Live Denials Q&A 11/7/24 - DRG Trends, Telehealth Changes + Tech Trends

<p class="p3">Episode Overview:</p> <p class="p3">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.</p> <p class="p2"> </p> <p class="p3">Key Topics Discussed:</p> <p class="p4">• 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.</p> <p class="p4">• 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.</p> <p class="p4">• 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.</p> <p class="p4">• 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.</p> <p class="p4">• 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.</p> <p class="p4">• 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.</p> <p class="p4">• 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.</p> <p class="p6">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.</p>

00:41:39

10/30/24 Live Q&A Mastering Payer Defense

Mastering Payer Defense</p> 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. </p> 00:00 Introduction and Overview</p> 00:13 Understanding Downcoding</p> 00:53 Expert Insights and Strategies</p> 02:20 Importance of Contracts in Payer Defense</p> 03:49 Presenter's Background and Expertise</p> 06:00 Webinar Disclaimer and Initial Questions</p> 07:10 Best Practices for Denial Escalation</p> 11:39 Identifying and Addressing Downcoding</p> 19:58 Effective Payer Conversations</p> 29:22 Navigating Payer Relations and Contracting</p> 31:01 Effective Appeal Strategies</p> 33:40 Documentation and Professionalism</p> 37:43 Leveraging State Insurance Commissions</p> 43:33 Filing Grievances: Medicare and Commercial Plans</p> 48:47 Legal Complaints and Final Steps</p> 52:19 Q&A and Closing Remarks</p>

00:57:27

Tech-Enabled RCM, Live Webinar (Recorded 10/18/24)

Transforming Healthcare Revenue Cycle with Technology and Human Expertise</p> 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. </p> 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.</p> Learn how to balance human intervention and automation to achieve efficiency and long-term financial success. For more information, contact Vanessa at vanessa@ftlorc.com and connect via LinkedIn or Facebook.</p> 00:00 Introduction and Webinar Overview</p> 00:11 About Vanessa Moldovan</p> 00:48 Mission and Services</p> 01:58 Importance of Technology in Revenue Cycle</p> 05:50 Key Terms in Technology</p> 09:37 Understanding Information Technology</p> 11:31 Software as a Service (SaaS)</p> 28:50 Human Factor in Technology</p> 35:49 Challenges in Revenue Cycle Management</p> 36:57 Understanding Common Objections to Technology Adoption</p> 37:55 Overcoming Resistance and Bad Experiences</p> 40:07 Perception of High Costs and Value Challenges</p> 42:34 Preparing for Technology Demos</p> 44:46 Maximizing Demo Effectiveness</p> 50:39 Evaluating Technology Integration and Support</p> 01:03:36 Exploring Innovative Technologies in Revenue Cycle</p> 01:10:29 Conclusion and Contact Information</p>

01:11:23

Live Denials Q&A 10/15/24 - Tips for Denial Beginners

Mastering Medical Billing: Overcoming Claim Denials and Utilizing Key Resources</p> 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.</p> 00:00 Introduction and Initial Query</p> 00:18 Clarifying the Issue with Modifier 90</p> 01:00 Understanding CLIA Requirements</p> 05:25 Dealing with UnitedHealthcare Denials</p> 07:12 Exploring Other Potential Issues</p> 09:33 Addressing Sentara Insurance Glitch</p> 12:00 Blue Cross Medical Advantage Claim Issues</p> 18:06 Cigna Appeal Process Challenges</p> 22:01 Medicare Advantage Plan Denials</p> 26:44 Medicare Billing Challenges</p> 27:17 Humorous Anecdotes and Introductions</p> 28:02 Addressing New Biller Concerns</p> 30:06 Sharing Tips and Resources</p> 31:33 Useful Websites and Tools</p> 34:08 Insurance Company Contacts</p> 35:02 AAPC Website Resources</p> 36:32 Medicare Denial Codes and Policies</p> 37:43 Importance of Bookmarking Resources</p> 39:20 Access to Payer Portals</p> 40:47 Training and Networking</p> 42:00 Medicare Billing Programs</p> 44:42 Final Thoughts and Suggestions</p>

00:53:36

Live Denials Q&A 10/3/24 - Tackling Tough Denials

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 <a href="mailto:denials@ftlorc.com">denials@ftlorc.com</a>.</p> 00:00 Introduction and Newcomers</p> 00:18 Challenges with Denials</p> 01:12 Colonoscopy Coding Issues</p> 01:54 Connecting with Experts</p> 03:55 Educational Resources and Support</p> 07:07 Podcast Discussion</p> 08:27 Using Contracts to Fight Denials</p> 10:54 Preparing for Payer Meetings</p> 20:26 Duplicate Claims and Denials</p> 24:05 Understanding Adjudication and Denials</p> 25:33 Credentialing Denials: Challenges and Solutions</p> 28:18 Common Issues with Authorizations and Network Status</p> 30:47 Fighting Back Against Incorrect Denials</p> 37:06 Technology and Tools for Managing Denials</p> 42:08 Addressing Underpayments and Downcoding</p> 50:06 Final Thoughts and Best Practices</p>

00:53:38

Ep. 34 Maximizing Provider Revenue with Payer Contract Insights

Maximizing Provider Revenue with Payer Contract Insight</p> 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. </p> 00:00 Introduction to the Podcast and Host</p> 01:23 Episode Overview: Maximizing Provider Revenue</p> 02:01 Understanding Payer Contracts</p> 03:04 Prior Authorization Guidelines</p> 05:28 Payer Reimbursement Policies</p> 08:08 Clean Claim Requirements</p> 11:34 Carve Outs in Payer Contracts </p> 14:03 Payer Plan Limitations</p> 16:24 Fee Schedules and Contracted Rates</p> 21:29 Requests and Recoupments of Overpayments</p> 23:34 Denials Without Proper Justification</p> 25:10 Timely Filing Guidelines</p> 27:17 Escalating Reimbursement Issues</p> 29:11 Conclusion and Next Steps</p>

00:32:51

Live Denials Q&A 9/17/24 - Utilizing Contracts When Resolving Denials

<p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 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.</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;">  </p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 00:00 Welcome to the Bimonthly Denials Q&A</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 00:26 Introduction to Denials and Career Background</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 01:27 Starting a Company and Industry Engagement</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 03:19 Denial Codes and Industry Changes</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 04:37 Complexity in Reversing Denials</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 06:35 Importance of Contracts in Denial Management</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 08:50 Accessing and Understanding Contracts</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 12:01 Technology Solutions for Denial Management</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 15:06 Open Q&A Session</p> <p class="MsoNormal" style="margin-bottom: 0in; line-height: normal;"> 23:12 Networking and Sharing Experiences</p> <p class="MsoNormal"> 52:18 Final Thoughts and Next Steps</p>

00:52:49

Ep. 33 Insurance AR: Claims with No Response

Navigating Insurance AR: Tackling Claims with No Response</p> 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.</p> Vanessa explains the significance of managing AR to maintain financial health and provides practical strategies for identifying, resolving, and preventing claims with no responses.</p> Key takeaways include the importance of tracking all claims, the role of technology, and assigning the right tasks to team members.</p> Vanessa also emphasizes the need for preventive measures and invites listeners to ongoing discussions and networking opportunities.</p> 00:00 Introduction and Welcome</p> 01:06 Episode Overview: Insurance AR and Claims with No Response</p> 02:00 Understanding Insurance Accounts Receivable (AR)</p> 03:57 Managing AR: Best Practices and Key Performance Indicators</p> 07:07 Focusing on Claims with No Response</p> 16:13 Steps to Resolve Claims with No Response</p> 22:22 Preventive Measures for Claims with No Response</p> 26:05 Conclusion and Upcoming Episodes</p>

00:27:49

Live Denials Q&A 9/5/24 - Hospice, SNF, Home Health denials + takebacks

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. </p> 00:00 Introduction and Purpose of the Q&A Session</p> 00:49 Challenges in Revenue Cycle and Denials</p> 02:07 Participant Introductions and Their Goals</p> 03:11 Open Forum for Questions and Discussions</p> 04:14 Lauren's Denial Issue with Chronic Care Management</p> 09:26 Exploring Possible Solutions and Resources</p> 21:08 Roseanne's Issue with Take Backs on ERAs</p> 28:22 Provider Targeting by Payers</p> 28:38 Options for Receiving Take Backs</p> 29:03 Challenges with Electronic ERAs</p> 29:44 Appeal Deadlines and Paper Forms</p> 30:11 Denials Due to Grouper Edits</p> 30:53 Hospital Denials and Resources</p> 33:13 Questions on Prolonged Services Billing</p> 37:08 Issues with Nursing Home Billing</p> 45:29 Seeking Expert Advice and Final Thoughts</p>

00:50:10

Live Denials Q&A 8/1/24 - Navigating Out of Network Denials

Show notes for today's live denials Q&A session:</p> <ul> <li> The differences in denials and appeals processes between in-network and out-of-network providers</p> </li> <li> Strategies for appealing out-of-network denials, including involving patients and leveraging laws like the Arisa law</p> </li> <li> Trends in payer requests for documentation and potential reasons behind sudden increases in these requests</p> </li> <li> Frustrations with payers' downcoding practices and lack of transparency in reimbursement</p> </li> <li> The shift in the medical field from a profession to a business, and the need for better revenue cycle education for providers</p> </li> </ul>

00:57:12