Monitor and Escalate Prompt Payment and Remittance Transparency Violations Before ICD-10 Hits

Getting paid promptly by payers is an ongoing challenge. State and federal prompt payment laws have pushed carriers to enhance prompt payment performance. However, the ICD-10 transition set for Oct. 1, 2015 will likely impact payer claim processing time and is expected to at least double denials.

Your ICD-10 planning should include a review of your process for escalating aged claims which lack a clear payer response. Make sure that once a claim is identified as aged beyond the prompt payment requirements for the payer and claim type, it is escalated with the payer by citing the prompt payment requirements. Make sure that financial reporting is correctly capturing the impact of pending claims on a payer-by-payer basis.

Also, keep abreast of payer-specific ICD-10 claim filing guidance pertaining to pending claim resolution. Many payers have an established ICD-10 contact person who may be able to provide guidance on resolving pended claims.

As you assess your pending claim identification and resolution process, consider your organization’s escalation policy regarding claims which were denied without clearly cited denial codes and remarks.

Payerview 2014, released by AthenaHealth, reports that Medicaid payers are still the poorest performing payers in regards to prompt payment and electronic remittance transparency. AthenaHealth scores payers not only on how promptly claims are processed but also on whether the payer uses “appropriate, clear adjustment reason codes accompanied by remark codes” so that billing professionals can easily and quickly correct deficiencies. This metric, ERA transparency, will likely be crucial during the ICD-10 implementation as billers try to determine why claims were denied and how to re-bill correctly under the new code set requirements.

Appeal Solutions has developed a number of follow-up letters for use during the ICD-10 transition. These letters would not necessarily be considered “appeal letters” since they primarily address a payers’ lack of prompt processing and/or lack of ERA transparency. Appeals are only initiated when a clearly-worded denial has been received. Therefore, when using an inquiry letter to follow-up on unprocessed/unclear remittances, the appeal process restriction on number of appeals should not be triggered.