PMG Audiocast Presentation Episode 3 - Denials Part 2

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Financial Update Five Minute Episode 3 – PMG Denials Part #2 “The Five” Created by Maxwell Kagan 2012

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Annual Financial Impact $2,434,414 Medical Necessity No Authorization Non-Covered Service Non-Billable Service Coding Error Bundling Registration- Eligibility Registration – Missing Info Provider Enrollment 9

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Actio n Plan: Identify which procedures are being denied and validate coding protocols. Ensure appropriate training is available for providers and staff. Establish QA process. ROOT CAUSE Procedures cannot be separately billed/reimbursed ACCOUNTABLE ROLE Clinic Manager, DPO PMG BUSINESS PARTNER Coding Documentation Quality Assurance DATA ELEMENTS TO EXAMINE Procedures, payer Annual Financial Impact $186,732 Bundling Registration- Eligibility Registration – Missing Info Provider Enrollment

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Actio n Plan: Identify payers that are problematic. Provide feedback to check-in staff. Ensure that mandatory training requirements are met and/or request additional payer specific training. ROOT CAUSE Insurance not verified or filing order of multiple insurances incorrect ACCOUNTABLE ROLE Clinic Manager, DPO PMG BUSINESS PARTNER MSO DATA ELEMENTS TO EXAMINE Payer(s) (filing limits), registrar Annual Financial Impact $149,487 Bundling Registration- Eligibility Registration – Missing Info Provider Enrollment

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Actio n Plan: Identify which users are contributing to problem and provide feedback. Ensure mandatory training requirements are met, provide additional training. ROOT CAUSE Patient demographic information is incorrect - patient cannot be identified ACCOUNTABLE ROLE Clinic Manager, DPO PMG BUSINESS PARTNER MSO DATA ELEMENTS TO EXAMINE Payer(s) (filing limits), registrar Annual Financial Impact $149,487 Bundling Registration- Eligibility Registration – Missing Info Provider Enrollment

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Actio n Plan: Identify which providers and payers are denying. Compare start date to DOS and confirm with Enrollment that provider is effective with payer. Consider modifying provider's schedule. ROOT CAUSE Provider is not enrolled with payer on DOS ACCOUNTABLE ROLE DPO PMG BUSINESS PARTNER MSO/Provider Enrollment DATA ELEMENTS TO EXAMINE Provider, payer, DOS Annual Financial Impact $338,755 Bundling Registration- Eligibility Registration – Missing Info Provider Enrollment

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What to do next: We are all committed to excellent outcomes! Watch your email for the newly designed PMG Denial Report around the beginning of September Understand what level and types of denials you have in your clinic(s) Engage Director of MSO Steve Figge sfigge@phs.org or 505-923-6462 to answer questions or clarify understanding Engage your Finance and Coding Business Partners Engage your physicians around denial data This is another great opportunity to improve our financial performance and BE UNDENIABLE!

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8 Thanks for watching Are there topics you would like us to cover in this VideoCast ? Please email your subject to mkagan@phs.org or call me at (505) 923-6355

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