Reference no: EM133398379

Case: Aaliyah is responsible for monitoring the cycle of an insurance claim for her employer, a large physician practice. The cycle begins at the practice when CMS-1500 claims are generated using medical management software prior to submission to the clearinghouse with which the practice contracts. Their clearinghouse processes nonstandard data elements into standard data elements because the practice submits claims electronically. Recently, Aaliyah has noticed that a significant number of claims have been rejected by the clearinghouse that the practice uses. Having been asked to contact the clearinghouse in an effort to determine the root cause of the rejections so that corrective action can be implemented at the practice, Aaliyah embarks on that important task.

Dakota was recently hired by Aaliyah on a temporary basis to fill in for the regular health insurance specialist who is on family medical leave. Dakota is credentialed and a graduate of a local medical coding and billing program (where Dakota learned how to complete claims, according to their resume), and previous work experience at a third-party administrator organization made it appear that Dakota had the appropriate background for the temporary position.

Aaliyah and Dakota met to discuss the volume of rejections from the clearinghouse related to recently submitted claims from the practice. Aaliyah explained the importance of accurate claims completion at the practice for submission to the clearinghouse so that the claims could be submitted in a timely manner to third-party payers. A summary list of the types of claims rejections received by the practice was shared with Dakota, who responded by saying that the completion of claims "from scratch" was not actually part of the job. At the third-party administrator organization, claims were automatically uploaded to the computer, and claim scrubber software was used to review medical claims for coding and billing accuracy before submission to the third-party payer. When errors were identified, Dakota submitted reports to appropriate health care provider offices so that corrections could be made and claims were made ready for submission to the payer. Those error reports were automatically generated, and Dakota just had to be sure the correct report was submitted to the correct physician practice.

Aaliyah immediately developed an understanding about the recent influx of claims rejections from the third-party administrator, and they worked together to develop a plan to ensure that future claims submitted would be accurate.

Use your critical thinking skills to brainstorm ways in which the plan was developed, including how Aaliyah and Dakota could ensure that future claims would be accurately submitted.

Question 1. Aaliyah has been asked to determine that root cause, and it has been identified. What is the root cause of the claims rejections from the third-party administrator to the physician practice?

Question 2. What plan will Aaliyah develop to ensure that future claims are accurately completed before submission to the third-party administrator?