate a change in treatment or continued treatment of a patient after the authorized course of treatment has expired, clinical data supporting their decisions are sent to the case managers along with the claims processing data involving the payer's contracting or review requirements. These data are used by the case manager to obtain additional treatment authorization.

Trending analysis of claims is conducted regularly by the claims office. This analysis includes assessment of payment denials, disputes involving claims, review procedures used by payers, and so forth. Data from trending analysis are shared with claims processing personnel, the intake coordinator, the case manager, and healthcare professionals to inform provider staff members of the treatment and billing practices that payers do and do not permit. This process minimizes the need to gather additional documentation to support a claim and enter into a lengthy claims appeals process. It also reduces losses of payment and improves cash flow by helping providers understand why payments were denied so they can prevent similar denials in the future.

To quickly identify lost claims, case managers call payers within two to three weeks of submission to verify that claims have been received. Case managers follow up claims that have not been paid in a timely fashion by tracking the length of time between claims submission and payment and interacting with payers whenever claims have been referred for further review. Finally, case managers negotiate discounts with payers before treatment begins and challenge any effort by payers to impose discounts on therapies that already have been provided. Individuals chosen as case managers, therefore, should have demonstrated negotiating skills. They should be comfortable working with payers on a continual basis and discussing monetary issues.

Claims processing strategies

The following actions illustrate what may be done to streamline claims processing by providers who have adopted a proactive case management program. The feasibility and desirability of instituting each of these actions will depend on the size and organization of a given provider and the nature of the case management program.

Bill for expensive therapies in small dollar increments. When the case management activity demonstrates that a given payer automatically refers claims totaling more than $5,000 for extensive review, the provider may choose to submit individual claims amounting to $1,000 or less every week rather than wait to submit a claim for the full amount at the end of five weeks and risk delay in payment.

Develop protocols that identify data needed to submit a clean claim to a payer. Payers' review strategies and payment policies are not uniform. For example, one payer may wish to see a copy of the plan of care, another may want a copy of the initial assessment of the patient, and a third may require information shared during patient care conferences conducted about each patient.