User Guide — Working the A/R

Full payment of a claim is not always achieved right away. If we have not heard from an insurance payer after a certain number of days, an "alarm" is triggered, and athenahealth will contact the payer about that claim. athenahealth will place phone calls, send faxes, check websites, or send demand letters regarding claims. The alarm waiting periods vary from payer to payer and are based on our experience of how long it takes that payer to respond.

athenahealth commits to initiate a follow-up contact within 20 business days on at least 95% of the claims that have remained outstanding past our standard waiting period — that is, after an alarm has been triggered. If we fail to meet that standard, we will credit you 2% of that month's invoice for every 1% below 95%.

Sometimes a claim is denied. athenahealth researches denied claims to determine whether the denial was legitimate and to establish whether there is any chance to get the claim paid. If we do not think the denial is legitimate, we will contact the payer and — based on the payer's guidelines — ask for a reconsideration, resubmit the claim after you have corrected it, or formally appeal the denial.

We use our payer knowledge and CMS's own CCI guidelines to support our activities. Often, we need additional documentation to support our appeal, in which case we will move the claim to your list. After you attach the necessary documentation, we will complete the appeal.

athenahealth commits to examine and take action on at least 95% of your denials within 10 business days. If we fail to meet that standard, we will credit you 2% of that month's invoice for every 1% we fall below 95%.

Sometimes you may disagree with our assessment of the legitimacy of a denial or zero-pay; that is, athenahealth believes that the denial is legitimate and you do not. In these cases, you may request one courtesy appeal on the claim, which we will prepare and submit for you.

Payers sometimes "pay" a claim with $0, which means "we're not denying this charge, but we're not paying for it either because it's within the global period or it's part of this other procedure performed the same day." athenahealth calls these situations "zero-pays."

We work zero-pays for $200 or greater on your behalf by assessing them for appealability and by submitting appeal letters citing the CCI standards in cases we believe have merit.

Note: We first post the adjustment and then group all the adjustments for assessment, so you may see zero-paid claims in CLOSED status that are actually being appealed.

If you find a zero-pay for less than $200 that you would like to appeal, you can tag the claim and we will send the appeal. Sometimes you need to provide more information in order for athenahealth to submit an appeal according to CCI, similar to denials.

If the receivable is the patient's responsibility, you must make the determination to send that balance to your designated collection agency. athenahealth maintains relationships with collection agencies and can set you up with an agency during onboarding. You can use your own agency instead. If you choose an agency that does not have a relationship with athenahealth, you will be responsible for producing and delivering the data that your agency needs.

athenaOne can track your contracted rates in what we call "allowable tables," compare actual payments, and provide you with concise data that will allow you to spot systematic underpayments. The Payment Mismatch Tracking report in athenaOne is designed to make it easy for you to prove to the payer that it has made a mistake in its adjudication system.

You are responsible for loading your allowable tables based on your payer contracts. athenahealth does not call the payers on your behalf because, in our experience, underpayment errors are most commonly the result of data-entry errors at the payer. The way to fix the problem is to contact your Provider Relations Representative. Because the contract is between your organization and the payer, athenahealth cannot be as effective as you are in making the case.