Episode Overview:

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.

Key Topics Discussed:

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

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.

Mastering Payer Defense

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. 

00:00 Introduction and Overview

00:13 Understanding Downcoding

00:53 Expert Insights and Strategies

02:20 Importance of Contracts in Payer Defense

03:49 Presenter's Background and Expertise

06:00 Webinar Disclaimer and Initial Questions

07:10 Best Practices for Denial Escalation

11:39 Identifying and Addressing Downcoding

19:58 Effective Payer Conversations

29:22 Navigating Payer Relations and Contracting

31:01 Effective Appeal Strategies

33:40 Documentation and Professionalism

37:43 Leveraging State Insurance Commissions

43:33 Filing Grievances: Medicare and Commercial Plans

48:47 Legal Complaints and Final Steps

52:19 Q&A and Closing Remarks

Transforming Healthcare Revenue Cycle with Technology and Human Expertise

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. 

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.

Learn how to balance human intervention and automation to achieve efficiency and long-term financial success. For more information, contact Vanessa at [email protected] and connect via LinkedIn or Facebook.

00:00 Introduction and Webinar Overview

00:11 About Vanessa Moldovan

00:48 Mission and Services

01:58 Importance of Technology in Revenue Cycle

05:50 Key Terms in Technology

09:37 Understanding Information Technology

11:31 Software as a Service (SaaS)

28:50 Human Factor in Technology

35:49 Challenges in Revenue Cycle Management

36:57 Understanding Common Objections to Technology Adoption

37:55 Overcoming Resistance and Bad Experiences

40:07 Perception of High Costs and Value Challenges

42:34 Preparing for Technology Demos

44:46 Maximizing Demo Effectiveness

50:39 Evaluating Technology Integration and Support

01:03:36 Exploring Innovative Technologies in Revenue Cycle

01:10:29 Conclusion and Contact Information

Mastering Medical Billing: Overcoming Claim Denials and Utilizing Key Resources

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.

00:00 Introduction and Initial Query

00:18 Clarifying the Issue with Modifier 90

01:00 Understanding CLIA Requirements

05:25 Dealing with UnitedHealthcare Denials

07:12 Exploring Other Potential Issues

09:33 Addressing Sentara Insurance Glitch

12:00 Blue Cross Medical Advantage Claim Issues

18:06 Cigna Appeal Process Challenges

22:01 Medicare Advantage Plan Denials

26:44 Medicare Billing Challenges

27:17 Humorous Anecdotes and Introductions

28:02 Addressing New Biller Concerns

30:06 Sharing Tips and Resources

31:33 Useful Websites and Tools

34:08 Insurance Company Contacts

35:02 AAPC Website Resources

36:32 Medicare Denial Codes and Policies

37:43 Importance of Bookmarking Resources

39:20 Access to Payer Portals

40:47 Training and Networking

42:00 Medicare Billing Programs

44:42 Final Thoughts and Suggestions

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 [email protected].

00:00 Introduction and Newcomers

00:18 Challenges with Denials

01:12 Colonoscopy Coding Issues

01:54 Connecting with Experts

03:55 Educational Resources and Support

07:07 Podcast Discussion

08:27 Using Contracts to Fight Denials

10:54 Preparing for Payer Meetings

20:26 Duplicate Claims and Denials

24:05 Understanding Adjudication and Denials

25:33 Credentialing Denials: Challenges and Solutions

28:18 Common Issues with Authorizations and Network Status

30:47 Fighting Back Against Incorrect Denials

37:06 Technology and Tools for Managing Denials

42:08 Addressing Underpayments and Downcoding

50:06 Final Thoughts and Best Practices

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 [email protected] 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