Billing for Suboxone Drug Therapy

Michele and I have been working on a book off and on for the last year on billing for Suboxone drug therapy. We’ve noticed that our blog entry on Suboxone treatment gets quite a few views and we’ve talked to many who have problems billing for this treatment. We work for a doctor who treats patients with Suboxone and have gone through all the problems of getting these claims paid. So we’ve decided to finish this book up and expect to release it over the summer. Just wondering if anyone has any specific questions in regards to Suboxone billing.


Did you ever have a problem getting your ERA’s? When you sign up for EFTs you get ERAs or electronic EOBs. It sounds like we’re talking in a foreign language – doesn’t it?

Medicare and many other major commercial carriers want to deposit funds directly into checking or savings accounts instead of sending paper checks so they try to get everyone to sign up for EFT or electronic funds transfer. 14 days after claims are submitted to Medicare a transfer is made directly into the providers account and an ERA is sent to the provider. An ERA is an electronic remittance advice. Now in some cases the provider will be signed up for the EFT but not get an ERA. Instead he or she will get a paper EOB.

You can be signed up for EFT without ERA. If you are signed up ERA then you either have to manually download them from the insurance carrier or get them thru your clearinghouse. But sometimes you are signed up for ERA but the ERA doesn’t come. If you get them thru your clearinghouse you need to contact them to find out where the ERA is. They usually will tell you to contact the insurance carrier. When you do that, they will either verify that the ERA was sent to the clearinghouse, or will detect a problem.

If they detect a problem, they usually will rectify it and reissue the ERA. If they confirm that they sent it to the clearinghouse then the clearinghouse will need to talk directly to the insurance carrier to determine why it wasn’t received and posted to your account.

Denial for Timely Filing

Each insurance carrier has guidelines for filing claims in a timely fashion. Some are as short as 30 days and some can be as long as 2 years. It is important to follow these guidelines or your claims may be denied for timely filing. Claims are often denied for timely filing when the claim actually was submitted in a timely fashion but not received by the insurance carrier. There are many reasons this can happen but the important part is how the biller responds to the denial. Sometimes claims are denied for timely filing when they were not filed within the timely filing period. This can be a problem.

Often claims are initially submitted with incorrect information. It may be a typo on the part of the biller, it may be that the patient offered the wrong insurance card at the medical office, or it may be that when the information was transferred from the person who took the info to the person who is doing the billing it wasn’t copied correctly. Lots of things can go wrong.

At any rate it doesn’t necessarily mean you won’t get paid for the services denied for timely filing but you do need to know how to handle them. For example, you may have submitted a claim in the proper time frame and it was denied for a reason such as incorrect ID#, patient’s name was misspelled, or it was originally sent to the wrong insurance carrier. Now you have fixed the problem and resubmitted it with the correct info but the carrier denies it for timely filing.

The denial must be appealed. Some carriers have special forms you must use, others don’t. If they do have a special form you should use it. Most likely they won’t accept the appeal if it’s not on their form. Usually the form will have a place to check off or write in the reason for the appeal. You should check off ‘timely filing’ or write in ‘denied for timely filing’. On one particular one we use we have to check ‘denied for incorrect reason’ and hand write ‘timely filing’ on the blank line. In any case you want to make sure you indicate you are appealing a timely filing denial.

If there is no form you could have a generic form that you use that just states ‘Claim denied for timely filing. Claim was originally submitted in a timely fashion. Proof attached.’ Whether you are using their form, or making your own, you should attach a copy of the claim, and your proof that you had filed it timely to that form. The proof needs to be something that shows when the claim was originally submitted and or when and how many times it was resubmitted.

If the claim was submitted electronically then you should have an electronic report showing the original submission. If the claim was denied electronically you may even have that electronic denial so that you can show what information was incorrect and that the claim was corrected and resubmitted.

If the claim was submitted on paper, your practice management system should provide you with some report showing the original submission date, and if the claim was submitted multiple times it should show each time submitted. Our system provides a patient ledger which shows the original date billed, the most recent date billed and how many times the claim was submitted in total. It must be something that was generated. It cannot just be a handwritten note stating ‘we submitted the claim on 1/1/2011.’
Reports generated from practice management systems generally cannot be altered and are accepted as proof by most insurance carriers. Some will state that if submitted on paper they must have proof from the post office that the claim was mailed. This is impossible for us and most. We mail so many items from our office it would be impossible to get proof on every item and then find a way to file that proof so that we could locate it if needed. There are very few carriers that will tell you this, but they are out there. The only way around this was if the claim was submitted electronically. They will accept clearinghouse reports as proof.

If your claim was denied for timely filing and it was not ever submitted in the time frame allowed then it is more difficult to appeal. If you have a valid reason for not submitting the claim then you can appeal based on that. For example, if the patient stated that they didn’t have insurance because they thought that they were not covered at that time but then found out later that they actually were covered, and the claim is then submitted but after the filing deadline, you could try to appeal. Write up a letter explaining exactly what happened, why the patient didn’t think they were covered, and what made them realize that they were. You’ve got a 50/50 chance, but it’s worth appealing.

Basically, if you feel that you have an explainable valid reason that the claim was not submitted in time, you can submit an appeal. If there was any way that the claim could have been submitted in the time frame, it will most likely be denied. But if you have a valid reason, it will most likely be overturned and allowed. It is important to file claims as quickly and timely as possible. But there are always things that come up that cause delays and timely filing denials do happen. If you have good systems in place, you will be able to appeal them quickly and efficiently and most will eventually get paid.

How Communications Affects the Relationship Between a Provider and a Medical Billing Service

In order for the billing to be done effectively it is crucial that the relationship between the billing service and the provider’s office is a good one. Frequent communications with your providers is key to a good relationship. It is important to keep them abreast of everything that is going on with their billing and all that you are doing. When we first started our business we didn’t see the point in telling a provider that we were taking care of a denial or appealing a particularly difficult claim. We assumed he knew we were taking care of it. But experience showed us that this is not necessarily true and you need to find a way to keep your providers up to date on the status of their accounts without bothering them.

Some providers say they don’t want to know about the issues, but someone in the office should be watching for what the issues are. You don’t have to speak to the provider every time you communicate. You can have a weekly fax or email that just gives the highlights of the issues for the week. It is important that they know that any issues that come up are being taken care of and you are showing them this by your weekly communication.

When there is no communications between the provider and the biller, the provider may assume that the biller is not doing that much because the biller isn’t telling the provider about all the things that he or she is doing. It is amazing how many things we do for providers that they never realize. If you don’t let them know then they don’t know you did it and they don’t realize all the services they are getting.

We work for many small providers who don’t keep track of their claims payments. Their whole perception of what is getting paid and what is not getting paid is based upon two things. Do they have any money in their checking account and the explanation of benefits they get from the insurance carriers. They rip open envelopes and tear off checks. If there is no check some only wonder what happened. They often do not understand the reason codes and have no idea why there isn’t a check attached. While we may be resubmitting a claim with a corrected diagnosis or ID#, one eob comes through as a denial before the second one comes through paid. Some doctors never notice that they were for the same claim. They only notice that one didn’t get paid.

To keep our providers updated of what we are doing, we send a simple fax or email when we complete the billing for the week letting them know what the issues were. It might read something like this.
Dorothy Winn—has incorrect ID# – do you have a copy of her ID card?
Melvin Black—appealed denial for timely filing with electronic reports
Mara Rosen—clearinghouse report states she no longer has that Blue Cross policy—so you have new info?

Much of the work you do is not just the data entry of the claims and payments but your providers may not have a clue as to the extent of this other work. If you are in the habit of letting the provider know, they will value you even more.

A lot of times billing services think that if they are not hearing from the provider then he/she must be happy. That is a really bad assumption. They may be thinking anything from “Wow my billing service is great!” to “Man, what are they doing over there? Sitting around playing solitaire?” If you want to be successful you really need to know what they are thinking. The best way is to ask. There is nothing wrong with getting in touch with a provider and saying “things appear to be going pretty smooth from our end. How do you feel they are going? Is there any areas you are concerned about?”

If they are worried about something they should tell you. Then you can either rectify it if it is something wrong, or clarify it if it’s a misunderstanding. Many billing services have lost clients based on lack of communication. It’s something that can be easily rectified.

Two More Books in the Works

We are on a roll now, spending quite a bit of time writing. Besides our new pricing book, we are working on two more books to be released in July and August. “Physical Therapy Billing Made Easy” and “Denials, Appeals and Adjustments” are next. Be watching for them!

Pricing Your Medical Billing Service

We are excited to announce that we will be releasing our 12th book “Pricing Your Medical Billing Service” next week. This book goes through the four common methods of charging for your services and all the things to consider. We list the pros and cons of each method and things that may influence your pricing. We tell lots of true stories that have happened to us as a result of the way we charged for our services. We also explain why one method is illegal in some states. It will be available in ebook format so you can download it to your computer.