Are You Ready for 2010

The end of the year is approaching fast. There are many things that need to be done as the new year is welcomed in to prevent your office from losing money. It is best to be ahead of the game to prevent revenue loss. If you plan ahead and organize, you can breeze into the new year with smooth sailing.

One thing that needs to be done before the first of the year is authorization switches. If you are in an office that requires authorization for your services you may have to have the authorizations moved over to the new year. Many carriers have the authorizations end on December 31st of the current year. There may still be unused visits, but the authorization must be moved into the new year. If you are an office that deals with authorizations, make sure your auths are in order for the new year. If you bill for providers who deal with authorizations you may want to remind them to make sure their auths are in order.

There are also many insurance carriers who base their timely filing on the end of the year. For example, one of the larger carriers in our area has a timely filing limit of March 31st for all claims for services in the previous year. If you have carriers with this type of timely filing rule then it is important to do the followup on any outstanding claims. Don’t wait until March 29th. That is too late. It seems like a no brainer, but you wouldn’t believe how many offices lose money to timely filing. Followup should be done regularly all year long, but if you have a carrier that you know has a timely filing limit based on the end of the year you should plan for it. If you do the followup in early January you will leave yourself plenty of time to check them again and resubmit if necessary before the limit.

Whether timely filing is an issue or not, it is good practice to clean up any outstanding claims from the previous year as quickly as possible. There is a better chance of having the most favorable outcome on a claim, which for most of us is payment, when the claim is processed as soon as possible after the services were provided. Claims left to drag on and on into the next year are not as likely to be paid.

We like to go through the office in December and see if we need to make any changes. We review our filing needs to reorganize our files. As we grow, so does our need to file information received from our providers. December is the month we like to clean out our file cabinets and move information no longer needed into storage. We like to step back and look around and see if in our haste to get our work completed we have overlooked things that could simplify our work.

Many of us set New Year resolutions with grand plans of all the things we would like to accomplish in the next 12 months. It’s a good idea to review last year’s resolutions to see if you have been realistic in your planning. Don’t just make these resolutions, but make a plan to implement them.

Of course, we must consider that tax time is quickly approaching and it’s a good idea to organize your records to prepare for income tax filing. It is good to have systems in place for dealing with end of the year issues. It will make the process of transitioning into the new year much easier.

Expand Your Medical Billing Business

Later this month we will be releasing our newest book. The reason we are so excited about this book is that it will offer the new medical billing service a way to increase their income while expanding their marketing by providing an added service. We discovered this effective marketing technique quite accidentally. Actually it arose as the result of a challenge/problem.

A few years ago we were billing for an eye doctor who worked at Wal-Mart eye centers. He kept moving around to different Wal-Mart locations. Each time he took on a new location it required a new Medicare application and notification to all the insurance carriers he participated with. At that time we took care of any credentialing needs of our providers free of charge. After the fourth or fifth Medicare application, we decided we couldn’t do this any more. (Sometimes we are slow learners.)

We started charging for our credentialing services and found that our doctors referred us to other doctors for their credentialing too. We started getting calls for credentialing that also lead to leads for billing. The beauty of the credentialing was that we got paid up front for the service. We got paid by credit card for an application when we finished the application. We didn’t have to wait until the money came in from the insurance carrier and then for the provider to get billed and pay us. This can be a great advantage to a new biller in so many ways.

First of all, it brings in cash much sooner than billing will to a struggling new business. Cash flow was definitely a problem when we started our business and credentialing income back then would have greatly helped our success.

Secondly, much of our credentialing business is from beginning providers who may be looking for a billing service or at least open to hearing about your billing service after you have done a great job handling their credentialing needs. These new providers aren’t that much different than you are. They too need help in getting their medical business started. The most difficult part of marketing a medical billing business is getting to talk to the provider to tell them about your service. When you offer credentialing services, you find doctors calling you.

So how do you get started with your credentialing services? That’s what we are so excited about. We spent the last six months writing our first credentialing book “Medicare Enrollment – Completing the 855I Correctly”. This is the first of a series of credentialing books we are writing and will explain everything you need to know about successfully completing a Medicare application. We explain how to determine which forms you need to complete for each situation, where to find and exactly how to complete the application, what pitfalls to avoid for quicker processing, and we provide you with a list of the required information a provider needs to send to you. Basically we provide everything you need to start completing Medicare applications for providers.

We will be releasing our new book “Medicare Enrollment – Completing the 855I Correctly” in mid December. Watch for the announcement in an email. If you are interested in pre-ordering this ebook, you can send me an email at alice-solutions@cnymail.com.

Facilities Billing on UB04 Forms

It used to be that only hospitals and ambulatory surgery centers were considered facilities and needed to file their claims on UB04 forms. But there are many other providers that are also classified as facilities that are now being required to file their claims on UB04 forms as well.

Many out patient drug and alcohol rehabilitation providers are classified as facilities. In the past they were allowed to file claims on CMS 1500 forms. Recently we are seeing a trend where more and more insurance carriers are requiring these providers to now bill on facility claim forms, or UB04’s.

This presents a problem for these smaller ‘facility’ providers. They do not usually have a professional biller or coder on staff. The person, or people who have been doing their billing have no experience with UB04 forms and don’t know what a rev code is. Some start out thinking it can’t be that much different, but in reality UB04’s and CMS 1500’s are very different.

The UB04 form requires rev codes and a type of bill along with the CPT codes that are used on the CMS form. The format of the UB04 is totally different as well. It is important that you know exactly which fields need to be completed and what information goes in them. We most commonly see denials for incorrect type of bill.

Another problem is that most practice management systems do not come with the capability to print UB04’s. So how do you get the computer to print them out? If you are lucky, your practice management system will allow you to print a UB04, but unfortunately that is not the norm. So you have to find another way. There are some inexpensive UB04 fill and print softwares out there, but that means double entry. You have to put the data in the UB04 software to print the form, and you have to enter it into your practice management system to track the claim. Still this is a reasonable option for some.

Many others fill the forms out by hand, or by typewriter. Personally, not an option for me. However, some carriers will not take handwritten forms anymore, so this may not work. Another way around this is to outsource the claims to someone with the capability of filing on UB04’s.

If you find yourself in a position where you need to switch over from CMS 1500 forms to UB04 forms the best thing to do is evaluate your situation and decide what will work best. If you are capable of filing the forms yourself, then become familiar with the UB04 form and how it needs to be completed. There are resources out there to help.

The PMBA (Professional Medical Billers Association) offers a course called Facility Billing 101 which covers all aspects of billing on the UB04 forms. The cost is only $99 for PMBA members and $129 for non-members. You can get more information here.

Coding to the Highest Level of Specificity

Insurance carriers often deny claims for not being coded to the highest level of specificity. As many billers are not coders they often don’t understand what has gone wrong or how to fix it.

If a service line is denied for this reason they are saying that the diagnosis code needs to be more specific. Some diagnosis codes are only three or four digits but many are five digits. The diagnosis must be coded to the absolute highest level for that code, meaning the most number of digits for the code being used.

For example, the diagnosis for hypertension begins with 401. However if you submit a cliam with the diagnosis 401 it will be denied. The code 401 requires a 4th digit. 401.0 is malignant essential hypertension. 401.1 is benign essential hypertension. 401.9 is unspecified essential hypertension. So to bill a claim with a diagnosis of hypertension it must be either 401.0, 401.1, or 401.9.

Another example of a diagnosis needing to be billed to a higher level of specificity would be diabetes. 250.0 indicates diabetes however you neeed a 5th digit to specify what type of diabetes. 250.00 is diabetes mellitus type two, 250.01 is diabetes mellitus type one (juvenile type), and 250.02 is diabetes mellitus type one uncontrolled and so on.

As you can see in the above example just putting 250.0 does not indicate specifically what the problem is. Without the fifth digit the claim is lacking enough information to be processed and therefore will be denied.

If you are unsure if the diagnosis is coded to the highest level of specificity you can look it up in an ICD9 code book or on the web. There are several websites with current ICD9 codes available. They will indicate if the code is coded to the highest level.

Some practice management systems have scrubbers that will catch under coded diagnosis and give you a warning. Sometimes the biller may recognize a truncated diagnosis (or a diagnosis requiring an additional digit.)

In either case the biller should go back to the coder or provider and ask them to be more specific with the diagnosis code so the claim can be resubmitted.

New Mental Health Law Affects Benefits

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) signed by George Bush as part of the financial rescue package in October 2008 will take effect 1/1/2010. This law greatly affects mental health professionals and billers.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 made changes to the Mental Health Parity Act (MHPA) of 1996 which allowed for too many restrictions to mental health benefits. The problem with the 1996 act was that it allowed for too many loopholes and still encouraged discrimination against mental health benefits.

The 2008 Act closed up some of those loopholes. For example, the 1996 MHPA allowed employers to limit the number of visits for mental health treatment whereas the 2008 Act states that mental health benefits can be no more restrictive than medical benefits.

The new law attempts to make coverage for mental health benefits equivalent to medical service benefits. If a health plan allows for out of network benefits for medical services, they must now allow the same out of network benefits for mental health.

The major provisions for the new law are:

• Does not allow employers or insurers to place stricter limits on mental health services than they have on medical benefits. This means not allowing higher co-pays, deductibles or limiting the number of visits.
• If a policy allows for out of network benefits for medical benefits it must allow the same out of network benefits for mental health.
• If a policy allows benefits for substance abuse, both in and out of network, the limitations cannot be more restrictive than they are for medical or mental health benefits.
• Any state parity measures are left in place.

We currently see many policies paying only 50% of the allowable with the patient responsible for the remaining 50%. Under the new law this will no longer be possible unless the health plan pays only 50% of the allowable for medical benefits as well as mental health. We have even seen mental health plans that pay only $10 per visit.

The Act unfortunately does not cover all insured people. Employers with 50 or less employees are exempt from this Act. Also, the law does not require health insurance plans to cover mental health and substance abuse disorders. It only applies to plans that have coverage for mental health or substance abuse.

What does this mean to the mental health provider? Mental health providers will not see as much discrimination for their services. Patients will not be penalized for seeing mental health professionals and will receive equal benefits.

It’s not a perfect solution and doesn’t cover everyone, but it is definitely a step toward equal benefits.

Are You and Your Providers Breaking the Law

We have had a very hot topic on our forum lately regarding how medical billing services charge their providers. Most billers charge either a flat monthly fee, a per claim fee, or a percentage of the billing. But did you know that some states have laws on the books that prohibit physicians from entering into certain types of “fee splitting” arrangements?

It is very common for a medical billing service to charge a percentage of the money collected as a result of their efforts in billing the insurance claims but many billing services don’t realize that this practice is considered fee splitting and may be illegal. Several states have laws banning this practice and some have prosecuted doctors for paying this way.

The reason for fee splitting laws was not originally intended for medical billing services but does include billing services and providers including doctors, therapists and other health professionals. It was originally designed to prevent providers who had arrangements with other Medical providers to receive a kick back for referring patients for their services. But the way the law is written no one is allowed to share a percentage of the income of the provider except partners.

Many billers prefer charging a percentage as it provides a motivation for collecting all money due a provider and a selling point in marketing. It seems like an easy way to determine a reasonable fee and compare charges with other billing services.

Unfortunately it is the doctor or provider who gets in trouble for this practice. It is the provider who is splitting his or her fee.

The problem for the billing service is that the practice of fee splitting totally negates the contract with the provider. Although many billing services get away with charging a percentage in states where fee splitting is illegal, some states are starting to crack down on this practice.

If you are in a state which prohibits fee splitting or work with out of state providers who may reside in the fee splitting states it is a good idea to look at other options of charging for your work. Many billing services charge per claim, a flat fee, or at an hourly rate.

Many billing services who currently charge a percentage and learn about the fee splitting laws are reluctant to change. They have been using the percentage as a marketing technique and don’t know how to change to a different form of payment.

As Linda Walker points out on our forum, she uses not charging a percentage as a marketing technique. She asks the provider if they want to work with someone who would ask them to enter into an illegal contract.

If you are currently charging your providers a percentage in a fee splitting state there are several things you can do to change to a different method. Average out what the provider has been paying you for the last six months. Consider any unusual fluctuations in charges and come up with a flat monthly fee. You can also count the average number of claims each provider sends you in a month and come up with a per claim fee.

Yet another method would be to keep track of how much time you spend on each provider each week and multiply that times the dollar amount you would like to collect per hour. If you decide on the hourly rate make sure you allow for all your expenses not just your time.

The states which have fee splitting laws that we currently know of are N. Y., and Florida This does not mean other states do not have such laws. This list is just the ones we are aware of. Linda Walker has more information on the laws in various states on her website at www.billerswebsite.com. If you run a medical billing service make sure you are not breaking the law by charging your providers in this fashion.

How Mandatory Electronic Claims Submission Affects Us

Recently the state of Minnesota mandated that all medical claims are sent electronically by July 15, 2009. If you are not from Minnesota, you may not feel that this affects you, but it does. It affects us all.

Costs are definitely cut down with electronic billing. Both insurance companies and the government would like to see all claims sent electronically. If Minnesota is effective with instituting the electronic mandate, you can be sure that other states will follow. It is just a matter of time.

The real question is how will this affect the individual providers and billing services. A very small percentage of medical offices or billing services are capable of sending all their claims electronically. Many small insurance carriers are not yet capable of accepting claims electronically. So how will we accomplish this major undertaking?

The providers in the state of Minnesota will have to at the very least have a computer with internet access in the office or they will have to hire someone who can submit the claims on their behalf. Don’t laugh! We still find offices that don’t have a computer. They won’t have to purchase an expensive practice management system if they don’t want to. They may have a good way of tracking their claims on paper but hopefully they are tracking claims. Anyone who has been in this business for any length of time knows of the office that looses thousands of dollars or tens of thousands of dollars by not tracking claims to make sure they are paid.

The Trade Association of State HMO’s (The Minnesota Council of Health Plans) has contracted with an independent company who is building the software that will be available to medical offices and billing services in the state of Mn. to submit the claims online. The biller will go to the site and enter the claim information and send it to the insurance company. The only problem with this is that the information will have to be entered again for tracking purposes. If the office has a practice management system, any claims that had to be sent through this new system will also have to be entered into the practice management system.

We don’t know how this affects the smaller insurance companies in Minnesota who were not yet capable of receiving electronic claims submissions. I presume they are scrambling to get ready. Not only has Minnesota mandated that medical insurance claims be submitted electronically, but they have also mandated that all insurance carriers use ERAs or electronic remittance advices (electronic eobs). This is huge too. Electronic remittances make posting payments much quicker and easier if you have the means to post them automatically.

At any rate, it will be very interesting to see how this all works out. All eyes are on Minnesota. We would be interested in hearing from anyone in Minnesota and how it is affecting them.

Filing Medicare Claims

When submitting professional claims to Medicare part B, there are some things that Medicare requires that differ from other insurance carriers. If you do not follow these guidelines or rules, you will find that your claims will be rejected.

First of all, most Medicare carriers are requiring that claims be submitted electronically, even if Medicare is secondary. If you are not capable of submitting your claims electronically you can apply for a waiver. An office with less than 10 full time employees can obtain a waiver granting them permission to file on paper. The CMS requires you to obtain a waiver certificate “demonstrating extraordinary circumstances”. If accepted by Medicare, they can then file claims on paper. If you do not qualify for the waiver then you must find a method to submit your claims electronically.

If your software is not capable of electronic billing, which in this day and age would be unusual, or if you just do not want to go thru the expense or trouble, you can get a free software from your Medicare carrier. The biggest problem with using the free software is that it many times is cumbersome to use, and it requires double entry of the claims. However, if you do not submit a lot of Medicare claims it can be a viable option.

Another little quirk with Medicare is that they require you to enter the word “none” in box 11 (or the equivalent of box 11 if submitting electronically) on the CMS 1500 form. We have had many providers over the years contact us because “Medicare won’t pay!” when it was all just because they didn’t have the “none” in box 11.

Whenever we train a new employee that is one of the things we try to drill into their head! “Don’t forget the ‘NONE’!” There is nothing more annoying to me than getting a rejection to find that the only problem is that ‘none’ was missing. We are working with a company who is building a rules engine to prevent problems like this from getting thru. The claims scrubber will alert you to the missing word before you submit the claims!

Then of course there are the modifiers required only by Medicare such as the AT modifier for chiropractors or the GP modifier for physical therapists. These modifiers are not used by any of the other carriers, but without them Medicare will not pay.

Another thing Medicare requires is referring dr name and NPI number for simple in office services such as EKG’s. So if one of my doctors decides to do an EKG on one of his patients, I have to put HIS name and NPI number in as the referring doctor, even though he provided the service. Seems kind of ridiculous to submit a claim for Dr. Smith doing an EKG where Dr. Smith referred the patient to himself. But if I don’t put it in, the EKG is denied.

Another Medicare quirk is that many Medicare carriers (maybe all) require that you do not put the NPI number in box 24J if you are filing a claim for an individual provider who bills using just their individual NPI number. When the NPI number is in 24J for an individual provider, the claims are rejected. However, if you are filing a claim for a group, the individual NPI # must be listed in 24J and the group NPI# must be listed in box 33A.

When a claim is denied by Medicare or any other carrier, it is important to identify why the claim, or service, was denied. If the denial on the eob is not clear, call to get an explanation. If you do not agree with the reason for the denial ask what the process for appealing the denial is. If the claim was denied for something simple that you can fix easily, make the correction and resubmit the claim. If you do not understand the denial even after getting an explanation from a customer service rep, you can always Google it, or post a question on a good medical billing forum, like www.medicalbillinglive.com/members. The important thing is to take care of the denial and not to ignore it.

Most Medicare rules are consistent from carrier to carrier, but some are not. Rules change and you’ve got to be ready to change with them. Stay on top of the requirements, take care of any rejections, and attend any seminars you can. It is important to completely understand Medicare rules to do a good job at collecting the money due for the services rendered.

DME Suppliers Must Be Accredited by 9/30/2009

Medicare is mandating that all DME suppliers become accredited in order to continue to become reimbursed by Medicare DME carriers for supplies given to Medicare recipients. Accreditation is the process in which an independent organization evaluates a healthcare provider and certifies that the healthcare provider meets certain quality standards.

There are several accrediting organizations including the oldest which is Joint Commission on Accreditation of Healthcare Organizations (or JCAHO). Their process includes an evaluation of the healthcare provider’s clinical service as well as the provider’s administration process, personnel management and information management.

This mandatory accreditation is due to the Medicare Prescription and Drug Improvement and Modernization Act of 2003. Some areas in the country had to meet a deadline in the spring of 2007 to be accredited, but ALL (but those exempt) providers will have to meet the September 30 deadline. Any DME supplier who provides equipment and services to Medicare beneficiaries will have to become accredited if they want to continue to be reimbursed by Medicare for their services.

Those expept from this ruling are:

Suppliers providing drug and pharmaceuticals only
Physicians, including dentists
Audiologist
Optometrists
Orthotists
Prosthetists, including occularists
Opticians
Occupational Therapist
Physical Therapists

The accreditation process can take from 9 to 12 months. As we approach the deadline the demand on these accredting organizations will become greater and the process may take longer. Any provider needing to get accredited should decide which organization they want to go through and contact them as soon as possible.

The organization will inform them as to the process. Most likely they will review the current services, practices and policies to determine if they meet the standards. If the standards are not met, they will determine what changes need to be made and develop a plan for the provider including a time line for implementing the necessary changes.

Once this is complete, the provider submits an application for accreditation to the organization. The application can be submitted when the changes are being made. The accrediting organization will then review the application and any supporting documentation and determine whether the supplier is eligible for accreditation.

The cost of becoming accredited varies depending on the size and complexity of the provider applying. Prices include the cost of surveyor, travel expenses, hotel, etc. The best way to find out what it will cost is to contact one of the accrediting organizations and ask for an estimate.

GW Modifier for Care Unrelated to Hospice Terminal Care

Many billers think that if a patient is a Hospice patient that they cannot get reimbursed for services if they are not reimbursed by the Hospice carrier. But actually there is a modifier, GW, that indicates that the care is unrelated to the patient’s terminal condition. In order for a patient to receive Hospice services they must have a life expectancy of six months or less if the terminal illness or disease runs its normal course.

Many people mistakenly think that this means that the patient must be bed ridden or critically ill. However, that is not always the case. In fact, many hospices encourage the patients to continue with social and recreational activities as long as they are able. They try to make the patient’s last few months, or weeks as fulfilling as possible.

This in some cases means that the patient may need to see a medical provider for something that is not related to the terminal condition. For example, maybe the patient has low back pain and seeing a chiropractor gives the patient relief. Their terminal condition is an inoperable brain tumor, or an inoperable aortic aneurysm. The back pain is not related to the terminal condition. The patient receives relief from the chiropractic manipulation.

The chiropractor can still see the patient even though they are receiving hospice and the chiropractor doesn’t have to get hospice to agree to pay for the care. They can bill the patient’s insurance using the GW modifier to indicate “service not related to the hospice patient’s terminal condition”.

There are other examples of care that can be rendered that is not related to the terminal condition. Maybe the patient gets conjunctivitis and needs to see an ophthalmologist to get treatment. Again, the service is unrelated to the terminal condition, but you can’t just ignore the conjunctivitis.

For me the problem is that I use the GW modifier so infrequently that when I need it I can’t remember which modifier it is. So I decided to make it an entry in my rolodex so that when it comes up, I can find it easily! Hey, whatever works.