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 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
Prosthetists, including occularists
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.