ochin billing workshop – part i

OCHIN Billing Workshop – Part I

Learning Forum 2012

1881 SW Naito Parkway • Portland OR 97201-5195 • Phone 503.943.2542 • Fax 503.943.2501 • Email: [email protected] • www.ochin.org

Charge RouterFunctionality Review and OCHIN Recommendations


What is the Charge Router?• Charge Router is a module sitting between

EpicCare and Billing.• A powerful tool that can review, modify and

distribute charges from multiple sources.• Charges from source applications such as

EpicCare Ambulatory, Interface, etc.• Charges can be sent to Professional Billing,

Hospital Billing or a 3rd party billing system


What can the Charge Router do?

• Charge Router Review WQs – Catch chart errors more upstream than Charge Review and

Claim Edit Review WQ– Hold charges until the whole encounter is completed and

ready for billing• Charge Handler Tasks– Data manipulation on the charges before they drop into

billing (i.e. add/delete charges, add/delete modifiers, change procedure codes, add pricing contract, etc.)


OCHIN RecommendationsWe have set up the following charge handler tasks for some OCHIN members, which might be beneficial for others as well:

• MAR Visit Hold Setup• Lab Visit Hold Setup• Addendum Biller Review WQ• Deletion of External Interface Lab Charges• Immunization Administration Charge Coding• Venipuncture Coding• Modifiers Addition/Deletion


• Work with your OCHIN Revenue Cycle analyst to request more information or to implement any recommended set up for your organization

• Questions?


Billing WQ Routing & Automatic Activities

Functionality Review and OCHIN Recommendations


How are credits created & resolved?

Created when a filed payment is:• A recoupment,• Left undistributed, or• Larger than the charge it’s matched to

Completed and removed from the Credit WQs when the balance is zero.


How are follow-up records created & resolved?

• Follow-up = charge + coverage

• Created when claim run is accepted.

• Completed & removed when insurance balance = $0


Organizing credit and follow-up records: Routing Setup

• Time-based – Deferral tabs in credit and follow-up WQs– Credit deferral WQs

• Rule-based– Self-pay vs. insurance credits– Payment types (co-pay, pre-payments) – Payor types– Many other options


Resolving credit & follow-up records: Automatic Activities

• Available per WQ or for entire SA• Can automatically perform:– Transfer to another WQ– Create an account note– Create an account letter– Send to System Deferred tab of a WQ– Perform auto-write offs, payment matching, and

transfers


Automatic Activities: Credit

• Auto Debit Off Small Balance• Auto Transfer Self-Pay Balance to Insurance• Auto to Oldest Outstanding Charge• Over-posted Payments Auto-debit


Automatic Activities: Follow-up

Define rules that automatically perform actions based on time elapsed:• Defer• Write-off• Resubmit claims• Perform an Next Responsible Party (NRP)• Change account status


Next steps

• Review your current credit and follow-up WQ workflows and needs

• Log a JIRA and meet with your Revenue Cycle Member Services analyst to discuss build requirements


Remittance Code MappingFunctionality Review and OCHIN Recommendations


Mapping of ANSI Codes

Why is this important?• Electronic files will not load correctly if an EOB/Remit

code is not currently in the system and/or mapped. How does a user know if this is the case?• Typically the Remittance is in a “Created” status.

Please enter a JIRA and an analyst will be able to determine if this is the case. They may request your assistance to determine what ANSI code it should be mapped to, if non-HIPAA standard code.


Mapping in EpicActions Taken:1-Not Allowed Adjustment2-Transfer to Self-Pay3-Next Responsible Party6-Write Off Insurance9-Denied14-Research

Consider: Review your Claims Research Follow-Up WQ. If there is a pattern of EOB codes that fall into that queue that do not need manual intervention, consider changing the mapping.

When in doubt….send to Research for Biller review.


Override Action/Assign Adjustment Code

• The Action and Adjustment codes can be different depending on the Payor.

• For example: The first screenshot can handle most if not all of your Commercial Payors, but maybe for your Family Planning Coverages/Payors you want a specific adjustment code stating “Family Planning Adj”.


NAA Vs. Write-Off• Difference between the action of 1-NAA and

6-Write Off Insurance• Benefits of using 1 instead of 6 (streamline of

manual payment posting)


Other Recommendations

• Remit files incoming with payor status of 4-Denial are mapped with action of 9-Denied

• If CO45 is sent by payor with full charge amount, override action of write-off/NAA and send to Research for biller review

• Identify patterns by code, by payor– Can map different actions at remittance code level

by SA and payor lists


Questions?

ochin billing workshop – part i

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