For the lack of a single billing code modifier, a specialty practice lost reimbursements equaling 16 percent of their gross income in their first year. "When we refiled the claims for that one doctor, it recovered $8,000 within four weeks," says Judy Campodonico, director of operations with MRG Management Services.
The error had been a common one: failing to add the 25 modifier to designate an office visit in addition to a procedure. "This is especially prevalent in procedural driven practices where the practice receives its procedural reimbursement, but nothing for the office visit portion," Campodonico says. Common situations for this kind of oversight include removing lesions or administering steroid and cortisone injections.
Campodonico stresses that action makes money. "If you miss something, correct and refile the claims to get the proper reimbursement," she says.
The same with denied claims — take action and appeal them. "I would say in 75 percent of the offices I visit, denied claims are either written off or get stuck in accounts receivable unaddressed," Campodonico says. "It may not be a huge percent of their claims — say one or two a month — but over a year's time, that can add up to a lot of money."
To ferret out denied claims, scan each carrier's payer report when it arrives. This states the status of each claim as accepted, denied or adjudicated and the reason why. "Go back to every line item and make necessary corrections to maximize your reimbursements," Campodonico says.
Many claims fail for simple reasons that can be easily corrected. For example, putting a number sign before a patient's apartment number will cause that claim to kick out and be denied. Correcting typos and the use of symbols represent easy fixes for a quick recovery of fees otherwise left ungathered.
Campodonico has about an 85 percent success rate with appeals using a simple process. "Carriers have medical policy rules, but that doesn't mean they won't reconsider for medical necessity when presented with thorough documentation."
Her ace-in-the-hole for successful appeals lies with a concise summary sheet and the involvement of a physician. "If you present the appeal professionally with your ducks in a row, carriers will respond," she says.
The summary opens with a brief paragraph asking the carrier to please reconsider the claim and states the reason. Then it lists the patient information and ID number, the date of service, and the provider name and number.
She also itemizes the enclosed documentation, such as labs, x-rays, treatment notes, and diagnostic test results on that front page. "Anything that was pertinent to that visit is included, so there's no questions they can ask and nothing is left up to interpretation," Campodonico says.
The final coup de grace rests in a short letter from the performing physician. Involving the physician adds a level of gravitas that's lacking when the billing department alone makes the request.
"Physicians don't mind writing a short letter explaining the need for treatment when they find out they're not getting paid," Campodonico says. "I know it's time consuming, but it's important. Don't let money sit there on the table or write it off. You might find that you're seeing some patients for free."
A common fee often left unclaimed results from fulfilling a carrier's request for additional information. In Alabama, practices earn a $5 research fee for each request, plus $1 per page for the first 25 pages and $.50 per page after that. "Blue Cross Blue Shield (BCBS) often requests information while they're holding the claim. But they will reimburse you for that effort," Campodonico says.
Do not leave this fee to the honor system, though. Attaching an invoice noting how many pages were sent ensures compensation for staff time, postage and copies. "Make sure the carrier knows they have to pay, rather than leaving it up to them. You don't want any room left for it to be overlooked," Campodonico says.
Beware the varied claim submission deadlines as well. Because of their dominance in the market, BCBS' and Medicare's one-year deadlines are common knowledge. The smaller carriers, however, offer less time to act. HealthSpring and Viva present a six-month deadline for claims submission, while UHC only offers 90 days.
The greatest danger with tight deadlines lies with Medicare patients who don't realize they're on HMOs. By the time the provider has submitted the claim to Medicare, and then reviewed the payer report to discover the denial, a good bit of time has elapsed. At that point, the shorter claims deadlines may have passed, and the provider never gets paid.
The Medicare denial code signifying a patient has HMO coverage is CO24. When discovered on the payer report, a simple call to Medicare customer service will generate the name and number of the HMO carrier for that patient. "Then call the HMO and say the patient isn't clear about their coverage," Campodonico says. "Give them the name and date of birth, and they'll usually give you the ID number, so you can file the claim and get paid."
"It's easy to get stuck in a rut on how you handle your reimbursements," she says. Annual internal reviews to keep up with changing requirements and outside audits can smooth glitches and insert needed steps to regain overlooked revenue. "Sometimes you've got to fight for what you've earned and think outside the box," Campodonico says. "Otherwise, you miss out."