Michele’s thoughts

We have always been the type of billing service that goes to all lengths for a provider.  We try to do everything possible to help them, as well as making sure we are doing everything possible to ensure that they collect what they are (legally) entitled to regarding their billing.  Cutting corners is not in our vocabulary.  Taking short cuts of writing things off that just need a little extra effort are against our policy.  Here’s where my perfectionism actually can go into overdrive.  But what I have learned over the years is that no matter what you do, no matter how hard you try, and no matter how good of a job you are doing, there are just some providers that will not be happy.  Whether it is that they don’t understand the whole process, or they just choose to not understand I don’t think I will ever know, but I am learning that you have to let them go.

Some providers just are not a fit.  Whether it is that they are not a fit for you, or that they are not a fit for any biller or billing service doesn’t matter.  What matters is that you recognize that they are not a fit.  “If it doesn’t fit you must acquit.”  Never mind, that was OJ.  OK so we’re not talking gloves that are too small but you have to have a sense of humor in this business or you will go crazy.  You also have to recognize when an account is not working out and learn to let go of them.  That can be hard if you have a personality like mine.  I want everyone to like me and I think I can fix everything, by myself, with no help, and make everyone happy.  Well, I can’t.  And that’s ok.

When you first start this business you figure you’ve got to take anybody to get your feet wet.  And sometimes that’s true.  But sometimes years later when you no longer need to take “anybody” you are still taking everybody whether they are a good fit for you or not.  It’s important to recognize that you need to analyze the situation to make sure it will be good for both you AND the provider before you take them on or when deciding if you should continue.  And if you already have a provider (or providers) that aren’t working out (and you know it!), you need to cut them loose.  It may not be easy, but you will be glad you did.

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New Year Denial Codes

With the new year has come several new reasons for denials of some of our insurance claims.  There were many CPT code changes that went into effect on January 1 so some of the denials we see are a result of these code changes.  Others, not so much.

One of the ones I found most interesting was for the first 12 claims I filed with a managed Medicaid carrier of the new year.  The denial stated that  the provider was not qualified to submit these codes.  I figured the problem was it the new codes, but a telephone call to the carrier revealed that the provider was not updated in the computer which they quickly corrected and reprocessed the claims.

Of course, you will find one or two carriers who were not yet ready for the new codes.  It seems the workers comp carriers seem to be behind in this area.  The point is to look into each denial reason and find out what the real problem is and then deal effectively with it.

Filing Effective Appeals

Medical insurance claims are often denied for a variety of reasons and a good biller must learn to file an effective appeal in order to limit write offs and keep aging claims to a minimum.  Denial decisions can often be overturned with a well written appeal.  When an error is made on the claim, often an adjustment can be filed to fix the problem but appeals are filed when a claim has been denied or paid incorrectly and there are no corrections that can be made to the claim.

There are several different methods of filing an appeal.  Some appeals can be done over the telephone while some appeals can be done through the insurance carrier’s website.  Other appeals must be filed on paper.  The secret to getting a denied claim paid by using an appeal is to do it right and to attach the necessary attachments to prove your case.

One of the most important things in filing an appeal is that the problem has not gone a long period of time with no follow up.  If you filed the claim nine months ago and never called to check to see what happened you have likely forfeited your appeal rights.  But if you have been experiencing an issue with a claim and have been acting on it on a regular basis, you have a good chance of getting it reversed and paid.  But you should make sure you have documentation showing the actions that have been taken.
Keeping track of the ongoing communications with the insurance carrier regarding the claim you are trying to appeal is very important.   We keep notes of every phone call, fax, or letter regarding a problem claim.  We note who we spoke to, what we were told and the date the communication took place.   We keep these notes in our practice management system on the claim encounter.  This information is critical to the successful overturn of a denial decision.

When it comes time to write the appeal, we determine the appropriate method of submitting it – either on the insurance carrier’s website, over the telephone, or in a letter.  We state all the facts of our attempt at correcting the problem and why we disagree with the determination.  We also attach copies of our records of the communication as well as any other attachments regarding the appeal.  For example, if a claim to a Medicare Advantage Plan is denied stating it is not a covered Medicare expense when we know that it is, we attach a copy of the Medicare LCD or NCD to support our claim as well as a copy of a Medicare eob showing payment for such services.  Of course we black out any PHI.   When you file a well prepared appeal and have good documentation to support your case, generally the denial decision is then overturned.

Common Reasons Claims Need to Be Appealed:

•    Timely Filing
•    Non Covered Service (when you believe it should be)
•    Requested Documentation not received
•    Reimbursement is not correct (claim paid as specialist with higher copay when provider is the patient’s PCP)
•    Services were bundled when they should not have been (insurance carrier didn’t recognize modifier(s))

Reasons a Claim Would Need An Adjustment instead of an Appeal
•    Claim was submitted with incorrect insurance ID number
•    Modifier was incorrect or missing
•    Date  of service was incorrect
•    Diagnosis was incorrect
•    Incorrect rendering provider was listed on claim
•    CPT code was incorrect