There’s Always Something New to Learn

If you are new to the medical billing business you will soon learn that there is always something new to learn. We’ve been running our business for 16 years now and we heard a new one from Medicare today.

When submitting claims to Medicare electronically they have always been paid in 14 days. When they are submitted on paper they are paid in 28 days. We submit to several different Medicare carriers and they are all the same. 14 days electronically and 28 days on paper.

Recently we started a new provider and sent her first batch of Medicare claims. Yesterday was the 14th day so we called to make sure they released the payment. We were surprised to hear they were still “pending”. After calling again today, to find them still “pending”, Michele talked to a rep who stated that yes they can be paid in 14 days but they have up to 30 days to pay. I don’t know if we have just been lucky that we’ve never run into this before. Anyone else out there seen this?

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Alice’s Marketing Corner – Use a Current Topic

When marketing your medical billing business it is a good idea to use a current topic to your advantage. Read Michele’s article about Medicare’s decision to change timely filing limits and then think about how you can use that to market. This is a great opportunity to put your marketing skills to use.

Medicare always gave us two years in the past to get claims paid. Now they are cutting it down to one year. Do you know of any offices that are having problems collecting Medicare payments? This is a great time to contact such an office and ask them if they would be interested in hearing how this new ruling is going to affect them.

You can use Linda’s great suggestion (on our forum) and offer to bring in lunch for the office to discuss this change. Or you can do a mailing centered around this change to many offices. Make sure you do follow up calls to the offices you mailed to making sure they got the info and asking if they are interested in hearing about the change in timely filing limits. At any rate whenever there is a change like this it is a great opportunity to market.

Medicare’s New Timely Filing Rules

CMS Changes the edits for timely filing denials on claims

Medicare has always had the most relaxed rules regarding timely filing. Under the old rules Medicare claims could be submitted for the last quarter of the year prior to the previous year – which means that claims for dates of service 10/1/08 or after can be submitted up to December 31st of 2010. There was a 10% penalty for any claims older than one year, but they would still be paid on. That has come to an end.

Under the new edits, claims will only be processed for payment for up to a calendar year. So for date of service June 22, 2010 the claim must be submitted prior to June 22, 2011.

The implementation of the new edits will be as follows: All claims with service dates prior to 1/1/2010 must be submitted prior to 12/31/2010 and will be processed according to the old guidelines. All dates of service 1/1/2010 and after will be subject to the new guidelines and will only be allowed within one calendar year.

This new ruling affects all Medicare provider types. It affects all physicians, providers and suppliers that submit claims to Medicare contractors including durable medical equipment suppliers, home health, Medicare Parts A & B. Basically anyone who provides services to Medicare beneficiaries and submits claims for those services.

It is important that anyone who does billing for Medicare providers understands the new edits. Much money can be lost. Don’t wait till the last minute. Begin clearing up any Medicare claims for dates of service prior to January 1st of 2010 now.

If you follow some key guidelines you should not have any problems even under the new edits. Claims should be submitted as close to the date of service as possible. If submitting electronically, electronic reports should be read and acted upon. Whether submitting on paper or electronically, follow up or aging reports should be run regularly and worked on. Any claims over 20 days if submitting electronically, and 45 days if submitting on paper should be checked on. Any denials received by Medicare should be acted upon quickly. If there is something that can be corrected, fix it and rebill quickly. If it is a patient issue, bill the patient so that they can handle anything from their end that needs to be done. This allows time to resubmit if necessary.

Honestly, the old rules were nice for us as a billing service. If we went into an office that was having billing issues we could usually recover most of their Medicare money. But with current accounts the timely filing edits didn’t effect us. Our policy is to not let claims get that old. But for offices that do not have good billing practices, the new edits may be tough.

Dealing With Overpayment$

Sometimes a provider is reimbursed too much money for the services provided which results in an overpayment. Sometimes the overpayment is made by the insurance carrier and sometimes it is made by the patient. In either case, it is important that the overpayment be returned to the appropriate person or carrier.

If a patient pays more than they are required to the patient must be notified as soon as the overpayment is discovered. The overpayment can be applied to a future visit if the patient will be returning but only if the patient agrees to that. The provider can not just indefinitely hold onto the money.

An example would be if a patient came in for an office visit and paid a co-pay. The provider ends up removing a mole which is considered surgery and doesn’t require a co-pay resulting in an overpayment. Once the office realizes the co-pay should not have been collected they can do one of two things.

1. Notify the patient of the overpayment. If the patient will be returning the office can suggest that they apply it as a credit toward the next visit. If the patient doesn’t want to apply it toward a future visit, the overpayment must be returned.

2. Send the patient a check for the overpaid amount with a note explaining the overpayment.

In any case a provider cannot just keep the overpayment. That is illegal.

If an insurance carrier makes an over payment it is important to first determine if it is truly an over payment. Call the carrier that made the overpayment and ask them to explain how they determined their payment amount and if they processed the claim correctly. If they confirm that they did make an overpayment they should reprocess the claim to show correct payment and send a request for the provider to return the overpayment.

Sometimes they will just ask the provider over the phone to return the overpayment. Personally I always ask them to request the money back with a written explanation. When you receive the written request for the overpayment attach a check for the overpayment to the request and send it to the address indicated on the request. If they don’t provide an address send it to the claims address but indicate “Attn: Overpayments”.

If you receive a payment from an insurance carrier and the entire payment is wrong or not rightfully due to the provider write “void” on the check and return it to the insurance carrier with an explanation of why the payment was not due. For example if the payment is for a patient that was not seen by the provider, write “void” on the check and attach a note saying “This patient was not seen in our office.”

If they state during the call that they processed the claim correctly and that there was no overpayment then you need to determine if there truly was an overpayment. Sometimes a patient has two insurance plans. The primary allows a certain amount and then makes payment Then the secondary processes the claim and allows a higher amount than the primary insurance carrier which results in a credit balance.

This is not actually an overpayment. The amount contractually adjusted off from the primary insurance carrier was more than needed to be adjusted off based on the secondary insurance carrier’s payment. Therefore there is not a true overpayment and no money needs to be returned. The patient’s balance just needs to be adjusted to offset the credit.

Sometimes a patient’s secondary insurance carrier is a privately purchased insurance. They do not always follow the same guidelines as other insurance carriers. Many times they ignore the amount paid by the primary and make payment as if no other insurance is involved resulting in an overpayment. In this case the overpayment amount belongs to the patient since they purchased the other insurance plan. The provider cannot just keep the money. The provider cannot collect more than he or she billed out for their services.

It is important that overpayments are not ignored. First determine if it is a true overpayment. If it is, determine who the overpayment needs to be returned to and then do what is necessary to return it. Remember only credit it to a future visit with the patient’s permission.

Individual NPI in Box 24J

In most cases it is mandatory to have the rendering provider’s individual NPI in box 24J when submitting cms forms. However, there are a few cases when box 24J needs to be left blank.

Most Medicare carriers require that box 24J be left blank if the billing provider is an individual provider. In that case, the provider’s individual NPI, or type I NPI would be entered in both box 24J and in box 33a. If this NPI is the same, Medicare requires that the NPI is NOT entered in 24J but that 24J is left blank.

I truly do not know why they do this, but it is the rule. So if you are submitting paper claims to Medicare for an individual provider who bills under just an individual NPI, or type I NPI, and Medicare has been denying your claims, that may be why. If the provider gets paid under a group NPI then you would put the individual NPI of the rendering provider in box 24J.