User Guide — Claim Worklists Feature

athenaCollector

With the Claim Worklists feature, you can manage your HOLD and MGRHOLD claim work queues. Use the Claim Worklists page to set up claim worklists and associate these worklists with claim worklist teams, to give you optimal control over your claim work queues.

 

You can "pend" worklist claims that cannot be resolved immediately, set a default pend period, and set a default to return a pended claim to the user who pended it. Billing managers and team leads can quickly view and work claims that are in a pending or escalated status on the Claim Worklist Dashboard.

 

 

Pending claims removes them from the worklist's assignable claims for a specified number of business days. Pending records can be useful when an action must take place outside athenaOne before billing staff can take the next step on a claim.

 

Examples of outside actions include:

  • A patient or payer needs to return a phone call.
  • A form must be sent or completed.

At the end of the pend period, athenaOne returns the records to either the user who pended them or to the worklist's assignable claims, where any member of the team can work the claim.

 

 

  1. Display the Claim Worklists page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Claim Worklists, click Claim Worklists.
  2. Click edit for an existing worklist, or click add new.
  3. Pend claims for — Defaults to three business days for all existing and new worklists; edit as necessary.
  4. Return pended claims to user — Defaults to Yes (pended claims return to the user who pended them). Deselect this option to return pended claims to an unassigned status.
  5. Click Save.

 

  1. Display the Claim Worklist Dashboard: On the Main Menu, click Claims and then click Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Click My Worklist. The Default Worklist and all the worklists of which you are a member appear in the Workspace.
    Note: Users with the Custom Claim Worklists: Access All Worklists role, such as billing managers, see all worklists for your practice.

  2. Under My Claims, click pend next to the claim.

  3. Pend for — Enter the number of business days the claim will not be assignable.

  4. Return to me — Leave the box unchecked to return the claim to the worklist's assignable claims immediately when the pend period elapses. Check the box for athenaOne to return the claim to your worklist when the pend period elapses.
    Note: If you do not work or re-pend the claim immediately after it returns to your worklist, athenaOne sends the claim to the worklist's assignable claims list via an overnight script.

  5. Enter any notes in the text box.

  6. Click Pend.
    The claim moves from your list of assigned records and appears under My Pended Claims, in case you need to refer to or work the claim before the pend period elapses.
    Note: The claim is now counted in the Pended Claims column on your Claim Worklist Dashboard page and also appears in the Assigned to me column as a pended record.

 

  1. Display the Claim Worklist Dashboard: On the Main Menu, click Claims and then click Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Click My Worklist. The Default Worklist and all the worklists of which you are a member appear in the Workspace.
    Note: Users with the Custom Claim Worklists: Access All Worklists role, such as billing managers, see all worklists for your practice.
  2. Pended Claims — Click a linked number.
    The pended claims appear below it.
  3. Review the claims. Click the X icon at the upper right to close, or:
    1. Click un-pend to move the record out of pend status and either return it to the user who pended it or return it to the worklist's assignable claims, depending on whether or not the user who originally pended the claim checked the Return to me box.
    2. Click assign to me to move the record out of pend status and add it to your list of assigned claims.
    3. Click assign to me and go to claim to move the record out of pend status, add it to your list of assigned claims, and display the Claim Edit page for you to review and work the claim.
  4. Click Save.

 

 

 

With the Claim Worklists feature, you can manage your HOLD and MGRHOLD claim work queues. Use the Claim Worklists page to set up claim worklists and associate these worklists with claim worklist teams, to give you optimal control over your claim work queues.

 

If yours is an athenaEnterprise organization, you can establish claim worklists across multiple practices. The team function allows you to direct work to particular teams and to prevent other teams from easily accessing other non-assigned work. You can use the Claim Worklist Teams page to create the teams.

 

You can build workflow-specific queues of work to parse front-end scrubs from back-end denials and specify custom rules. You can:

  • Organize and sort the claims into very specific worklists.
  • Segment your claim work queues by workflow.
  • Create custom claim worklists across HOLD and MGRHOLD and then associate that work with a specific team.
  • Use the team feature to assign specific work to groups outside the current role architecture.

 

 

athenahealth recommends that you first create a list of current claim management workflows at your practice. This list should include the individual or team responsible for each workflow. You can create teams and worklists independently, as they are not predicated on each other in athenaOne.

 

Your practice administrator should assign the following user roles to the appropriate personnel in your practice:

  • Claim Worklists: Admin — Grant this role to billing administrators who will create and manage teams and worklists. Users with this role can access the Claim Worklist Teams page and the Claim Worklists page.
  • Claim Worklists: Access All Worklists — Grant this role only to billing supervisors or superusers who need visibility into all of accounts receivable (AR). Users with this role can access the Claim Worklist Dashboard, the Claim Worklist Teams page, and the Claim Worklists page. Users with this role are assigned escalated claims if they are available in a specific worklist. These users can de-escalate a claim or assign it directly to another user.
  • Claim Worklists: Productivity Reporting — Grant this role to users, administrators, and supervisors who need visibility into productivity and management of claim worklists. To see the Reporting tab, you must grant this role in conjunction with either the Claim Worklists: Access All Worklists role or the Claim Worklists: Work Claims role.
  • Claim Worklists: Work Claims — Grant this role to users who edit claims as part of their daily work. Their usernames will appear in the list of eligible users (by practice) on the Claim Worklist Teams page. Users granted this role can access the Claim Worklist Dashboard and escalate claims out of their worklists. If a user is also a team lead, that user is assigned escalated claims.
  • Claim Worklists: Manager Access — Grant this role to billing managers responsible for managing billing staff or billing work. Users granted this role can access the following advanced Claim Inbox features:
    • View the Claim Worklists and Escalations tabs.
    • View all pended and escalated claims in their worklists (the default filter options show claims pended and escalated by that user).
    • Escalate claims to any user.
    • View and assign all claims in hold (feature available only to users with the Claim Worklists: Manager Access role or permission).
    • Reassign claims to users (feature available only to users with the Claim Worklists: Manager Access role or permission).
    • Apply kick codes to claims (feature available only to users with the Claim Worklists: Manager Access role or permission).

Note: Team leads can view, work, de-escalate, and reassign any pended and escalated claims in their team worklists, in addition to working their own assigned claims.

 

 

 

Claims can be escalated for several reasons:

  • The user does not know how to work the claim.
  • The claim should be in a different worklist.
  • The claim needs to be addressed by a user with different expertise, for example, a practice manager or billing manager.

To view escalations, a user must have the Claim Worklists: Access All Worklists or Claim Worklists: Manager Access user permission.

 

You can use the Claim Inbox page or the Claim Worklist Dashboard page to escalate claims out of a worklist. If you cannot work a claim because it is improperly categorized or you do not have the expertise to correct the claim, you can move that claim to another user using the tool, eliminating the need to phone or send email.

The claim escalation does not route claims to athenahealth. The escalated claim disappears from your My Claims list and appears under a new heading, indicating an escalation.

 

The escalation point of contact can work the claim, reassign the claim to another user, or de-escalate the claim back to its original worklist.

 

Escalated claims never leave their assigned worklist, and they remain in a general pool of claims available to many users. The key difference between an escalated claim and a regular claim is the order in which claims are assigned to users with different permissions. Users who are expected to address escalations are assigned escalations before any other claims (if present). All other users are never assigned escalations.

 

 

 

 

The worklist processes all claims as part of a continuous script. It assigns claims to only one worklist, and it begins with the highest priority worklist first.

 

 

 

After a worklist is created, all claims that meet the criteria for that worklist will be placed in that worklist until they no longer meet those criteria or until that worklist is changed or deleted. From within a worklist, they will be assigned in reverse chronological order (oldest first.) This is why it is important to use date filters to build parallel worklists if there is any backlog.

 

 

 

The most recent hold will be addressed first. If there are multiple active holds, the claim will be moved to the worklist corresponding to the next hold once the most recent issue is addressed.

 

 

 

A team can be assigned to multiple worklists.

 

 

 

This is the number of claims an end user can assign to his or herself by clicking on the "Assign" button from My Worklist. This moves claims out of a worklist and into an individual's own worklist, until it is worked or released.

 

 

 

This moves a claim from an individual's My Claims worklist back to the worklist it was assigned from. It can then be re-assigned.

 

 

 

The script to update claims that are worked can take a few minutes to update the status of a claim on the My Worklist page. You do not have to release it; the claim will move on its own shortly.

 

 

 

The claim worklist framework respects all other permissions as set up by a practice. If a user is assigned to only a specific provider group, he or she will only be able to access claims within that provider group.

 

 

 

Currently, audit claims are identified via the athenahealth posting process as being Medicare RAC (Recovery Audit Contractor) claims. We will expand this to include other payers' audit systems as they come online.

 

 

 

 

The Custom Claim Worklist feature is not a solution in and of itself that will solve all AR problems. It is a set of tools that, when combined with best practice workflows, will provide improved visibility into the state of current AR for any practice.

 

 

If your practice has a large backlog of AR that has been untouched for longer than a few months, the first thing you should consider is creating duplicate workflows for your teams; one for current AR, and another for the backlog. This will ensure that the current claims do not lapse into backlogs. The way to do this is to create two identical worklists, but change the date filter so that one looks at claims that are part of the backlog (for example, claims that have been in their current status for longer than 30 days) and claims that are current (in their current status <30 days.) These can be assigned to the same team, such that the team can work through their current worklist, and then spend any time remaining on working the backlog. Use the naming convention of the worklist to call out the differences.

 

 

 

The value of the team creation tool is that it enables you to mirror how you are actually set up to work claims. If you have a back office billing team, but they are further segmented by provider group for instance, you can create teams to reflect how your teams structure their work. The easiest way to do this is to quickly map who is doing what work, and then create teams that mirror that structure. Remember, individuals can belong to multiple teams, and teams can be responsible for multiple worklists.

 

 

 

This is a great way to increase visibility into what a particular team is working on any given day. It also allows for a more fluid setting of priorities, at the discretion of the billing manager. For instance, you could have one part of the team focus on Self-pays, while another addresses OVERPAID claims.

 

 

 

This powerful tool groups various rejection reasons that are part of a family of problems. For example, if you create a parent worklist based on the rejection reason category "credentialing," you can group all credentialing-related issues in one bucket. You can eventually break this group into multiple worklists by other criteria, such as payer, provider, or age.

 

 

 

There are filters for Custom Rules. If you use Custom Rules to sort your work, create a worklist or worklists around them.

 

If you created Custom IRCs, they will appear as a filter on the worklist admin page. Use the previous work you have done to establish these to your benefit by managing AR with these custom IRCs.

 

Begin with broad criteria, and narrow your criteria as you become more comfortable defining worklists. It is best to begin with the broadest category you can think of, and then create multiple iterations of that worklist. Remember that the worklist will automatically assign work in reverse chronological order, so create a master list, and then begin by adding date filters.

 

 

 

As with any set of tools, there will be a period of adjusting to the newness of them. With client worklists, we've tried to lower the risk of experimenting with new worklists by making the system dynamic. That means if you create a worklist that doesn't turn out as you expected, you can make changes to it in real time. We established the Admin Only function of this tool so that administrators can begin to experiment with zero risk; because no one will be able to see worklists when they are created in Admin Only, there is no risk associated with creating and editing worklists.

 

 

  1. Create a worklist with a high priority for all Self-Pays. If you have a large amount of self-pays, consider breaking them into multiple worklists.
  2. Use the "Outstanding Amount" filter to segment claims into meaningful bands of value.
  3. Use dollar filters to eliminate zero-pay or low-value claims from certain worklists.
  4. Aggressively audit and update your teams and who comprise them. This should be done at least monthly, as well as on an ad hoc basis as needed.
  5. Use the days in status filter for any worklist that has a backlog. (Because the worklists will default to sort by oldest claim first, if you don't create a separate backlog, you will by default be assigning the backlog to your users first. Use multiple date ranges to create worklists banded by age. (For example, you can create a worklist that looks at claims in status less than 5 days, 6-14 days, 15-30 days, 30-60 days, 60+ days, or any other combination of meaningful date ranges.)
  6. Create separate queues for front-end scrubs and back-end denials. This will enable your teams to focus on getting claims out the door, or addressing denials, depending on what is most important to each team.
  7. Pull all your audit claims into a high-priority worklist by using the Audit Claims claim issue type. RAC claims are difficult to locate currently. The Audit Claims claim issue allows you to pull them all into a distinct worklist. athenahealth constantly updates our catalog of other payers' audit programs, and adds them to this category, so you do not need to actively monitor for new audit programs.

 

 

 

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