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Episode Overview:
In this episode, we dive into the latest trends and challenges in the world of healthcare denials, focusing on payer-driven issues and solutions. The discussion spans denial trends, specifically around inpatient DRG downgrades, and the nuances of navigating denials and claim processes. We also cover technology gaps, regulatory shifts, and emerging solutions in the revenue cycle, particularly for claims with no response and payer-driven reimbursement barriers.
Key Topics Discussed:
• DRG Denials and Humana’s Query Compliance: Robin brings up a denial trend where Humana denies inpatient DRG claims based on “non-compliant queries,” prompting insights on how other professionals are tackling this issue.
• Technology for Claims Without Response: A compelling case is made for creating automation around claims that have not received a denial or payment. This includes potential decision trees for follow-up actions on claims without EDI data to improve efficiency.
• Prior Authorization and Payer Challenges: The conversation highlights the industry’s struggle with prior authorization, arguing that innovation should focus on reducing the overall burden rather than automating current processes, which only minimally alleviate providers’ challenges.
• The Telehealth Dilemma Post-2024: With telehealth flexibilities set to expire at the end of 2024, Whitney raises concerns over how practices primarily based on telehealth services, especially those offering behavioral health, will adapt. Regulatory changes are dissected, with possible strategies suggested to navigate this impending change.
• Innovations in Denial Management: Attendees discuss tools for denial tracking and payer insights, like Cleopatra Queen of Denial, a software solution developed to trend denial types across categories for better negotiation leverage.
• Building Technology That Truly Helps the Revenue Cycle: A call is made for technology that directly addresses payer-driven issues, rather than administrative burdens, suggesting a focus on innovation that simplifies payer policies and medical necessity criteria.
• Professional Events and Resources: The episode includes a discussion on upcoming events, like Joe Rivett’s denial forum, offering listeners insight into where they can learn more about denial management, payer perspectives, and effective appeals writing.
Listeners are encouraged to reach out and share their own experiences with denial management challenges, particularly around DRG downgrades and telehealth changes, fostering a community of shared insights and solutions.
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Mastering Payer Defense
In this episode, Vanessa Moldovan, CEO and founder of 'For the Love of Revenue Cycle,' dives deep into the complexities of downcoding and mastering payer defense strategies. She discusses essential steps including understanding contracts, interacting effectively with payers, and leveraging legal options and state insurance commissions. Vanessa also shares insights gathered from a healthcare attorney specializing in defending providers against insurance companies. Tune in to learn actionable strategies to safeguard revenue and ensure fair payment while maintaining professional relationships with payers.
00:00 Introduction and Overview
00:13 Understanding Downcoding
00:53 Expert Insights and Strategies
02:20 Importance of Contracts in Payer Defense
03:49 Presenter's Background and Expertise
06:00 Webinar Disclaimer and Initial Questions
07:10 Best Practices for Denial Escalation
11:39 Identifying and Addressing Downcoding
19:58 Effective Payer Conversations
29:22 Navigating Payer Relations and Contracting
31:01 Effective Appeal Strategies
33:40 Documentation and Professionalism
37:43 Leveraging State Insurance Commissions
43:33 Filing Grievances: Medicare and Commercial Plans
48:47 Legal Complaints and Final Steps
52:19 Q&A and Closing Remarks
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Transforming Healthcare Revenue Cycle with Technology and Human Expertise
Join Vanessa Moldovan, CEO and founder of For the Love of Revenue Cycle as she delves into the intersection of innovative technology and Revenue Cycle Management (RCM). Discover the critical role of technology such as Artificial Intelligence (AI), Large Language Models (LLMs), and Software as a Service (SaaS) in optimizing financial processes and patient data management.
This episode covers essential topics including vendor selection, key technological terms, and the importance of human factors in successful technology adoption. She tackles common objections to new technology, and provides practical strategies for evaluating software solutions and maximizing the benefits of software demos.
Learn how to balance human intervention and automation to achieve efficiency and long-term financial success. For more information, contact Vanessa at [email protected] and connect via LinkedIn or Facebook.
00:00 Introduction and Webinar Overview
00:11 About Vanessa Moldovan
00:48 Mission and Services
01:58 Importance of Technology in Revenue Cycle
05:50 Key Terms in Technology
09:37 Understanding Information Technology
11:31 Software as a Service (SaaS)
28:50 Human Factor in Technology
35:49 Challenges in Revenue Cycle Management
36:57 Understanding Common Objections to Technology Adoption
37:55 Overcoming Resistance and Bad Experiences
40:07 Perception of High Costs and Value Challenges
42:34 Preparing for Technology Demos
44:46 Maximizing Demo Effectiveness
50:39 Evaluating Technology Integration and Support
01:03:36 Exploring Innovative Technologies in Revenue Cycle
01:10:29 Conclusion and Contact Information
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Mastering Medical Billing: Overcoming Claim Denials and Utilizing Key Resources
In this comprehensive episode, we dive deep into various medical billing challenges and solutions. Key discussions include handling billing issues with UnitedHealthcare, specifically around lab claims and CLIA validation, and addressing billing problems with Medicare Advantage and other insurers like Cigna and Blue Cross. We offer practical advice on resubmissions, correct coding, and documentation to avoid denials. The importance of leveraging resources such as the AAPC website, MACs for webinars, and networking for educational support is emphasized. The episode features expert insights, such as those from healthcare attorney on combating downcoding and dealing with insurance companies. New and experienced billers alike can benefit from tips on maintaining contact lists, timely filings, and utilizing payer portals effectively.
00:00 Introduction and Initial Query
00:18 Clarifying the Issue with Modifier 90
01:00 Understanding CLIA Requirements
05:25 Dealing with UnitedHealthcare Denials
07:12 Exploring Other Potential Issues
09:33 Addressing Sentara Insurance Glitch
12:00 Blue Cross Medical Advantage Claim Issues
18:06 Cigna Appeal Process Challenges
22:01 Medicare Advantage Plan Denials
26:44 Medicare Billing Challenges
27:17 Humorous Anecdotes and Introductions
28:02 Addressing New Biller Concerns
30:06 Sharing Tips and Resources
31:33 Useful Websites and Tools
34:08 Insurance Company Contacts
35:02 AAPC Website Resources
36:32 Medicare Denial Codes and Policies
37:43 Importance of Bookmarking Resources
39:20 Access to Payer Portals
40:47 Training and Networking
42:00 Medicare Billing Programs
44:42 Final Thoughts and Suggestions
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In this engaging podcast episode, participants dive deep into the complexities of denial management and revenue cycle strategies. Led by Vanessa Moldovan, a discussion unfolds around real-world challenges in handling denials and retractions within the healthcare finance sector. Key topics explored include the importance of working in denial management to gain comprehensive insights, effective strategies for managing Medicare and Medicare Advantage issues, and dealing with common denial reasons such as duplicate claims, out-of-network, and lack of authorization denials. The podcast also emphasizes the role of technology in streamlining these processes, highlighting how automation and AI can ease the burden of manual claims review. Participants are encouraged to utilize contracts proactively to fight against unjust denials, and valuable resources, like subject matter experts and tech solutions, are shared to empower professionals in the industry. For further guidance, listeners are invited to reach out to Vanessa at [email protected].
00:00 Introduction and Newcomers
00:18 Challenges with Denials
01:12 Colonoscopy Coding Issues
01:54 Connecting with Experts
03:55 Educational Resources and Support
07:07 Podcast Discussion
08:27 Using Contracts to Fight Denials
10:54 Preparing for Payer Meetings
20:26 Duplicate Claims and Denials
24:05 Understanding Adjudication and Denials
25:33 Credentialing Denials: Challenges and Solutions
28:18 Common Issues with Authorizations and Network Status
30:47 Fighting Back Against Incorrect Denials
37:06 Technology and Tools for Managing Denials
42:08 Addressing Underpayments and Downcoding
50:06 Final Thoughts and Best Practices
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Maximizing Provider Revenue with Payer Contract Insight
In this episode of 'For the Love of Revenue Cycle,' host Vanessa Moldovan shares essential insights on how to maximize provider revenue by understanding and leveraging the nuances of payer contracts. Topics covered include addressing prior authorization denials, navigating payer reimbursement policies, ensuring clean claim submissions, and utilizing fee schedules and carve outs. Additionally, Vanessa offers strategies for managing payer plan limitations, timely filing guidelines, and escalation procedures for unresolved reimbursement issues. Listeners are encouraged to harness technology and AI-driven solutions to streamline these processes for enhanced revenue cycle performance.
00:00 Introduction to the Podcast and Host
01:23 Episode Overview: Maximizing Provider Revenue
02:01 Understanding Payer Contracts
03:04 Prior Authorization Guidelines
05:28 Payer Reimbursement Policies
08:08 Clean Claim Requirements
11:34 Carve Outs in Payer Contracts
14:03 Payer Plan Limitations
16:24 Fee Schedules and Contracted Rates
21:29 Requests and Recoupments of Overpayments
23:34 Denials Without Proper Justification
25:10 Timely Filing Guidelines
27:17 Escalating Reimbursement Issues
29:11 Conclusion and Next Steps
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In this episode of the bimonthly Denials Q&A, host Vanessa discusses her extensive experience and expertise in handling denials, focusing on changes and challenges in the field. She emphasizes the importance of understanding contracts, payer guidelines, and exploring new technologies to improve denial management. Vanessa shared insights on leveraging contract information and innovative technology to fight back against complex denial processes. Key topics include the use of CARCs, dealing with Medicare Advantage plans, navigating E&M downcoding, and strategies for obtaining necessary documents from payers. Listeners are encouraged to stay proactive, utilize technology, and network within the healthcare billing community to address evolving denial issues effectively. Email Chester Montefering at Recon.health at [email protected] for more information on utilizing contract automation.
00:00 Welcome to the Bimonthly Denials Q&A
00:26 Introduction to Denials and Career Background
01:27 Starting a Company and Industry Engagement
03:19 Denial Codes and Industry Changes
04:37 Complexity in Reversing Denials
06:35 Importance of Contracts in Denial Management
08:50 Accessing and Understanding Contracts
12:01 Technology Solutions for Denial Management
15:06 Open Q&A Session
23:12 Networking and Sharing Experiences
52:18 Final Thoughts and Next Steps
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Navigating Insurance AR: Tackling Claims with No Response
In this episode, Vanessa Moldovan, CEO and host of 'For The Love of Revenue Cycle,' delves into the intricacies of Insurance Accounts Receivable (AR), focusing on claims with no response.
Vanessa explains the significance of managing AR to maintain financial health and provides practical strategies for identifying, resolving, and preventing claims with no responses.
Key takeaways include the importance of tracking all claims, the role of technology, and assigning the right tasks to team members.
Vanessa also emphasizes the need for preventive measures and invites listeners to ongoing discussions and networking opportunities.
00:00 Introduction and Welcome
01:06 Episode Overview: Insurance AR and Claims with No Response
02:00 Understanding Insurance Accounts Receivable (AR)
03:57 Managing AR: Best Practices and Key Performance Indicators
07:07 Focusing on Claims with No Response
16:13 Steps to Resolve Claims with No Response
22:22 Preventive Measures for Claims with No Response
26:05 Conclusion and Upcoming Episodes
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In this episode, Vanessa Moldovan, CEO and Founder of 'For the Love of Revenue Cycle,' leads a live Q&A session on handling denials in medical billing. Participants from different sectors of the healthcare revenue cycle, including medical billing for home visits, nursing homes, and surgery centers, discuss challenges they face with denial codes, modifiers, and reimbursement issues. Key topics include understanding the new FY 2024 hospice final rule, addressing denials related to modifier codes, and strategies for handling electronic remittance advice (ERA) take-backs. Suggestions for actionable steps and resources, such as consulting specific websites and joining relevant forums, are also shared.
00:00 Introduction and Purpose of the Q&A Session
00:49 Challenges in Revenue Cycle and Denials
02:07 Participant Introductions and Their Goals
03:11 Open Forum for Questions and Discussions
04:14 Lauren's Denial Issue with Chronic Care Management
09:26 Exploring Possible Solutions and Resources
21:08 Roseanne's Issue with Take Backs on ERAs
28:22 Provider Targeting by Payers
28:38 Options for Receiving Take Backs
29:03 Challenges with Electronic ERAs
29:44 Appeal Deadlines and Paper Forms
30:11 Denials Due to Grouper Edits
30:53 Hospital Denials and Resources
33:13 Questions on Prolonged Services Billing
37:08 Issues with Nursing Home Billing
45:29 Seeking Expert Advice and Final Thoughts
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Show notes for today's live denials Q&A session:
The differences in denials and appeals processes between in-network and out-of-network providers
Strategies for appealing out-of-network denials, including involving patients and leveraging laws like the Arisa law
Trends in payer requests for documentation and potential reasons behind sudden increases in these requests
Frustrations with payers' downcoding practices and lack of transparency in reimbursement
The shift in the medical field from a profession to a business, and the need for better revenue cycle education for providers
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Tech-Enabled RCM: Tips and Solutions with Mike Marshall + Vanessa
In this episode, Vanessa welcomes Mike Marshall to discuss the intricacies of revenue cycle management (RCM) and the challenges faced by healthcare organizations. Mike is currently the Managing Director of the North American division of e5 Workflow, with a rich background in healthcare focusing on turnaround projects for operation, finance, and revenue cycle management.
They explore the root causes of common RCM issues, the hesitations around adopting new technology, and emphasize the necessity of becoming tech-enabled to survive in the current market. The conversation delves into innovative solutions, actionable data, optimizing human resources, and technological advancements like AI and automation. They also provide guidance on selecting vendors and the importance of staying informed about industry innovations through networking, conferences, and professional advice.
00:00 Welcome and Introduction
00:31 Introducing Mike Marshall
01:03 Industry Challenges in Revenue Cycle Management
02:09 Hesitancy in Adopting Technology
03:48 The Pain of Outdated Systems
07:35 Fear of Change in Revenue Cycle
11:32 Importance of Training and Support
16:47 Encouragement to Explore New Solutions
21:19 Leveraging Technology for Efficiency
33:15 Medicare Challenges and Strategic Technology Integration
33:52 Middle Management and Delegation with Technology
35:08 Industry Changes and Knowledge Gaps
36:04 Leveraging Technology for Delegation and Efficiency
36:53 Outsourcing and Onshoring in Revenue Cycle Management
39:34 Navigating Vendor Selection and Industry Resources
45:16 Maximizing Conference and Vendor Interactions
53:40 Evaluating Automation and AI Claims
57:55 Strategic Technology Integration and Conclusion
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In this episode, Vanessa Moldovan hosts a Q&A session focused on the challenging issues of denials in revenue cycle management. Vanessa, along with the attendees, discusses the complexities around denial prevention, resolution, and best practices. The session covers specific payer issues, including downcoding by Anthem and Humana, as well as rampant documentation requests from UnitedHealthcare. The discussion also provides strategies for handling denials, escalating issues to provider representatives, utilizing contracts, and ensuring accurate coding practices. Expert insights are shared on balancing the administrative burden, proactively managing claims, and leveraging technology to streamline processes. The conversation aims to empower healthcare providers and billers to tackle denials effectively while advocating for systemic changes in payer operations.
00:00 Introduction and Welcome
03:27 Purpose of the Q&A Session
04:28 Host's Background and Experience
05:25 Community and Participation
07:00 First Question: Handling Downcoding 1
1:44 Discussion on Denial Trends and Strategies
23:02 Challenges with Payers and Denials
31:41 Industry Trends and Payer Practices
35:26 Frustrations with Office Testing and Pre-Authorization
37:22 Tactics for Fighting Unjustified Denials
38:27 Challenges Faced by Small Practices
40:21 Importance of Documentation and Predetermination
42:16 Role of Professional Organizations and Social Media
49:12 Differences in Denials: In-Network vs. Out-of-Network
54:53 Leveraging Contracts and Provider Networks
58:46 Final Thoughts and Recommendations
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n episode 31 of 'For the Love of Revenue Cycle,' the host discusses patient accounts receivable (AR) in a clinic setting, emphasizing the importance of professional billing over facility billing. Key topics include naming conventions in billing systems, the role and definition of a guarantor, and the nuances between insurance processing and payment. The episode delves into best practices for managing patient AR, handling self-pay arrangements, and understanding patient financial responsibility, especially under high deductible health plans. The host also explores the impact of technological innovations on both pre-service and post-service collections, strategies for reducing collection costs, and compliance with federal and state regulations. Finally, the session provides practical recommendations for managing self-pay balances and patient shares, offering financial assistance, and ensuring consistency in collections policies. 00:00 Welcome and Introduction 01:27 Understanding Patient Accounts Receivable (AR) 01:54 Naming Conventions and Guarantor Responsibilities 05:40 Insurance Processing and Patient Responsibility 19:26 Collecting Patient Payments 22:58 Technological Innovations in Revenue Cycle 25:34 Best Practices for Self-Pay Balances 27:00 Handling Balances After Insurance 28:03 Developing Effective Collection Policies 34:45 Conclusion and Final Thoughts
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Get ready for Season 3 of For the Love of Revenue Cycle, premiering tomorrow with Episode 30! I'm back with a deep dive into denials and accounts receivable in the revenue cycle.
Listen in, as I unpack the complexities of denials and their impact on healthcare organizations. I'll share insights from recent industry events and personal experiences, highlighting key strategies for prevention and resolution.Also, stay tuned to the end for a big announcement about For the Love of Revenue Cycle.
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In this episode, we dive into effective strategies for preventing and resolving denials in healthcare billing. Our speakers cover essential tips like checking the place of service, sharing experiences, and networking with other professionals. We explore various types of rejections in healthcare claims, emphasizing the need to understand their origins and track them meticulously. Discover valuable insights on managing appeals and reconsiderations, staying organized, using timely filing tools, and navigating complex appeal letters. Plus, learn about the importance of resources for identifying plan types and tackling excessive medical documentation delays. Join us for this comprehensive discussion on mastering healthcare billing challenges.
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Corey started Covered Health to automate the most challenging element of appealing denied medical claims by streamlining the access to diverse databases and sources to pinpoint denial root causes. I decided to partner with Covered because we share the same vision: preventing patients from getting stuck with bills that should be covered by their insurance, and helping to empower revenue cycle management experts to resolve those denials with greater efficiency.
We discussed Corey’s motivations for starting Covered - his brother Russell's experience with unfair insurance denials during his struggle with Ulcerative Colitis. Corey’s family was hit with massive bills, and at a time when they wanted to focus on Russell’s health, instead they were focused on denied claims. Covered intervenes to help providers overturn denials, and prevent bills from becoming patient responsibility.
Corey discussed his journey through the Special Forces, Parachute Health, and running sales for healthcare companies, eventually selling into insurance plans prior to starting Covered.
We discussed my career as well, and turning down Harvard undergraduate in pursuit of a life and career that aligned with my values of giving back and sharing what I've learned with others, which is why I started this podcast.
Corey and I met because he was looking for a podcast on denials and he found mine! We connected over a shared passion to create a denial resolution tool with the goal of harnessing the multitude of databases & sources of truth that a biller has to access in order to identify the root cause of a denial and create an appeal.
We are not only reducing the clicks required to gather the information, but creating a smart tool that will guide RCM professionals through the decisions required to compile the body of the appeal, and eventually generate it for them.
We addressed Covered’s competitive differentiation within the denial management space, and the rapid advancement of AI and LLMs, which have given an advantage to new companies. We touched on the slow moving nature of incumbents, and why they often don’t succeed in building product lines that are as innovative as their original core offering.
If Covered’s mission to fight back against incorrect denials resonates with you, we want to connect! Especially (but not exclusively) if you are an independent specialty provider group, an RCM company fighting denials, an, or a regional/community hospital/health system. If you are struggling to address denials as a result of staffing shortages/payer policies/behavior, or you are just passionate about denials, please reach out!
Today, Covered acts as a software enabled services company, utilizing technology to overturn denials (they’ve returned tens of thousands of dollars to physicians). In addition to helping Covered build out their product, I am helping Covered to actually fight denials as an extension of customer RCM teams. If you're struggling with denials, we can immediately step in and help you, and help identify trends and root causes. In special cases, we also provide consulting services.
One of the advantages of fighting denials on behalf of our customers is that we enter their world, and get to see their problems firsthand. That, in turn, allows us to tweak our product for each customer based on their specific pain points.
You can learn more about Covered on their website, and you can find Corey on Linkedin. As you discover more about Corey and his mission with Covered, I encourage you to check out his podcast Healthcare Reimagined (Apple or Spotify).
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Dive into the world of healthcare industry in our special episode of PM Symposium where we uncover the many facets of the revenue cycle. Hosted along with Jennifer McNamara, we discuss the impact of practice managers, the importance of understanding the revenue cycle, and how to combat revenue leakage. We explore some of the major challenges including staffing shortages, the lack of standardization and the crucial role of both management and line workers. Tune in to gain invaluable insights, understand the power of community teamwork and informed decision-making. See you at the practice management symposium on February 16th!
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Hello Friends! Welcome to the kickoff of season 3! I am overwhelmed to still be running this podcast after 2 years. Thank you as always for your support. In this episode, I share what the topic of season 3 will be and share a big announcement. Speaking of the big announcement, here is the link that I reference. https://fortheloveofrevenuecycle.aweb.page/p/7d25c7b7-9c16-490c-95cd-7bd2052fd396
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Hello friends and welcome to episode 28 of For the Love of Revenue Cycle. Thank you so much for tuning in today! A big welcome back to my loyal listeners and a special shout out if today is your first episode. This season is part of the going back to the basics from season 2. I know that it has been about 5 months since Episode 27 was posted. As you may recall, me and my production team were experience technical difficulties. But here we are back again!
In this final episode of Season 2, I’m going to share with you my experience with using reporting and analytics in revenue cycle management. This will include discussing why I believe analytics is so vital, what my favorite reports are and how I use them to run a clean revenue cycle.
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