August 2007 Newsletter
Did You Know?…
Batch Rejects
Medicare provides electronic reports, entitled the “Batch Control Listing” (also known as the BCL) and the “Reject Report.” Within these reports, intermediaries will sometimes include “batch level rejects,” which regrettably, have been coined “batch rejects” in Quadax vernacular. This poor choice of words was realized recently while visiting a client, who interpreted this information as though all of their Medicare claims were rejected.
Rest assured, this is not an all-or-nothing situation; rather, it is typically a small number of claims within a days’ batch that fail the payer’s validation rules, usually in regard to the physician’s association to the group.
Recently, in conjunction with the use of the National Provider Identifier (NPI) and a corresponding taxonomy code, an increase in the frequency of batch level rejections was experienced as Medicare, and the provider community, worked through the registration snafus.
The ability to identify and then report these rejections to the affected client is complex, because the payer is reporting that the provider is not on record as being associated with the group; therefore, provider information is not returned. This then requires a manual interrogation of the original file and a comparison to the report, so that the tracking thread can be created and the claim regenerated within Xpeditor.
The backlog has since been addressed, and normal daily auditing of these files has resumed. Old habits die hard, but we are now more sensitive to the choice of words used to identify these situations, and future occurrences will be reported as “batch level rejects” in an effort to separate them from the more devastating “batch reject.”
Scraping Nuances/Effort
The creation of payer-rejected claims (those that make it through Xpeditor’s edits, only to be rejected by the payer—usually for eligibility-related matters) has been a well-accepted component of our service. As our client base grows, so too do the expectations of the process. At best, the scraping of details from the inconsistent variety of reports returned is an inexact science. We have written a Policy Paper on the topic, which our account representatives can provide on request.
An ongoing review of these report files does, on occasion, identify changes that need to be accommodated so that informational messages are not re-posted as rejected claims.
We will continue to rely on our customers, as well, to point out when the process breaks down, which is more frequent than any of us prefers! Format changes, NPI, and payer mergers have been the most recent variables affecting the accuracy and completeness of the process. Until or unless HIPAA concludes on a standard response file, the creation of payer-rejected claims will require diligence and teamwork to maintain this vital feature.
Remit Posting Files
Clients who have engaged Quadax to create “proprietary” posting files from a payer’s 835 are finding that the increased volume of changes is impacting the effectiveness of the process. For instance, payers now include a PLB segment in the 835 to report provider-level adjustments, which are not specific to a particular claim or service. Additionally, multiple adjustments per provider number can be placed in one of these segments.
Since this is a relatively new phenomenon, a vendor’s dated “proprietary” specifications may not include a mechanism to report these amounts, which could be positive and/or negative.
Attempts to accommodate our clients through the creation of formulas or calculations have produced a mixed bag of results and can create a snowball effect on remittance-related events for a particular customer.
If at all possible, we encourage all of our clients to post directly from the 835, since this “standard” will eventually apply across the board to all payers. Many of our clients are finding that their vendors are much more responsive to 835 quirks than to complaints regarding proprietary format shortcomings.
CMS-1500 Provider Addresses
With the advent of NPI, payers are more closely scrutinizing the address of the provider, the result of which has been an increase in the number of file rejects experienced by our Transmissions Auditing Department. New edits have been implemented that require more complete information, such as a full three-line address, to alleviate the impact on our global client base. On the whole, only a small number of our clients are experiencing these new edit messages.
Attending/Operating Physician Errors
On a routine basis, the EDG (Edits and Documentation Group) reviews claims that pass through the Quadax edit engine, but then subsequently reject at the payer. Regularly, we have found that claims without an appropriate Attending and/or Operating physician number or combination name/number are “forced” through the edit, only to be summarily rejected by the payers.
As requirements for NPI become stricter and contingency plans are eliminated, it is inevitable that Quadax edits will have to become tighter. By reviewing the variety of “batch processor” error reports available within Xpeditor, you can determine if you are experiencing a problem in this area.