Physicians and their staffs are busier than ever, and ever changing reimbursement regulations continue to add to their workloads. No one wants to leave money on the table with rejected claims, but local experts say that often is the case.
Billers sometimes are not inclined to review “dead” or no-pay claims, said Joanna Trivett, owner of MD Reimbursement Services in Birmingham. “They tend to put those in a stack because, of course, money is not coming in on them and they’re more interested in patients that have money coming in.”
Every insurance company gives a reason for nonpayment of a claim, and “you’ve got to work that,” Trivett said. “It could be simply coding it to higher level. It could be that the procedure you’re filing doesn’t match the diagnosis code or maybe you’ve missed a modifier that needs to be there.”
“The biggest deal now is NPI (national provider identification) and what it has done on the carrier level,” said Nancy Ellis, vice president of Birmingham medical billing and information technology firm MediSYS. “A lot of them are changing and modifying their systems, and we are changing and modifying our system to meet the requirements.”
With the new NPI numbers, the chances of claims being rejected are greatly increased, Ellis said. Instead of one or two claims being thrown out, the “whole batch” could be rejected, said Rhonda Boatwright, manager of software support services at MediSYS.
Electronic Claims
With the advent of NPI numbers, Medicare is pushing providers to file claims electronically. Small providers still are allowed to submit paper claims, but larger providers now are required to file electronically, Trivett said.
If a provider does not want to invest in new software, “CMS does provide (free) software that they can use,” she said.
Audit Trails
One of the main reasons for nonpayment is the failure to review audit trails on electronic claims, Boatwright said.
“If you think of an audit trail, it’s kind of like going to the bank and making a deposit, maybe of cash, and walking away without a receipt,” Ellis said. “You hope it’s in your account, but you really don’t know. That’s the same concept of the audit trail.”
If a claim does not pass what is known as the “level 3 edit” on the audit trail and the biller does not correct and resubmit the claim, the claim will remain unpaid. However, if a biller submits claims before a specific cutoff time in the afternoon, she can pull the audit trail the next day and know immediately if the transmissions were accepted, or if not, what corrections need to be entered, said Jane Weir, MediSYS quality assurance director.
“It’s kind of like balancing your checkbook,” Ellis said. “Nobody really likes to do it. You assume that no one is stealing money from you, or that everything balances, but if you ignore it for too long, it will have a snowball effect. And quite often, they don’t realize it until the check they’ve expected doesn’t come in the mail.”
For May, almost 26,000 Medicare claims were rejected in Alabama due mostly to NPI-related problems, Weir said. “That’s a simple thing,” she said. “If they (billers) were looking at their audit trails, they wouldn’t have these 26,000 claims being rejected.”
Diagnosis and Procedure Codes
To receive the correct reimbursement, a biller must use the proper diagnosis and procedure codes. Diagnosis codes can be up to five digits. Each year some codes change, and some will be raised to a higher level.
If you still use older three-digit codes, “you definitely need to be checking your coding books to make sure you’re coding to the highest level of the current year,” Trivett said. “That not only could limit your reimbursements, but sometimes they will be denied because it’s not a valid code anymore.”
Claims should include a procedure code for every service performed for the patient, Weir said. “That alerts the peer reviewers to know that these procedures need to be looked at in a different light than what they’re looking at them now.”
“Incident to” Rules
Physicians should be familiar with Medicare “incident to” requirements, said attorney Cynthia Ransburg-Brown, a partner in the Birmingham office of Sirote & Permutt who specializes in healthcare law. “You can bill a non-physician, or even a physician, as ‘incident to’ another physician,” Ransburg-Brown said.
For example, if a physician orders an injection and a nurse gives the injection, the service can be billed as though the physician provided it.
“The kicker is the doctor has to be in the office,” Ransburg-Brown said. “A lot of people don’t realize that the physician has to be on site — not necessarily in the room, but on site — so that the service can be reimbursed” at the appropriate rate.
“I think a lot of people run afoul of the ‘incident to’ rules, and you just don’t want to have to do a refund or a recoupment from the government. You might as well follow the rules from the get-go.”
Patient Information
Another problem area is out of date or incorrect patient information.
“If they do not have the patient’s correct insurance ID number, the claim will not go through,” Trivett said. “A couple of years ago, insurance companies changed from using Social Security numbers” to identify patients, but some practices continue to submit the wrong information on claims.
She recommends that at least once a year, physicians ask each patient to fill out a new information sheet to make sure details such as insurance numbers, address and date of birth are correct.
Also, a physician must obtain an authorization number for a referral if an insurance company requires one. Without that information, the carrier will deny the claim, “and you’ve just performed services for free,” Trivett said.
Fee Schedules
When the time comes for partners to discuss the annual budget for their practice, Ransburg-Brown recommends reviewing the Medicare physician fee schedule proposed for the next year.
“Look at the key codes the office uses to see whether or not there is a significant reduction planned for your key services for the next year,” she said. “It makes a big difference, like with some of the radiology services that were cut significantly in ’07.
“If you made plans to do something different in your office — add a new staff member, do some sort of expansion — and the government has cut significantly some of your major codes, you need to be prepared for that.”
July 2007
