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.

Options for Out of Network Providers

Many providers opt to take the road of staying out of network, or not participating with insurance carriers. This has been going on for many years. Usually it tends to be specialty providers such as mental health providers but with the increasing changes of insurance billing more and more providers are opting to take this path.

What does that mean for the provider and the patient? Well for the patient it means that they need to verify if their insurance provides out of network benefits. If they do have out of network benefits, then the claim may be submitted and payment, if any, will be made directly to the patient. The provider may not necessarily file the insurance claim for the patient. They may simply provide the patient with a statement that will allow the patient to submit the claim themselves. Some, although in our experience, it is rare, actually still submit the claim even if they are not in network. For the provider it may mean that the patient may choose to go to a different provider that is in network with their insurance.

Are there any other options for these providers to assist the patient with the claim submission process while remaining out of network and not incurring expensive overhead costs such as office staff to submit the claims? We actually were introduced to a company that developed a phone app to assist patients with submitting out of network insurance claims! The app which is free to download, allows a patient to take the statement given to them, enter all of the information into the app with just a few questions, and submit the insurance claim to their insurance carrier. Then they receive notifications when the claim is sent, and when the claim is received by their insurance so that they can easily follow up.

The app actually allows providers to register themselves (no charge!) so that if their patients use the app the provider will come up on a search and the patient can simply select them without having to enter the provider’s demographics, NPI or tax ID. They also provide handouts for the out of network providers to give to their patients, or put out in their office to walk the patients through the process. There is even an option for providers to pay a small monthly fee that allows their patients to submit claims using the app at no charge to the patient. So if the provider would like to submit claims on behalf of the patient but they don’t want to have people on staff to handle that, they can incur the cost and it’s much cheaper than having an employee.

This may seem like an odd topic for a billing service to be discussing. After all, we are the ones doing the billing for most providers. However, we often come across a provider that is out of network, and our service really doesn’t make sense for them. Or we all know that patient that has a provider they love, but the provider is out of network and they need to submit the claim on their own. My daughter used to go to an out of network dentist that she absolutely loved. She had a slight fear of dentists and he was amazing. I wish this app had been available back then!

So if you know any out of network providers, or if you have a friend or family member that struggles with submitting their own claims, you can find out more about this program at https://reimbursify.com/

Is It Illegal to Waive Co-pays?

Providers often waive co-pays or coinsurance for friends, colleagues and patients who are suffering a financial hardship.   But what is their legal responsibility?  Although you don’t hear of providers being arrested for not charging a patient their share of the cost of the service, the provider can still get in trouble for performing this practice.

First of all there is the issue of offering a professional courtesy.  Professional courtesies must be distinguished from waiving patient responsibilities.  A professional courtesy is when the provider waives the entire fee for a physician, or the dependent of a physician.  A professional courtesy may also be a discount such as 50% for such an individual or the provider may choose to waive only the patient’s out of pocket expenses as well.  This is known as accepting “insurance only” as payment in full.  The issue is that this professional courtesy is often extended to many others such as staff, family of staff, friends, etc.

Generally if the professional courtesy is the waiving of the entire fee or a percentage of the entire fee it is considered legal.  However, if the professional courtesy is waiving the co-pay or the patient responsibility it is generally considered illegal especially if the patient has a federal insurance plan such as Medicare.  This is true even if the patient is a physician.
It would also be considered illegal if the professional courtesy was extended to a patient who is in a position to refer business to the provider.  This could be considered fraud and abuse, especially in the case of Medicare patients.  Waiving patient responsibility for Medicare patients violates a federal statute that states that the provider knows that waiving the patient responsibility is likely to influence the patient to seek care from that provider.

Federal law never allows waivers of patient responsibility to be offered as part of any advertisement or solicitation.  Basically a provider cannot use the enticement of waving the patient’s responsibility to get a patient in the door.  A provider is not allowed to advertise a special where they will waive the patient’s co-pay for a new patient consultation to try to get more patient’s into their practice.

Many providers do not understand why they cannot decide to extend a break for services rendered to a family member or friend.  They feel that they have a right to choose if they want to collect the money that the insurance carrier deems to be the patient’s share.
The insurance carriers feel differently about the situation.  They feel that by waiving the patient responsibility the provider is intentionally charging a different price for the same service.  For example, a provider charges $100 for a level 3 established patient office visit and the patient’s insurance carrier pays $80 and the patient has a $20 copay.  If the provider waives the $20 copay the insurance carrier feels that the provider is willing to accept $80 for the level 3 established patient office visit.  Based on that they feel that they overpaid the provider $20.  They should  have paid $60 and the patient should have paid $20.

Why does the insurance carrier feel this way?  Basically all of these concepts, deductible, co-pay and co-insurance, are cost share obligations.  The rules of managed care state that the patient CANNOT see the doctor until they make their co-payment. Managed care is governed by federal law and is not open to interpretation. To “write-off” a co-pay, or to allow a patient in to see the doctor without collecting the co-payment, is against federal law.

Some individual states agree with the insurance carrier’s perception and have declared the insurance only courtesy is insurance fraud.  If the provider accepts insurance only then the state feels that they are misrepresenting their fees by charging insurance carriers a fee that is higher than the fee that they actually intend to collect.

There are many situations where waiving the patient’s responsibility either in the form of a deductible, co-pay or coinsurance is deemed illegal.  Federal plans and managed care plans are covered under federal law and most commercial plans, depending on the state, are covered under state laws.  If not illegal, it is most likely a violation of the provider’s contract with the insurance carrier.  Violating the contract may result in the provider being removed from the insurance carrier panel.

Basically, providers are not supposed to ‘forgive’ patient responsibilities without proof of financial hardship.  Such financial hardship cases must be consistent and not provided routinely and the hardship should be documented in the patient’s chart.  Therefore, the best course is to avoid waiving the patient responsibility unless a financial hardship has been established.  Office policies should be reviewed regarding any courtesy discounts to make sure that they are compliant.

Why EHR is Costing Providers Money

EHR can cost providers a lot more money than they realize.  Of course there is the obvious, the cost of the EHR program, but it actually can go much deeper than that.

Many smaller providers have opted not to use an EHR program because they either don’t want the expense of the program or they just don’t want to be bothered.  For example, a small chiropractor may figure that it is more of a hassle to use an EHR program than to just take the penalty for not using one.  Many providers think that EHR programs are too expensive to warrant the cost.  They don’t realize that there are inexpensive programs and actually free programs available.

Currently eligible professionals, or EPs that are not demonstrating meaningful use are penalized by Medicare.  The penalty for 2016 services is 2%.  It will go up to 3% in 2017.  So if an EP is not using an EHR program they are receiving less pay for services to a Medicare patient.

If they do use an EHR program and they demonstrate meaningful use then they are not being hit with the penalty.  But they have the added cost of the program plus the costs associated with using the program.  For some providers there is no additional cost but for others there is more time involved with using the EHR program.

But there is another way that EHR programs are causing some providers to lose money.  Many EHR companies tell providers that their program does the billing for them so they no longer need a biller or an outside billing service.  Some actually offer billing services for a small additional cost which is usually much less than they are paying for their current billing.  The problem is that even though these programs have detailed claim scrubbers (software that checks for errors) and makes it so that errors are almost eliminated, that doesn’t replace the need for a biller.

Even with the added checking systems there are still issues that need to be dealt with.  The program doesn’t correct mistakes such as invalid ID number.  It is not uncommon for a patient to forget to give updated insurance information, or for that information to not be entered into the system.  The system (or clearinghouse) will reject the claim but a human will have to go in to see what went wrong, correct the information, and possibly contact the patient.

Medical billers do much more than simply enter data into a computer.  They also analyze the data going in.  Auto-posting of ERAs is a great feature.  It is a huge time saver to have the payment information automatically entered into a system.  But that information still needs to be looked over.  For example, if a claim is entered for an office visit and an EKG and the ERA comes in with payment for the office visit but not for the EKG the system may simply write off the EKG since it was not paid.  But it’s possible that the EKG was not billed properly.  If the office visit was for pre-operative clearance for knee replacement surgery and the primary diagnosis for the EKG was knee pain then the EKG may be denied.  But a biller may look deeper at the visit and see that the provider did the EKG because the patient has atrial fibrillation or coronary artery disease.  The primary diagnosis for the EKG should have been the atrial fibrillation or coronary artery disease, not knee pain.  If it had been coded that way the EKG may have been allowed separately from the office visit.

The point is that computer software can be a great tool in assisting with the billing process but it doesn’t replace the biller.  There are still many tasks that require a human.  Even if all claims are submitted 100% correct, insurance carriers may not process them correctly.  When claims are rejected incorrectly they need to be resubmitted and/or appealed.  Sometimes adjustment requests must be made.  All of these tasks must be done by a human.

“Denials, Appeals and Adjustments” Revised

We are excited to announce that we have completely revised our “Denials, Appeals and Adjustments” including information on ICD10 denials.  We really went through this book adding information and more example appeal letters and adjustment forms.

If you have previously purchased this book, we will be happy to send you a free copy of the new revision!

Send me an email with the email address you purchased the ebook under or the receipt (any proof you purchased) and I will send you a new revision.

Here is more information on “Denials, Appeals and Adjustments”.

If you have not purchased “Denials, Appeals and Adjustments” in the past here is your chance to purchase it on sale.  Use the coupon code DENIALS and get a 20% discount on this book through 4/30/2016.

We have been working hard to revise many of our books and courses as we strive to keep them all current.  Watch for our next announcement of which book and course we will be revising next.

Shop here for ebooks.

Shop here for online courses.

Here is a list of all our online courses.

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
6.    HIPAA, HITECH and Regulatory Issues
7.    Reading EOBs, Handling Denials and Filing Appeals
8.    Working with a Practice Management System
9.    Operating a Medical Billing Business
10.    Marketing a Medical Billing Company

Our Free Medical Billing Forum

We offer a free forum for all our readers to ask any billing or marketing questions you may have.  We personally log onto the forum several times a day to answer any questions we can help with.  This forum is an extension of our ebooks.  If you purchase any of our books and still have a question we make our forum available for those questions.  You don’t even have to purchase any our books.  The forum is free to everyone except spammers.

If you haven’t visited our medical billing forum yet, make sure you check it out.

Work Flow

Once when talking to a doctor, I compared billing to laundry.  No matter how much you do, you are never done!  In our office we sometimes struggle with prioritizing.  Recently we implemented weekly wrap-ups from 8 AM to 12 PM every Friday morning.

Weekly wrap-ups are used to take care of any jobs from the week that didn’t get done or any projects that come up.   Some weeks it may be one person’s work load was heavier than normal or they were out on vacation so we all work on that person’s work.  Sometimes a special project comes up that we can all work on.  Some weeks there may not be anything so we all just work on our regular work.  Or it may be that we have taken on a new account and have to work an old aging report.  It can go quickly with everyone working on it.

We found this practice works really well.  Often when there is a big project to do, it tends to be put off.  With this system, we just add it to our weekly wrap-up list and it gets done.

5 Things to Make working your aging report easier

It has certainly been established that most of the revenue lost in medical offices is due to the aging report not being worked regularly.  In order to make sure a provider is collecting all that is due the aging reports must be run regularly and worked to ensure that all claims are processed correctly.  Many times this important task is pushed to the bottom of the pile or completely dropped.

The main reason that the aging report is not run regularly is because it is a very time consuming task.  So what if we told you that there is a way to make working your aging report easier?

There are actually several things that can be done to make working the aging report easier.  Here are 5 of them:

1.    Work the report regularly.  Working the aging report regularly makes it easier to work because the problem claims are being taken care of and missed claims are being checked on.  Working the aging report regularly cuts down on the claims that are on the report.  If the report is not worked regularly then the report will continue to grow larger.
2.    Note actions taken on problem claims in the computer.  This will cut down on checking on claims that are already being taken care of.
3.    Get rid of claims that are uncollectable.  Having claims on the report that are not collectable just mucks up the report.  For example, if you have a claim that is two years old and you have no grounds for appeal, and you cannot bill the patient, then you should get the claim right out of the system.  (Noting of course why the claim is uncollectable.)
4.    Check your clearinghouse reports.  Many times the answers to why claims are not paid are right in the clearinghouse reports.  If these reports are not checked then the claims will remain outstanding with no explanation as to why and they will need to be worked.  If the clearinghouse reports are checked and action is taken on problem claims, these claims will either not be on the aging report (because they will have been processed) or they will have an explanation as to why they are on the report and no further action will be needed.
5.    Get enrolled with insurance carrier websites to do claim status checks.  Checking claim status online is much easier than making a phone call.  Enrolling in as many insurance websites as possible will make it much easier to work the aging report.

Denial Tip #2 Handle Denials Quickly

We find that many providers’ offices and even billing services tend to put denials aside to take care of them later.  This is a bad idea and can actually end up costing the provider money.  The best time to handle a denial is as soon as the denial is received.

Some insurance carriers have time limits on when denials must be handled.  For example, one of our local insurance carriers only allows sixty days from the date of the denial for a denial to be handled.  If an appeal needs to be submitted, or information must be corrected, it must be done within sixty days or it will not be accepted.  Often when the denial is put aside more time passes than intended.  This can lead to missing the time limit on handling the denial.  Maybe there is still time to file the appeal or submit the information, but there is no time for research or gathering the information needed for the appeal or correction.

Another reason it is not a good idea is that the claim is still showing as outstanding in the practice management system.  This means it is still showing up on aging reports and may result in unnecessary work being done.  If the denial is set to the side with no notations made in the system, the person working the aging report may not realize that the claim was denied and call to check on the status.  This would be a waste of time since the claim was denied and the information on the denial was obtained.

Here at Solutions Medical Billing, we take the information of any denied claims and put it right in our work folders for that individual provider.  When the claims and payments are entered for that provider the denials are worked as well right then.  If a denial is set aside or put in a drawer it is much too easy to let it fall through the cracks.

Much money is lost by providers every year on denied insurance claims.  Handling denials quickly will help reduce the amount of money that is lost.