Providers can reduce denials and speed payments by developing smarter strategies for submitting medical records to payers.
Commercial health plans and government payers like Medicare and Medicaid require claims attachments—typically medical records—to process payment for certain procedures. “Understanding when a claim requires an attachment is a huge challenge for the provider community,” says Crystal Ewing, manager of data integrity at ZirMed, Louisville, Ky. “Every insurance carrier may have different rules on when an attachment is needed.”
For example, Humana’s website offers a sample list of procedures and services that may require submission of member medical records as claims attachments for review. These procedures include emergency room services, bariatric surgery, infertility-related treatments, and other services. Similarly, Minnesota’s Department of Health Services also lists claim attachment criteria for providers enrolled in the state’s publicly subsidized Minnesota Health Care Programs.
What is challenging for providers is that a payer’s list of services requiring claims attachments may vary by plan. This makes it difficult for providers to understand what materials are needed to adjudicate claims for the same payer. “There is a secondary level of complexity there,” she says.
The bottom line is that it can be very difficult for providers to know when to appropriately submit these types of attachments, Ewing says.
Implications for Providers
Knowing how to submit claims attachments may be another challenge. Currently, providers use a variety of methods to send claims attachments to payers, says Ewing, who is on the board of directors for the Cooperative Exchange, the National Clearinghouse Association. She points to a 2016 survey by the Cooperative Exchange that found that most providers manually submit their claims attachments by uploading them to payer web portals. Other methods of submission include electronic data interchange, secure fax, and even secure e-mail.
If providers fail to submit claims with the required attachments, they may face problems like slower collections and a higher denial rate, Ewing says. They also may struggle with productivity issues and higher labor costs because staff will need to resubmit claims.
On the other hand, providers could save more than $4.00 per transaction if they moved from manual submission to electronic submission of claims attachments, according to the 2016 CAQH Index.
Advice for Providers
For organizations that want to streamline their claims attachment processes, Ewing suggests the following advice.
Automate where you can. “Work with your technology vendor to build and maintain a list of rules for claims that always require attachments,” Ewing says. This includes CPT, HCPCS, or ICD codes that always require documentation. “Using rules that allow you to send attachments when you are sending the claim will help you avoid denials or letters from payers pending that claim.”
Build a plan-specific database. Providers can ask their vendors to use historical denials data that allow them to put processes in place to prevent future denials. For example, Medicare always requires an operative note and documentation when using a modifier 22 stating why the case was beyond the usual range of difficulty. The provider can develop a workflow that helps them manage these types of claims.
Develop a process for managing when health plans are added and policy guidelines change. “Introducing an audit review process as well as an enhancement process to add and maintain the rules helps ensure the information is accurate and up-to-date,” Ewing says. Providers also can utilize a vendor to help with this process.
Invest in staff training for your preauthorization, patient access, accounts/receivable and contracting teams. “Your staff are your subject matter experts,” Ewing says. These teams can help your organization re-engineer workflows to improve efficiency. For example, a team that includes the patient access, billing and coding, and A/R teams might meet regularly to review denial and appeal issues. This process could identify if a rule or an update is needed to the payer/policy database, Ewing says. “The content is the key, and developing a process to continue to build and maintain that content is critical to the success of process improvement,” she says.
Developing a Standard
“Many organizations are trying to define an electronic standard for claims attachments transactions,” Ewing says. “It’s a hot topic in the industry now.” Today, organizations like Health Level Seven (HL7) International, a not-for-profit standards-developing organization, are exploring machine-to-machine communications standards, such as their Fast Healthcare Interoperability Resources Specification, also known as FHIR.
Policy makers originally discussed an industry standard for submitting claims attachments electronically as part of the Affordable Care Act, but their efforts were stalled because of a lack of consensus across the industry, Ewing says.
Yet efforts to standardize are still underway. In July 2016, the National Committee on Vital Health Statistics sent a letter to the secretary of the Department of Health and Human Services with recommendations for the industry to adopt updated electronic claims attachment standards.
“Once a standard is built, it will make it much easier to understand how the industry can communicate effectively across all stakeholders,” Ewing says. “If you look at where the industry is going with the switch from fee-for-service to fee-for value, clinical information in claims attachments is going to be extremely important for providers to be paid effectively for keeping patients as healthy as possible.”
Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill., and a member of HFMA’s First Illinois Chapter.
Interviewed for this article:
Crystal Ewing is manager of data integrity at ZirMed, Louisville, Ky.