Making Difficult Decisions

Difficult decisions

There usually comes a time in the medical billing business when we are faced with making a very difficult decision.  This decision may be either that you have to fire an employee or that you have to end a contract with a provider.  In the over twenty years that we have been in business we have had to make a handful of these difficult decisions.

Unfortunately with the number of people that we have employed we have had to make the decision to fire some of them.  With some it was an easy decision.  With others it has been difficult.  The bottom line is if your business is to succeed then you have to make the decision with the best interest of the business in mind.  You can’t go on emotion.

We’ve also had to make decisions throughout the years on ending contracts with some of our providers.  Sometimes those decisions are easy as well.  When we suspect a provider of fraud of any kind we bring it to their attention.  If they are not going to immediately rectify it, we terminate the contract.  No second thoughts.  But sometimes we have to decide to terminate a contract for other reasons.  Reasons that are not as black and white.  It can be a very difficult decision.

But again, we have to think about what is best for the business and sometimes accounts are not good for the business.  This can be difficult to accept, especially if you are just starting out and clients are not easy to come by.  But some accounts can be difficult (not the work itself!) and can actually cost you more to do than you get paid.  Sometimes one account can drain a business and make it so that the other accounts suffer.  It is important to recognize this and consider terminating the contract (or simply not renewing it) if that will be best for your business.

We have seen many businesses faced with difficult decisions.  Many times the owner (including us!) will let emotions come into play.  It is important for the success of your business that you face each decision with the question “What is best for the business?”

Adjustments and Appeals – What’s the Difference?

When does one file an appeal and when is an adjustment to an insurance claim appropriate?  This can be a confusing situation to a new biller.  When a medical insurance claim is rejected or not paid, usually some action must be taken.  Often it is either that an appeal must be filed or an adjustment to the claim made.
The basic difference between an appeal and an adjustment is:
An adjustment is done when a claim needs to be reprocessed for some given reason.  Appeals are done when there is a disagreement with an insurance company’s decision regarding the processing of the claim.
An adjustment is a request that a processed claim be reprocessed based on new or changed information now being provided.  Basically it is a request for information on the original claim to be corrected with this new information.  An example of the appropriate use of an adjustment would be if a claim was submitted with an incorrect diagnosis or CPT code.  The claim may be denied by the carrier and it is discovered that the claim had incorrect information.  An adjustment would then be filed with the correct information.
Some insurance carriers require the use of a specific form which generally may be found on their website to file an adjustment while others may accept a generic one.   Attach a completed adjustment form to the corrected claim and write “Corrected claim” across the top of the CMS 1500 form.   Circle the item that is being corrected and attach a copy of the EOB.
Appeals are filed when one disagrees with the decision the insurance carrier made in processing the claim.  Often claims are appealed for timely filing or when there is additional information that should be considered.  Appeals are sometimes filed by telephone but often either an appeal form or an appeal letter is required.   As with an adjustment, some insurance carriers require the use of their own appeal form which can usually be found on their website.
An example of when an appeal may be needed is if a claim is initially denied stating the service provided was not medically necessary.   However the provider feels that the service was warranted.  An appeal can be filed with a copy of the medical records and an explanation from the provider as to why the service was medically necessary.
For more information on filing adjustments or  appeals with many example letters, check out our ebook “Denials, Appeals & Adjustments”.  From now through Memorial Day you can get a 20% discount on the book with the coupon code SPRING