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.

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.

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.

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.

New Online Medical Billing Course

We are very excited about the progress of our new online medical billing course we will be offering next month.  It is so exciting to offer information that so many medical offices and medical billing services need to train their employees on the full range of issues that must be dealt with in the medical office with billing insurance claims.   We will use this course ourselves to train all our future employees.  🙂  🙂

You can check out our progress on our new webiste here http://www.medicalbillingstudycourse.com

NEW Online Medical Billing Course

New Comprehensive Medical Billing Study Course offered by medical billing experts Alice Scott, Michele Redmond and Merry Schiff designed specifically for the medical biller to understand complete practice management.  Because it is designed by experts currently operating a billing service today the courses include important information often omitted from other courses.

In hiring employees who have graduated from medical billing courses for their medical billing business Alice and Michele found a disconnect between the classroom and workplace in the knowledge required for the actual work in the field of medical insurance billing.  In many courses much time is spent on subjects not really relevant to billing insurance claims with information not required for the job of billing.  Many courses lack or don’t go into enough depth on topics that are crucial to billing.

Partnering with teacher/author Merry Schiff and Linda Walker, Alice and Michele are bridging this gap with their new course designed to teach a student exactly what they need to move into the field of medical billing with the tools they need to succeed along with free support as they learn.

Merry found that in developing a course for a university she was limited in what she could offer and was directed as to what should be included in the course.  She was unable to include topics she felt important to include.   Merry is very passionate about this industry and wanted to create a course that included all aspects that a biller would need to succeed in this field.  When Alice and Michele started their billing service back in the early 1990s Merry was one of their first mentors.   Merry was interested in teaming up with Alice and Michele as she liked their writing style and ability to communicate with the reader in easy to understand language.

Linda Walker founded a medical billing business in 1997 after over 10 years experience as a claims examiner with major health insurance company.  She is the founder of Practice Managers Resource & Networking Community with over 7000 subscribers.  Linda also holds an Associate’s Degree in Business Administration, a paralegal certification along with various other designations in the health insurance industry.  She is passionate about legal issues that affect healthcare and her primary focus is on consulting.

Alice and Michele used their experience with training employees combined with Merry’s experience in writing and teaching and Linda’s knowledge and background to develop a comprehensive course designed to cover exactly the knowledge required to start working in the medical billing field.  They have the perfect combination of working knowledge and experience to develop a well rounded course designed to bring the student up to speed much quicker than other courses.

The first three courses will be released October 15, 2013

Online at www.medicalbillingstudycourse.com

Courses offered are:

Medical Billing Study Course containing 10 separate courses which can be purchased individually or as a package including

1                     Introduction to Medical Billing

2                     Understanding Coding and Modifiers

3                     Life Cycle of an Insurance Claim

4                     Billing Medicare, TRICARE and Medicaid

5                     Billing the Blues, Commercial, Disability and Workers Comp Claims

6                     Working with the Practice Management System

7                     Reading EOBs, Handling Denials and Filing Appeals

8                     HIPAA and Legal Issues

9                     Operating a Medical Billing Business

10     Marketing a Medical Billing Business

Alice Scott & Michele Redmond are mother/daughter owners of a medical billing service for the past 19 years and bill for providers all over the United States.  They are authors of 15 books on the subject of medical billing that are available both online and through Amazon.  They have trained other billers from all over the United States both in billing and running a medical billing business.   Alice & Michele have consulted with many medical offices across the US on topics ranging from HIPAA compliance to analysis of billing practices.

Merry Schiff has 54 years of experience consulting and training medical billers.  She contracted with a major online university to create and teach a medical billing course with more than 1500 students.  Merry founded and is the Executive Director of the first professional medical billing association, NEBA, with over 1000 members.  Her experience ranges from owning and operating a medical billing business to writing an 800 page medical billing textbook to developing the first home study medical billing course.