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.

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.

 

 

 

 

Taxonomy Codes on the New CMS 1500

Some insurance carriers are just beginning to require the use of taxonomy codes on insurance claims.  Our local Blue Cross Blue Shield recently sent us a notice that taxonomy codes must be reported on insurance claims effective June 16, 2014.  Claims submitted without taxonomy codes will be returned according to BC/BS.

This is just the very beginning of the requirement of the taxonomy code, but we will see more insurance carriers jumping on board.  A taxonomy code is a national specialty code used by providers to indicate their specialty or provider type.

There were many new changes that went into effect this year and it is crucial that all offices keep up with these changes to insure a consistent income.   Taxonomy codes for each provider can be obtained on the NPI website by doing an inquiry on the provider you require the taxonomy code for.  Taxonomy codes should be entered in box 33b on the CMS 1500 claim form.

 

 

 

 

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.

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.

Understanding PQRS

In order to keep from being penalized next year we will need to learn about the new PQRS or Physician’s Quality Reporting System. It is required by Medicare to report patient’s condition and treatment. The program is supposed to be an incentive by allowing for a small payment for participation but in 2015, next year, physicians will be penalized for not registering and participating in the program. This is quite complicated and covers many specialties as well as PCPs. It will amount to a secondary CPT code added to the claim. We will be offering more information on PQRS next month.

It is used to report not only the present condition of the patient to Medicare but the ongoing goals and how the patient is proceeding through the course of treatment.  This is only for Part B (professional services, Railroad Retirement and Medicare Secondary Payor by eligible providers. These eligible providers are:

Doctor of Medicine
Doctor of Osteopathy
Doctor of Podiatric Medicine
Doctor of Optometry
Doctor of Oral Surgery
Doctor of Dental Medicine
Doctor of Chiropractic

Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
Certified Nurse Midwife
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional
Audiologists

Physical Therapist
Occupational Therapist
Qualified Speech-Language Therapist

New Online Medical Billing Course Available

We now have available 6 courses up and running for our online medical billing course with the last four available next week.  Included are:
  1. Introduction to Health Insurance and the Medical Billing process
  2. Understanding Coding and Modifiers
  3. Life Cycle of an Insurance Claim
  4. Billing Medicare, TRICARE and Medicaid
  5. Billing Blue Cross/Blue Shield, Commercial, Workers Comp and More
    HIPAA, HITECH and Regulatory Issues
  6. Reading EOBs, Handling Denials and Filing Appeals
  7. Working with a Practice Management System
  8. Operating a Medical Billing Business
  9. Marketing a Medical Billing Company
   Each course may be purchased individually for $129 per course or you may purchase one of our specially discounted bundles packages here.
     We are offering a special limited time discount to our readers.

Medicare Psychological Rates Increase

Medicare announced rate increases for mental health services this week.  According to the Centers for Medicare and Medicaid Services some of the greatest increases for 2014 Medicare payments go to providers of mental health services including clinical psychologists. 

The largest increases will be for neuropsychological testing.  There were a few codes that the rates were reduced including an initial evaluation, the 90791 which was reduced by 15.5%.  According to the APA the following are estimates of the approximate change to individual codes. 

Code

Percent Increase/Decrease

Psychiatric diagnostic evaluation (90791)

-15.5

30-minute psychotherapy (90832)

-1.5

45-minute psychotherapy (90834)

+1.5

60-minute psychotherapy (90837)

+3.5

Psychoanalysis (90845)

+17

Family psychotherapy w/o patient (90846)

+34

Family psychotherapy w/ patient (90847)

+15.5

Multiple family group psychotherapy (90849)

-4

Group psychotherapy (90853)

+3