6 Steps To Effectively Appeal A Claim

In a perfect world all submitted claims would be processed and paid, on the first submission.  But anyone in the billing world knows that is not how it works.  Many claims are processed and paid on the first submission, but some are not.  The ones that are not need to be dealt with. Some just need to have a minor correction and resubmitted, but some need to be appealed.

What does it take to successfully appeal a claim? 

  1. Have a process in place  –  knowing how to file an appeal and having a process in place for the most commonly filed appeals is key.  It will save time and frustration.  When a process is already in place, it makes preparing and filing the appeal much easier.
  2. File the appeal as quickly as possible  –  most insurances have a time limit on when appeals can be filed.  The quicker the appeal is filed, the better.  If for any reason the appeal was not received, it can be resubmitted if there is enough time.  If the appeal is filed quickly, it allows for these types of issues.
  3. Identify the reason for the appeal  –  make sure that the appeal is noted as an appeal and that the reason for the appeal is clearly stated on the first page of the appeal.  If the insurance carrier has a specific form, use that form and make sure to check the appropriate reason for appeal.  If no form is available attach a letter or cover sheet identifying that the claim is being appealed and why.
  4. Attach any/all documentation to support the appeal  –  the more documentation supporting the appeal, the more likely to receive a favorable response.   For example, on a timely filing appeal, attach any clearinghouse reports, practice management reports, and/or USPS reports showing when the claim was submitted.  Also attach a letter explaining any delays.  When submitting an appeal because the doctor disagrees with a service/procedure being denied for medical necessity, attach all medical records, a statement from the doctor explaining his/her argument, and any medical documentation supporting the service/procedure for the diagnosis.
  5. Note the patient’s file  –  make sure to document when the appeal was filed and how it was filed.  It is also a good idea to keep a copy of the appeal (electronically) so that it can be referenced if needed. 
  6. Follow up  –  If a response to the appeal is not received in a timely manner, follow up with the insurance carrier to find out the status of the appeal.  Sometimes insurance carriers will state that they did not receive an appeal.  If a follow up is done, the appeal can be resubmitted.  Don’t just sit back and wait for a response.  Most insurance carriers respond to appeals within 30 days. 

Many providers do not appeal denied claims.  This can cause them to lose a lot of revenue.  Appeals do not have to be complicated.  Once a system is in place it doesn’t take that much effort.  Follow the six steps above and stop your practice/provider from losing revenue that they are entitled to.

Update on place of service and modifiers for telehealth…

As the COVID-19 Pandemic continues, providers and billers look for updates on coding for telehealth services.  Prior to COVID-19 the average biller didn’t have to know anything about telehealth billing but post COVID-19 almost all billers have had to learn.  So where are we almost eighteen months later?  Basically in the same position. Each insurance carrier has their own guidelines for billing telehealth services.  Most of the restrictions have been lifted allowing almost all providers to provide telehealth services.  The insurance carriers were scrambling to set up guidelines for billing and they didn’t all set up the same.  Here are some of the ones we know:

Medicare requires that telehealth services be billed with a place of service code of 11 and a 95 modifier.

TRICARE requires that telehealth services be billed with a place of service code of 02 and a 95 modifier.

CIGNA  requires that telehealth services be billed with a place of service code of 11 and a 95 modifier.

MVP  requires that telehealth services be billed with a place of service code of 11 and a 95 modifier.

Aetna requires that telehealth services be billed with a place of service code of 02 and a 95 modifier.

Health First requires that telehealth services be billed with a place of service code of 02 and a 95 modifier.

Emplem requires that telehealth services be billed with a place of service code of 11 and a 95 or a GT modifier.

Most BCBS plans requires that telehealth services be billed with a place of service code of 02 and a 95 modifier.

There is no way to list them all.  Bottom line it is important to figure out how the carrier that is being billed requires it to be submitted and follow those rules.  If a claim is denied, check with the carrier to see what their requirements for telehealth services are and refile the claim.

7 Steps To Improve Billing And Collections

We get a lot of questions on how to improve billing and collections.  It is crucial in today’s world to make sure that all that is due is being collected.  Providers have added expenses to ensure patient safety in this pandemic state we are still in, and many offices cannot see the number of patients in the same amount of time, that they were seeing pre-pandemic.  It is important that nothing is slipping through the cracks. 

There are several things that can be done to improve billing and collections that start before the patient is seen, and continue on through until the claim is paid. 

  1.  Insurance Verification  –  we cannot stress enough how important it is to make sure the patient is covered under the plan/policy that they are presenting with.  There is so much confusion out there today with all of the Medicare Advantage Plans, and Medicaid Advantage Plans, not to mention patients changing jobs or employers changing insurance plans.  It is crucial to make sure the correct insurance is being billed from the beginning, and to make sure the provider accepts the patient’s plan and does any pre-authorization that may be required.  Since most insurances allow online access, this is an easy task.
  2. Accuracy inputting patient data  –  make sure the front office staff (or whoever is responsible for inputting the data) is careful when inputting the patient information.  Simple typos can be very costly and time consuming to correct.
  3. Verify information  –  when repeat patients come in, verify their information.  Make sure they have the same insurance plan, and the same demographic information.  Correct data makes for clean claims.  Incorrect data can cause delays or even denials of claims.
  4. Collect copays  –   copays should always be collected at the time of service.  It is more likely that a provider will be paid if the money is collected in the office.  Also, it costs money to send out patient statements.  If the copay is collected at the time of service it eliminates the chance that the provider will not get paid, and cuts costs of sending out statements unnecessarily. 
  5. Submit claims timely  –  we still hear of billers that hold claims before submitting.  There are different reasons behind why.  Some just don’t have time, while others believe that sending a bunch together is more efficient.   However, the quicker you submit the claim, the quicker you will learn of a problem if there is one, and the quicker payment will be received. 
  6. Check clearinghouse reports regularly  –  most clearinghouses provide daily reports of denials and rejections.  These should be checked regularly.  The quicker a denial or rejection is handled, the more likely it is to be corrected. 
  7. Work Aging Reports  –  most medical offices lose money on unpaid claims because they are not working aging reports regularly.  It is important that an aging report is run, and any claims outstanding over 30 days are checked on.  Most clearinghouses (at least the good ones) allow for claims to be checked through the clearinghouse.  At the very least they will indicate if the claim was accepted by the insurance carrier.  Most will provide payment information or the reason the claim wasn’t paid if it was denied.  Denials should be caught before the aging report, but if they slip through they will get caught now.  The aging report is the last step for catching money before it is lost.  Unfortunately many offices put this job on the bottom of the to do list and it often gets left untouched.  Offices that are not working the aging report regularly can be losing up to 30% of their revenue. 

Billing and collections is one of the most important jobs in the office.  It is right up there next to treating the patients.  If the providers are paid for their services, they won’t be able to continue treating patients.  Following the 7 steps above will help make that process as smooth and efficient as possible.

Is this a good time to get into Medical Billing?

Alice asked me to jot down my thoughts for this month’s newsletter and I thought “I don’t have time to jot down my thoughts!  I’m swamped.”   But then I stopped to think “Why am I so swamped?”  And that gives me the topic for my thoughts.  Over the twenty years we have been in business we have heard one question above all others:  “Is this a good time to get into Medical Billing?”  The answer has always been “Yes!” but now I say it with even more enthusiasm.

Lately we have been receiving more calls than ever inquiring about our services or asking for help.  Providers are being hit from all directions and they need help making sure they are not losing money.  PQRS, EHR, Meaningful Use, low reimbursements, higher out of pocket costs, and the list goes on.  It is more crucial than ever that providers make sure that the person handling their billing is doing a good job.  Gone are the days when providers could afford to lose a little here and there (not that I ever understood those days anyway!).  In order for a provider to stay afloat they need to make sure they are collecting all that they are entitled to.  So when anyone asks us “Is this a good time to get into Medical Billing?” we say “Absolutely!”

The next question we get asked is “What do I need to do to get started?”  That question cannot be answered in one sentence.  It really depends on your background.  Do you have any experience in medical billing?  Are you looking for a career or do you want to start your own business?  Do you have any experience in owning a business?  The answers to those questions will determine your next step.  Most people we come across have little or no experience in medical billing.  If you have no experience you really need to learn medical billing even if you plan on starting a billing business and hiring others to do the work.  You need to understand billing to know that they are doing everything right.

There are a lot of places that will tell you they will teach you all you need to know.  The problem is many of them are extremely outdated and can be outrageously priced.  Many are taught by people who have never done billing or who haven’t done billing in forever and they don’t really teach actual day to day billing. The billing field changes literally daily so it is so important that you are learning current billing and that whatever method you choose is up to date.  Alice and I have written several books on medical billing but our books are for specific parts of the business and just can’t teach you what you need to know to actually do medical billing.  So in 2013 we teamed up with Merry Schiff to create reasonably priced, current online medical billing classes.  You can read more about them at:  A Step Above Medical Billing Study Course..  So if you are considering a career in medical billing, Yes this is a Great time to get into it!

10 Must Ask Questions in Choosing the Right Billing Service

Outsourcing medical insurance billing has become much more prevalent in recent years. The need to collect maximum reimbursement for services has caused many doctors and therapists to look to professional billers to do the job. When a provider meets with a billing service to consider using their services there are several key questions that should be asked to determine if they will meet your needs.

What is the turnaround time for submitting claims?

The expected turnaround time for submitting a provider’s claims should be written into their contract and compliance plan. Most billing services submit claims within 3 to 5 days of receiving the claims but we have seen some who give no indication of when the claims will be submitted. Worse yet, we have seen billing services fail to submit claims after two weeks of receiving them. In order to avoid timely filing issues and to insure a constant cash flow it is crucial to submit claims as soon as possible.

Do they have a compliance plan and a business associate’s agreement?

While it is not the responsibility of the billing service to provide a business associate’s agreement it is a violation of HIPAA laws to not have an signed BAA between the billing service and the provider. All billing services should be aware of this law and make sure their clients are not in violation of any laws.

A compliance plan outlines in writing the policies and procedures of the billing service in regards to the services they provide. The Office of the Inspector General has issued a guideline for compliance plans for third party billing services.   The guidelines identify risk areas specific to third party billing services and can be found at http://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf. A provider can ask for a copy of the billing service’s compliance plan to see how they actually handle their work, training, internal auditing and continuing education.


What reports do they provide?

Reporting capability is an extremely important part of running a successful medical practice. There are many reports which when generated can give the provider a good idea of how the practice is running. Good practice management systems will provide many helpful reports. There are a few free practice management systems with very limited or no reporting capabilities. You want to make sure that reports will be provided upon request. The following are examples of some reports that should be available to you.

Insurance Aging Reports – All medical offices or their billing service should be running and working regular aging reports. These reports show all insurance claims which remain unpaid. These reports can be run for all claims out over 30, 60, 90 or 120 days. Any claims that have been sent electronically and not paid in 30 days should be checked on.   If the billing service is running regular aging reports they should be providing providers of the results preferably on a monthly basis.

Year End Reports – Will they provide a year-end report showing figures needed to report on income tax returns. This may or may not be a necessity to all offices but it is important to some.

Transaction Reports – Often a transaction report may be run for various reasons which can identify any insurance claims sent during a specific time frame or with a specific insurance carrier.

Day Sheet – A day sheet will provide a report of every entry that was made through out the day.

Patient Balance Report – This report will show exactly how much money is owed to the practice by each patient. This is often the report used to send out patient statements.

Insurance Analysis Reports – An insurance analysis report is often helpful to a provider to determine how much of their business is with each insurance carrier.


Will I be able to communicate directly with the person who does my billing?

Some billing services do not allow the employee who is actually working on the account to communicate with the provider.   While it is important to be able to go to the owner or manager of a billing service with bigger issues, the daily issues that come up with insurance ID numbers or dates of birth should be handled directly with the person working on the account.


Do they answer the phone and if not what time frame so they return calls? – This may seem like a “no brainer” but we have many providers tell us they cannot get a person in charge on the phone with their billing service. We have actually had a doctor hire us because we answered the phone when he called. We have also been told by providers that if their billing service does not want to discuss a problem with them they won’t return the call at all. This is crazy. In order to have a good working relationship it is imperative to establish good communication up front.


Do they require using their billing service forms? – If the service does require that you use their forms, make sure this will not cause a lot of extra work in your office. Most services are willing to work with the forms or system the provider is currently working with.


Do they have access to your money? – In most cases the checks or electronic deposits go directly to the providers who then forward payment notifications to the billing service. Some billing services set up a lock box to receive payments and then they are responsible for depositing all payments into the provider’s bank account. Some billing services even receive all cash payments made in the office and have direct access to the money in the bank account.  Unfortunately with the fraud and embezzlement that can be common in this industry this is not always a good idea. It is not necessary for a billing service to have access to the provider’s cash or bank account even if they do make the deposits.


How often do they work aging reports? – Aging report should be worked between every four to six weeks. With some carriers instituting 90 days timely filing limit and sometimes even less, claims can be denied for timely filing if aging reports are not worked regularly.   In our personal experience we find that many offices and even billing services do not work aging reports on a regular basis causing much lost revenue.


What is their system for patient billing? – Patient statements should be sent out regularly. Does the billing service have a system for patient billing? Do they handle collections?


These are just some of the important questions a provider should ask. There may be other questions that are specific to the provider’s needs. The important thing is that the provider should learn everything they can about the billing service before making a decision. All too often providers enter into an arrangement with a billing service without asking the right questions. Not all billing services are equal or will meet the needs of the provider. A provider should interview them thoroughly and check references before entering into a contract.





Business Associates Agreement Now Required

Back in September of 2013 it became a requirement that any provider using an outside medical billing service must have a Business Associates Agreement on file.  This is the responsibility of the provider, not the billing service, but only 2 out of over 40 of our providers even contacted us to see if they have one.  That amazes me.  I’m not sure why.  I know providers main task is to treat patients, but they must make themselves aware of the other responsibilities that they have as well.  If they don’t then they need to make sure that they have someone else looking out for them.

For example, have an office manager, or their spouse making sure that they are keeping up with all these changes.  I can only wonder how many are ready for ICD 10.


We recently sat down with a husband and wife, both MDs, who had no idea about the BSA.  We don’t do their billing but we do other work for them.  When we mentioned it they had no idea what we were talking about.  And their billing service didn’t mention it to them either (no surprise there though).


If you are a billing service, or if your office uses a billing service, make sure that the BSAs are on file.  If you are a service, do your providers a favor and do it for them.  Tell them it is their responsibility but you have one all ready for them.  They will appreciate that and knowing that you are looking out for them.  They will also be reassured that you are up on what’s happening.

New Marketing Opportunity

In the last two months we have signed up more new accounts than we generally sign up in a year.  When we talk to others we find that this is very common right now.  This is a great time for medical billing services to be out marketing.  Providers are looking for solutions to the problems that are arising with all the changes happening in the field of medical billing.  The change to ICD10s seems to be freaking out a  lot of providers.  Some just do not wish to update their software to become compliant with the changes.  Some just want some of this work taken from their offices.

We have also heard and seen ourselves that some billing services have recently gone out of business.   We were recently contacted by a marketing service we previously used.  Our representative told us that they have had really good results lately particularly with medical offices that have been billing in house.  They feel with all the changes in the field this year that it is too much to handle the billing in house any longer.  The rep also told us that several medical billing services have gone out of business leaving their accounts to find new billing services.

With the costs involved in updating practice management systems for the new CMS 1500 forms and ICD10 codes, many struggling businesses decided to call it quits.  We personally are seeing the results of a local billing service that wasn’t doing a very good job fall apart.  This is a great opportunity for the billing service that wants to offer great customer service to their clients to advance.  It’s a great time to be marketing!

Lots of Changes for 2014

It seems that this  year in particular there are so many changes in the field of medical billing that it is cause for concern in many medical offices.  With the implementation of the Affordable Care Act, (more commonly known as Obamacare)  (and what’s affordable about it??) the implementation of ICD10 diagnosis codes, the threat of being penalized for not satisfying the PQRS requirements and the newly revised CMS 1500 forms there is almost panic in many medical offices.

Everyone is asking how the Affordable Care Act is going to affect them and who really knows.  It’s going to cause more people to be covered with health insurance so there will be more doctor’s visits and more insurance billing to be done.  Other than that we don’t know what will happen.

The requirement to file claims on the newly revised CMS 1500 form requires new software.  This can be an expensive upgrade for many.  Some offices do not want to go through this and are looking for alternatives.

The implementation of ICD10 codes is going to be a challenge for many offices.  As we haven’t seen a change like this in many years it is difficult to predict how it will affect us.

Coding Course for Medical Billers Now Available

Medical billers do not need to know all the information required that a certified medical coder does, but a medical biller does need to understand medical coding.  There is much about medical coding that a medical biller does need to know about a biller’s responsibility regarding coding, when they can change a code to correct a denied claim, how to change over to ICD 10 codes and when they can use modifiers.  We’ve developed the product for those who need help understanding the coding aspect of medical billing.  Now available is our new online medical billing course “Understanding Coding and Modifiers” designed specifically for medical billers.  We offer this course individually or bundled with our other online medical billing courses.

Medicare Denying Payments Due to Enrollment

As of January 6, 2014 as part of the Affordable Care Act, Medicare will deny payment to Home Health Agencies, Imaging services, Durable Medical Equipment Providers and clinical laboratories for referred tests if the referring doctor is not listed in the PECOS system.  Doesn’t seem fair does it?  Seems like they are penalizing the wrong provider.

Why did this happen?  Since 2009 the AMA has strongly advocated to Medicare that it require the ordering and referring physicians to enroll or verify enrollment in Medicare through the PECOS online enrollment system. In 2010 Congress passed a law requiring physicians who order or refer testing for Medicare patients to enroll in Medicare and use their NPI numbers on such claims.

The Internet-based Provider Enrollment, Chain and Ownership System enables providers to submit an initial Medicare enrollment application, view or change their enrollment information,
track their enrollment application through the web submission process, add or change a reassignment of benefits, submit changes to existing Medicare enrollment information, reactivate an existing enrollment record, withdraw from the Medicare Program or
submit a change of ownership (CHOW) of the Medicare-enrolled provider.
See: https://pecos.cms.hhs.gov/pecos/login.do

CMS has now published a final rule on these requirements.  This new rule affects

  • Imaging or lab services, home health agencies, and DME suppliers
  • referring doctors of these services
  • medical billing services

The imaging centers, laboratories, home health services and DME suppliers will be affected by non-payment of services referred by the non-compliant providers.  If providers who are not enrolled in PECOS refer Medicare patients to them for testing or services, claims for those services will be denied .

The non-compliant referring doctors will be affected by the irate providers who are not being paid because the referring doctor was non-compliant.  They will be forced to comply or these facilities will refuse to service their patients.

The medical billing services will be affected by the marketing opportunity this presents.  Medical billing services can go to the PECOS website to see who is not compliant and then approach them about how they can help with this problem.

For a list of who is registered in PECOS click here http://www.oandp.com/pecos/

If you need to register with PECOS, it is not necessary to complete your application online. 

The 855I paper application form can be completed in place of the online PECOS application.  If a paper application form has been completed within the last few years the applicant will already be listed on the PECOS site.