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

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 chester@recon.health 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

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

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

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

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

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.