Handy Tips from a Successful Home Infusion Collector
By: Cheri Sciacca, Mediware Reimbursement Services
With the challenging margins most providers of home infusion services face, it is crucial that your collections staff follow up with claims in a timely manner to ensure that you are reimbursed in full for the complex services provided. A day in the life of a collector can be challenging given the multiple tasks and strict filing limits that must be followed. See below for our tips from the perspective of the home infusion collector to ensure your day is prioritized by activities that yield the highest return, which will ultimately drive positive cash flow.
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• Organization: It is crucial that the collection staff have an organized plan of what activities they are responsible for and prioritize those tasks so that each day is productive. Each day the collections team will need to run daily reports concerning follow-up, claims past due, partial pay reports, denial reports, and claims with no follow up. Depending on what software system you use, it is very easy to have the system help with these reports and in some cases, auto-schedule the reports so they are ready when you are. Using these reports will help the collector know which claims require immediate attention.
• Explanation of Benefits (EOB) Follow-Up: It is also important to work EOBs in a timely fashion. Depending on the specific payer, you may only have a limited time to respond. Once the denial or payment is posted to your claims or in your account, the collections team will need to look at these within 48-72 hours. Analyzing the issues and payer codes immediately will help resolve problems and provide a steady cash flow. Procrastinating on this process will ultimately grow your outstanding A/R and may even result in bad debt.
• Managing Appeals: When managing appeals, it is important to know what the payer expects for the appeal and what the timely appeal limits are. Some payers have an appeal form that will need to be attached to the claim, if you are unsure of the process, seek the information from the payer either by calling or checking the website for more information. You will need to verify that any pertinent documentation to justify payment is included with the claim such as: signed delivery tickets, prescriptions, a copy of the claim, a copy of the EOB, and any additional information required. Also crucial is to ensure that if you need to mail the appeal, the address to where the appeal needs to be sent is correct as it is frequently different than the address to where claims are mailed. You should always try more efficient ways to send an appeal and if you are under short deadlines, try to fax directly so that the appeal will be in their hands within timely guidelines.
• Calling the Payer: When reaching out to the payer, make sure to have all information relevant to the claim easily accessible including: the contract, NPI and tax ID number, reference number if you have called before, and who you spoke with as well as dates when you called. The collector will need to know ahead of time what the issue is as to why the claim was not paid in full, what you are asking from the person on the phone, and what documentation you have to support your position. Many CSRs are located outside of the country and it can be challenging to communicate and understand what is needed from both parties, especially if they have a limited understanding of home infusion. It is also important to review your other outstanding claims for this patient to see if they have similar issues from the payer. If you do find that for a single patient there are multiple claims under the same payer that have the same issue, it is best to address all the open claims with the CSR while on the phone to save time.
• Timely Follow-Up: All payers have different timely filing guidelines, which makes it crucial to review your contract to know what is expected from each payer. To ensure that your organization is committed to avoiding timely filing, it can be helpful to establish an internal audit program that incentivizes staff to work claims within timely guidelines. Linking these metrics to merits ensures that your collections staff have a vested interest in managing claims and yielding a positive return.
• Aging: To prioritize which claims need the most immediate attention, refer to a top 100 patients analysis report that outlines those patients with the highest balances. After closing the month, it is a best practice to run this report to analyze where you are at currently and how your efforts need to change from month to month.
While managing home infusion collections is no easy task, following the tips outlined above are a great way to manage your day in doing tasks that yield the highest return for the business. Mediware Reimbursement Services is also committed to managing home infusion reimbursement for large pharmacies across the U.S. See how their team of over 60 billing experts are dedicated to growing your collections with proven results.