Be Intentional and Proactive with Your Claim Editing Process

Author: Heather Chartier, MS, RHIA, CCA 

According to the March 2022 two-part claim edit management survey NAHRI in partnership with 3M Health Information Systems conducted on acute care hospitals and health systems with 500+ beds, respondents say the denial rate (67%) is the number one edit tracked, followed closely by timely claims submission rate (62%) and reimbursement (55%).¹ Nearly one-fifth (17%) of facilities do not track the effects of edits.²

This week’s blog post asked revenue cycle industry leaders about their custom claim edits processes and management of them.

Lynn Wilder is a Health Information and Revenue Cycle Professional serving the healthcare community for over 20 years. Her responses to these questions reflect her personal experience and opinion.

Christine Lynch is a Revenue Cycle Consultant with over 22 years in the healthcare industry. She has become a trusted advisor focusing on working with clients to better understand and resolve their revenue cycle challenges.

Question: How do you define custom edits and where are they best located? 

Lynn’s Answer: Claim editing is the process of verifying that the bills or claims submitted by large medical groups are coded correctly. Custom edits are those built into your organization’s automated editing software in addition to the universal or standard claim edits such as the National Correct Coding Initiative Edits, Global Edits and Correct Coding or ICD-10-CM edits. Custom edits cover additional requirements including payer, specialty, provider, or location specific edits specific to the organization’s needs.

Christine’s Answer: My definition of a custom edit is an edit that is payer or situation specific that is created based on an organization’s need. Our edits are varied and located throughout the revenue cycle. Ideally, we try to manage them in the prebill stage versus the post bill stage.

Question: Who creates your organization’s edits and are they created internally or by a vendor?

Lynn’s Answer: Growing demand for standards and accountability has led to a best practice of basing edits on industry recognized third-party sources that clearly explain edits in a language that providers and patients can understand. Edits are sourced and explained at the level of code-to-code relationships and should be resourced and based on American Medical Association CPT guidelines, CMS guidelines, Correct Coding Initiatives, commercial and Medicare code sets, medical societies, and other widely accepted third-party sources.

Christine’s Answer: We involve individuals across the revenue cycle such as the integrity team, health information management, patient financial services and patient access to provide input so we do not rely solely on vendors. We build them into our system. When we involve a vendor, it saves time as they are the ones that have done the research as to how edits function and flow.

Question: What do you consider to be the most important requirement for a custom edit and why?

Lynn’s Answer: The most important requirement for custom edits is for them to equally reduce the burden of unnecessary administrative costs for consumers, providers, and health plans and to simply practice good business, provide full disclosure and transparency, and build trust.

Christine’s Answer: The custom edit should be vetted to avoid having too many to overwhelm the system. Each edit should bring value and improve the workflow. A good balance is when we can ensure we are capturing all of our net revenue and optimizing turnaround time on payments for our services.

Question: What is your benchmark for timeliness in resolving a custom edit?

Lynn’s Answer: For claim processing, we are expected to process clean claims as quickly as they are submitted with a 3-5 business day window.

Christine’s Answer: Within 5-7 days of the edits hitting a work queue for front end users. Some will require additional follow-up.

Question: How do you ensure the process doesn’t get bottlenecked, and how do you approach process improvement when it does?

Lynn’s Answer: Depending on the size of the organization, and the number of claims being processed, in addition to the amount of and type of automation the organization has in place will greatly dictate best practice for avoiding bottlenecking. Division of responsibility allows one group to concentrate on commercial insurance, one group to concentrate on Medicare/Medicaid, etc. Staff and delegate according to your greatest need. Ensure the software being used has been loaded with custom edits that help automate most of the processing to allow your human resources opportunity to review as quickly as humanly possible.

Christine’s Answer: Keep the edits to a minimum and perform 1:1 rounding with departments asking them key questions to identify if the edit is functioning properly, if there are any delays in the process, and if additional training may be needed. Additionally, we have a second reviewer to alleviate any bottlenecks.

Question: Who have you seen typically responsible for resolving edits and what skills are required to do this work?

Lynn’s Answer: From the submission side, typically the office staff or administrative assistants are responsible for resolving edits – most probably needing to query a provider regarding a specific treatment, running it past the coder for coding edits and correcting any office/provider demographic edits on the claim. The most relevant skill for this work is having great attention to detail. Best practice would be to ensure that all the standard, expected data fields on any claim form are completed appropriately. Get to know the provider you work for, the treatments done in the office, create coding cheat sheets for the most popular services. On the claim processing side – these folks are professional coders, nurses, and folks with higher education, degrees, and credentials in the medical field.

Christine’s Answer: I have seen anyone from health information management directors, coding teams, and individual departments work edits. It is what works best for each organization. Someone that has attention to detail and is teachable is ideal for this role. We approach the process via quality on the front end so that we don’t have rework on the back end.

Question: Is it challenging to find staff with the skills needed to resolve edits. Why or why not?

Lynn’s Answer: Yes, on both fronts. The claim submission, reviewing and paying process is confusing and requires a high level of understanding of the revenue cycle, coding, medical records, insurance, information technology, terminology, and overall methodologies of the healthcare industry.

Christine’s Answer: Yes, an individual is expected to have a broad skill set and it helps to have a good understanding of how the patient/medical record moves through the organization from registration to billing.

Question: How are you using edits to monitor and track factors such as timely filing, reimbursement, and denials?

Lynn’s Answer: Automated edits track dates of service, codes (for services rendered), submitting provider NPI, member demographics, and can determine if providers have uploaded documentation for the claim. For example, in some cases, the automated system can flag when the same NPI has submitted for the same member on the same day of service and the claim has already been paid. Or if the claim was already paid to another provider in the same office who already submitted a claim. Or if an annual exam was already billed within the year. Until the actual edit is verified, the claim is ushered into the review queue, and the actual edits on the claim are tracked in the claim processing database.

Christine’s Answer: We use monthly scorecards for performance evaluation and process improvement. We cannot manage what we do not know.

Question: During the prebilling period, how would you describe your facility’s processes for reviewing claim edit patterns and resolving them?

Lynn’s Answer: Look for documentation uploaded by the provider. Attach the documentation file number to the claim number and forward it to the analyzer’s queue. At this stage of the process, the staff are responsible for tracking claims submitted without any documentation or claims missing provider NPI numbers or missing member demographics. Mostly missing items are identified, and not so much the accuracy of the claim and supporting documentation.

Christine’s Answer: We conduct monthly internal audits and randomly sample high dollar, high volume accounts. After we conduct audits, we use interdepartmental committee meetings to assist with identifying root causes by digging deeper into claims. In some cases, we need to go down each account line by line to resolve them.

Question: How have you seen specific data points for different payers tracked, and after Covid-19, have you noticed any changes in claim edit patterns or volumes by payor or category?

Lynn’s Answer: As a result of COVID-19, claim edits were created to designate COVID diagnosis codes and telemedicine codes specifically. Patterns and volumes by payor and category continue to be tracked and monitored.

Christine’s Answer: We have noticed an uptick in additional documentation requests across the board since COVID, no specific payers.

Question: Do you have any best practices on edit maintenance that you can share?

Lynn’s Answer: Billing codes and coding rules are in a constant state of change. With the regulatory climate, Medicare requirements, commercial edits, and a variety of other technological issues that could arise, it is important to manually check edit results against expected rules often and consistently to avoid problems.

Christine’s Answer: Ensure that your edits are pared down and identify a dedicated person who will research and review ongoing updates to maintain them.

Doing The Right Thing

Ensuring the right edit gets to the right person at the right time and having a combination of automation, interdisciplinary groups meeting regularly, monitoring metrics closely, and in some cases, vendor assistance provide the right combination for reducing confusion and headaches when managing your claim edit process.

AUTHOR: Heather Chartier, MS, RHIA, CCA

Heather Chartier is an accomplished leader, explorer, freelance writer, and entrepreneur. With nearly a decade of nationwide healthcare industry experience and business acumen, she specializes in building lasting relationships and empowering people and organizations to grow.

Her visionary perspective has earned her opportunities to work on multiple health systems quality campaigns, such as those earning an “A” grade and Top Hospital designation by Leapfrog and those recognized as the No. 1 Best Hospital in Dallas Fort Worth, by U.S. News and World Report. In 2014, She earned her dual Health Information Management & I.T. Leadership Master’s degree at The College of St. Scholastica.

She is passionate about creating authentic connections through healthcare writing that enable targeted readers to be informed, inspired, and transcended.

Besides writing healthcare and lifestyle blogs and taking on additional freelance writing projects, she is happiest spending time with her husband and training their three dogs, Hank, Gary, and Elle, in their forever home of Conway, South Carolina.

About GeBBS Healthcare Solutions

GeBBS Healthcare Solutions, a ChrysCapital portfolio company, is a leading provider of Revenue Cycle Management (RCM) services, HIM services and Risk Adjustment solutions. GeBBS’ innovative technology, combined with over 14,000-strong global workforce, helps clients improve financial performance, adhere to compliance, and enhance the patient experience. Headquartered in Los Angeles, CA, GeBBS has won numerous accolades for its medical coding outsourcing and medical billing outsourcing, including being ranked in Modern Healthcare’s Top 3 Largest RCM Firms, Black Book Market Research’s Top 20 RCM Outsourcing Services, Modern Healthcare’s 2023 Top 10 List of Largest RCM Firms in the U.S., Based on Employee Strength and Inc. 5000’s fastest growing private companies in the U.S. For more information, please visit www.gebbs.com

Resources:

1. BEST PRACTICES FOR TRACKING AND RESOLVING CLAIM EDITS. (2022). NAHRI and 3M. Retrieved October 20, 2022 from https://nahri.org/category/nahri-leadership-council
2. CREATING AND MANAGING CUSTOM EDITS. (2022). NAHRI and 3M. Retrieved October 5, 2022 from https://nahri.org/resources/creating-and-managing-custom-edits-0
3. Wilder, L. (2022, November 12). Personal communication [email].
4. Lynch, C. (2022, November 2). Personal communication [phone interview].