Each reimbursement claim goes through an adjudication process once it reaches a clearinghouse and eventually, every biller will receive a denial.
Depending upon the reason, healthcare providers can appeal the decision and MIBs will play a major role in the process. In this enlightening article, well known physical therapist, Nitin Chhoda, explains how to resolve disputes without going through an official appeal.
Many claims are denied for oversights and mistakes that can easily be rectified. Winning payment for their clients requires MIBs to develop an appropriate strategy that addresses the cause of the claim denial.
The first step is a written communication that demonstrates exactly why the claim denial was made in error. The following are some important factors to consider when appealing a denied claim:
Active policies
Improper submission
Level of care
Medical necessity
Networking problems
Pre-authorization
Pre-existing conditions
Procedures that are not covered
Proof the Patient’s Policy is Active and In Effect
When new insurance coverage goes into effect, the information may not have been added to the clearinghouse database. Proof must be provided that the patient’s policy was active and in effect at the time of treatment.
This can be accomplished with a copy of the valid insurance card or a letter from the patient’s employer that provides the pertinent information.
Adhering to the Payer’s Reimbursement Submission
Each claim undergoes close scrutinization. Individual insurance companies have their own policies, procedures and protocols for reimbursement submissions.
Not adhering to these will generate a claim denial, but can generally be fixed by correcting any error or making the appropriate revisions and resubmitting the claim.
Required Level of Care
A carrier may decide the level of care exceeded what was required. Supplying supporting documentation for the claim will usually clear up the matter.
Is the Medical Necessary?
It’s the responsibility of the practitioner to prove through appropriate documentation that the treatment or procedure provided was medically necessary. The clinician must provide a written letter that explains any extenuating circumstances.
Network Unavailability
Payer policies may require patients to only see specific practitioners within their network of participating providers for treatment to be covered. Clinicians need to explain if an in-network provider wasn’t available.
Circumstances of Missed Preauthorization
If a preauthorization wasn’t obtained prior to treatment, explain to the payer the circumstances that prevented the request, such as a medical emergency. The clinician should also supply evidence that the authorization would probably have been approved anyway.
Pre-Existing Conditions
Many policies have exclusions for any disease or condition that affected the patient prior to when their policy went into effect.
To eliminate a claim denial, the onus is on the medical provider to demonstrate that treatment wasn’t due to a pre-existing condition.
Each insurance policy has specific restrictions, requirements and limitations. MIBs will need to ensure that the claim was coded correctly and the procedure was covered. If the coding was accurate but proof of coverage can’t be assembled, don’t appeal.
An appeal isn’t always indicated when a denial is received. When all the requirements, coding and conditions of the policy has been met and a denial is issued, it’s important for the MIB to provide the needed documentation and evidence to support the reimbursement.
These strategies provide carriers with clear and logical explanations as to why the denial should be removed and funds facilitated to the practice’s account.
Under the Affordable Care Act known as Obamacare, approximately 30 million new patients will enter the healthcare system. The Association of American Medical Colleges estimates that by 2015, the U.S. will require 60,000 more doctors than it will have at that time.
The group expects the shortage to increase through 2025, as fewer individuals are motivated to pursue medicine as a career under Obamacare legislation.
The potential for a physician shortage was further noted by a Physicians Foundation poll in 2010.
Forty percent of respondents indicated they would retire early, take employment at a hospital, look for a non-clinical job or quit the profession entirely due to Obamacare.
Medicare patients might need to locate a new clinician and travel longer distances to access healthcare.
Highlighting An Existing Problem
According to Dr. Reid Blackwelder, president of the American Academy of Family Physicians, a growing population, along with an aging population that requires more care, is the driving forces behind a physician shortage.
Obamacare is simply accelerating a problem that already exists.
Obamacare places an emphasis on primary care doctors and makes them the lynchpin of many of its initiatives, the exact place where the largest need is and will be in the future.
To address the need, Obamacare allotted $1.5 billion to the National Health Services Corp, which provides support to healthcare professionals in areas with physician shortages. Obamacare anticipated that practitioners in rural areas would be especially impacted where patients have fewer options than those living in more densely populated areas.
ACOs and Reduced Reimbursements
Accountable Care Organizations (ACOs) created under Obamacare are teams of medical professionals that treat patients as a group for coordinated care.
Primary care physicians are the pivot points in these teams, creating an even greater need that could take practitioners away from the pool of available healthcare providers needed in underserved areas.
Much of the cost to implement and support Obamacare is being taken from Medicare funds. Obamacare reduces Medicare reimbursements, providing the potential to limit clinician access to millions of individuals.
Many practitioners have already stated that they won’t continue to see Medicare patients due to payment cuts.
New Opportunities for NPs and PAs
A clinician shortage could be partially alleviated with qualified physician assistants (PAs) and nurse practitioners (NPs). PAs and NPs can examine patients, diagnose, prescribe medication and make referrals if needed.
In many states, they’re required to work under the direct supervision of an M.D.
Some practitioners are reluctant to embrace a model that relies more heavily on PAs and NPs, or that gives expanded responsibility to nurses.
Health and Human Services Secretary, Kathleen Sebelius, said physician assistants and nurse practitioners are key elements in providing services under Obamacare, especially in rural and inner-city neighborhoods.
If physicians do carry through with their plans to exit the medical profession or seek other options, it could very well lead to a severe shortage of primary care clinicians at a time when 30 million new patients enter the system. Those circumstances could lead to less access to healthcare services rather than more.
In the 21st century, paying for visits to healthcare providers is a simple process for patients. They simply present their insurance cards, make a copay and go on their way.
The system can be a nightmare for medical insurance billers (MIBs), who complete hundreds of reimbursement claims each week covering a wide spectrum of treatment. In the following article, Nitin Chhoda examines what MIBs need to know about healthcare coding basics.
MIBs will encounter a multitude of technical terms in healthcare coding that will affect the codes used when preparing a claim for reimbursement.
Billers will need to be fluent in medical terminology and healthcare coding procedures to accurately code claims.
The knowledge enables them to submit claims that are reimbursed quickly, meet the demanding standards required by insurance carriers, and maintain compliance with federal and state standards.
Documentation
Billers will be working with multiple and disparate healthcare coding documentation that provides substantiation to payers that the services, procedures and treatments provided were needful and appropriate to the practitioner’s diagnosis.
Each piece of documentation is the evidence that carriers will utilize for reimbursements and a single omission will result in a denial.
CPT Codes
The acronym CPT stands for current procedural terminology. CPT codes will be used on claims to describe the medical services and procedures provided by the practitioner.
CPT codes must match the services they represent to avoid denials and payment interruptions. This is very important.
ICD-9 Codes
The International Classification of Diseases (ICD) codes will soon be updated to CPT-10 to encompass new diseases and technology. The alpha-numeric healthcare coding is the primary diagnostic tool used to document and explain the signs, symptoms, illnesses and diseases clinicians will encounter.
The codes provide insurance companies with essential information about a patient’s condition and resulting treatment.
Some billers will encounter alpha-numeric C codes and V codes:
C codes are used to identify the external causes of poisonings and injuries.
V codes are utilized to categorize factors that have a direct influence on a patient’s health status, along with encounters that aren’t due to an illness or injury.
Modifiers
There are times when a procedure is altered from its original description. Healthcare coding modifiers are used when a procedure requires additional time and expertise, or has extenuating circumstances.
Billers will use the two-digit modifiers in the CPT healthcare coding to report such occurrences. They provide MIBs with the means to bill very specifically and obtain additional revenues to compensate practitioners.
Modifiers are also appropriate when a technical component (TC) is involved.
Sometimes a clinician will need the use of equipment, labor and/or supplies to perform a procedure that is maintained by another specialist or medical facility.
Modifiers in healthcare coding are used to explain that those items are billable by entities other than the practitioner.
MIBs will encounter a host of different codes and medical terminology that must be entered on claims accurately to facilitate quick reimbursements and avoid costly denials and delays.
Medical billing staff who are familiar with the healthcare coding basics are well on their way to becoming masters in their profession.
The demand for medical insurance billers (MIBs) continues to grow and many individuals are eager to launch a career in the field.
The popularity of medical billing has given rise to a multitude of unfounded claims by scam artists who insist it’s a career path with minimal work and quick rewards. In this informative article, Nitin Chhoda explores the claim cycle and the MIB’s responsibilities.
The insurance claim cycle is the process of billing a third party entity that pays for the medical care of one of its subscribers.
The claim cycle begins the moment a patient makes an appointment with a provider and doesn’t end until the full amount has been deposited in the practitioner’s bank account.
Patient Paperwork
Medical histories, questionnaires and other forms impart necessary data about the patient’s past and current ailments, complaints, procedures and treatments.
A release of information is required so MIBs can file a claim and obtain payment from the patient’s healthcare insurance carrier. During the claim cycle, a release is critical, as MIBs can’t share the needed information with an insurance company without the patient’s permission.
Essential paperwork also includes a copy of the patient’s photo identification and their insurance card. Health insurance fraud is a very real crime for which MIBs must be wary. The insurance card contains information on who is eligible for services, along with exclusions, restrictions, limitations and prerequisites that must be met for payments to be dispersed.
Patients may also have coverage under multiple policies. Each insurance plan will have established deductibles and co-pays that constitute the patient’s portion of the final bill. Make sure that these are all reviewed during the claim cycle process. Always attempt to collect these fees before the patient sees the provider, or have the patient make alternative arrangements for paying.
Computing Power
All of the data must be entered into the MIBs billing software program or electronic medical records (EMRs) system where it can be accessed and retrieved for transmitting, tracking and monitoring reimbursement claims. Care must always be exercised in the claim cycle process to ensure the information is entered correctly to avoid delays and denials.
EMR technology is especially helpful, as it can identify users of potential claim problems.
A patient encounter form must be created and the appropriate ICD and CPT codes entered to substantiate the provider’s diagnosis and subsequent treatment. Any referrals, diagnostic tests and pre-authorizations must be documented, along with follow up visits if needed. The claim cycle process contains a full accounting of medical fees which must be entered and a claim form is always created that will be transmitted electronically to a clearinghouse.
Claims and Follow Ups
Once the claim arrives at the clearinghouse, MIBs will receive electronic verification. Clean claims that are free of errors are forwarded to the payer for remittance. Those with problems will be denied and returned. Clearinghouses and insurance companies are experts at finding even the smallest reason to justify delaying payments. So the billers must not end the claim cycle when they submitted the claims but rather when every claim has been reviewed and accounted for.
Once the claim is approved, it’s the task of the MIB to track the payment, see it securely deposited at the clinician’s chosen banking institution and recorded in the patient’s account.
Overdue payments must be investigated and appealed when appropriate. Billers will need to contact patients about any outstanding balance, be prepared to send unpaid accounts to collections, or write it off as a loss at the provider’s discretion.
The insurance claim cycle is completed when each portion of the payment is collected from the insurance carrier and the patient.
With EMR technology, receiving remittance from commercial payers can take as little as 10 days, and 30 days for government operated plans. MIBs are a crucial element in the claim cycle process, working to ensure that the practices of their clients receive the funds to which they’re entitled.
Medical insurance billers (MIBs) once dreamed of a modern way to submit claims that eliminated paper records and allowed claims to arrive almost instantly at their destination.
With electronic medical record (EMR) technology, the future is now. In this informative article, EMR expert, Nitin Chhoda, explains what billers need to know about electronic claim software.
MIBs have the option of purchasing billing software or an EMR for their company’s needs. EMRs offer a wider range of functionalities for use in the 21st century medical billing enterprise.
Modern and convenient, they provide the critical security measures and protections mandated by HIPAA for the transmittal of reimbursement claims.
Counting Costs
Medical billing software costs range from $500 to $5,000. EMR technology can be obtained from reputable sources, with monthly user fees as low as $49. Both types of software systems accomplish the same objective, but EMRs offer other functionalities that can make a biller’s job easier and enable them to offer additional services.
Claims and Security
The Affordable Health Care Act mandates that billers submit reimbursement claims electronically. Claims that aren’t will be denied. Submissions must also conform to HIPAA security regulations for transmitting medical data. EMR software complies with both of those goals, has built in safeguards to protect patient information, and will alert everyone within the network in the event of an attempted breach.
Coding and Billing
The upcoming transition to ICD-10 codes has many in the medical field concerned about revenue disruption. Electronic medical records are capable of handling the addition of all the new codes and insurance plan modifications with efficiency and finesse, including those used outside the U.S. Most billers won’t encounter the foreign coding, but an EMR allows MIBs to be prepared.
Billers must implement HIPAA’s 5010 transaction standards for digital transmissions before utilizing the new codes.
Document templates can be created for any practice or specialty with an EMR, and can be modeled on documentation with which staff members and billers are familiar. The systems can be integrated with other clinicians, pharmacies and medical facilities for referrals, prescriptions and diagnostic testing. The full complement of documentation is available to billers for clean claims that are approved quickly.
Modern Communications
Many billers are tasked with monitoring and tracking the financial accounts of their clients’ patients.
An EMR allows MIBs to communicate with patients through multiple means that includes phones and mobile devices, mail and email, and text and voice messages.
MIBs can remind patients about outstanding balances and monitor if deductibles and co-pays have been met.
Electronic claims are no longer a futuristic dream. They’re available now with instantaneous and secure transmissions that conform to the Affordable Health Care Act and HIPAA.
The multi-functionality of EMR software allows MIBs to painlessly integrate the new ICD-10 codes, collect client revenues quicker, and offer all the services practitioners require.
If you are not using an EMR system already, then the time to consider it is now. That’s not all. You want to ask the important question “Is my EMR system recognized and tested by the Office of the National Co-ordinator (ONC) and how can I verify this?”.
Healthcare is changing and practitioners must transform their practices to remain in business.
Government Sanctioned EMR Technology
We’re living in a new world, and I call it the “Obamacare Economy”. As a clinician, it’s your responsibility to document, code and bill effectively, and make sure everything is reported to CMS and other payers. You can achieve this the hard way with pen and paper, or the easy way with EMR technology.
Even through physical therapists are not ‘eligible professionals’ and therefore not eligible for Meaningful Use incentives like physicians, physical therapists should consider using (at minimum), a base EHR certified technology from January 1, 2014 to be eligible for PQRS incentives, according to a CMS Rule published 11/16/2012 that can be found here:
“Therefore, based on the comments received, we are also finalizing to the requirement that a direct EHR product be certified by ONC as Certified EHR Technology (CEHRT), and therefore meet the definition of CEHRT in ONC’s regulations (see 45 CFR 170.102), to submit PQRS measures. (For the 2014 Edition EHR certification criteria, please refer to 77 FR 54163)”
“We are discontinuing the qualification process and requiring that a direct EHR product be CEHRT beginning in 2014. A certified quality reporting module may be part of CEHRT, but CEHRT as a whole is more comprehensive. Please refer to ONC’s standards and certification criteria final rule for additional information on requirements for CEHRT (77 FR 54163).”
A CEHRT is defined as “EHR technology certified to the 2014 Edition EHR certification criteria that meets the Base EHR definition and would support the objectives, measures, and their ability to successfully report the CQMs, for the MU stage that they seek to achieve.”
These are the minimum modules that an EMR must be certified in to meet the requirements of being a CEHRT and being able to directly submit PQRS in 2014.
Includes patient demographic and clinical health information, such as medical history and problem lists
Demographics § 170.314(a)(3)
Problem List § 170.314(a)(5)
Medication List § 170.314(a)(6)
Medication Allergy List § 170.314(a)(7)
Has the capacity to provide clinical decision support
Clinical Decision Support § 170.314(a)(8)
Has the capacity to support physician order entry
Computerized Provider Order Entry § 170.314(a)(1)
Has the capacity to capture and query information relevant to health care quality
Clinical Quality Measures § 170.314(c)(1) through (3)
Has the capacity to exchange electronic health information with, and integrate such information from other sources
Transitions of Care § 170.314(b)(1) and (2)
Data Portability § 170.314(b)(7)
Has the capacity to protect the confidentiality, integrity, and availability of health information stored and exchanged
Privacy and Security § 170.314(d)(1) through (8)
The EMR software you use must satisfy these criteria, and must be tested and accredited by one of the four bodies approved by the ONC.
ONC Certified Base EHR Technology – Is Your Vendor Certified by one of the ‘Big Four’?
The Office of the National Coordinator for Health Information Technology is responsible for certifying electronic medical records software, and it does so through FOUR ‘Certification Bodies and Testing Laboratories’, which play a key role in the ONC HIT Certification Program.
Certifying and testing Electronic Health Record (EHR) technology provides assurance to providers and other purchasers that an EHR system offers the necessary technological capability, functionality, and security to help them meet the Meaningful Use criteria, and helps maintain quality and consistency across the certified products. Once again, physical therapists are not eligible for Meaningful Use funds, but a minimum ‘base EHR’ technology is required for reporting PQRS measures.
In the ONC HIT Certification Program, ONC-Authorized Certification Bodies (ONC-ACBs) conduct certification and Accredited Testing Laboratories (ATLs) conduct testing.
A single organization can be both an ONC-ACB and an ATL. ONC has authorized the following certification bodies to serve as ONC-ACBs in the ONC HIT Certification Program:
Certification Commission for Health Information Technology (CCHIT)
Drummond Group
ICSA Labs
InfoGard Laboratories, Inc
Only test tools and test procedures that have been approved by the National Coordinator can be used to test Complete EHRs and/or EHR Modules in order for them to be eligible for certification by an ONC-Authorized Certification Body (ONC-ACB). ATLs are authorized to test Complete EHRs and/or EHR Modules according to the 2011 and/or the 2014 Edition EHR Certification Criteria.
The test tools and test procedures that align with the 2014 Edition are available here
On this site, providers can access all certified software and select individual products or combinations of products to use to attest for Meaningful Use funds through the CMS. Providers can also look for EHR vendors that have been tested and certified for certain specific criteria (these will appear as ‘Modular EHR’ technologies).
Try it out by selecting a 2011 or 2014 Edition software, placing it in the shopping cart, and see the resulting message that is generated.
What this Means for Physical Therapy Private Practice Owners
Physical therapists who bill Medicare must report PQRS measures (and Functional Limitation G codes) to avoid penalties and the best way to do this is with the use of an EMR system. Your EMR should be a registry, or provide claims based reporting options to CMS, or better yet, be recognized by the ONC as a ‘Modular EHR’ that fulfills the requirements of a ‘base EHR’.
Technology like this offers the ability to collect reimbursements quicker, maintain security compliance, and increase the profitability of practices.
EMR systems contain functionality to track multiple variables that affect the practice and market services successfully. The software can be deployed on tablet technology for portability, allowing therapists to save time during the patient encounter and complete paperwork electronically for quicker billing turnaround.
The EMR technology of the future must help grow your practice. It’s not enough for an EMR vendor to be ‘just another vendor’ that sells you software for scheduling, documentation, compliance and billing. It’s not enough for the software to have perks like appointment reminders and home exercise programs.
Your practice needs way more than that to be able to help you grow in the Obamacare economy, and that’s why we built In Touch EMR.
Your EMR software has to go above and beyond what it’s doing now.
It has to help you increase profits by integrating all the following within the interphase of the EMR software:
Increase referrals from physicians with automated marketing systems
Increase referrals from patients with automated newsletters, greeting card, phone, text and email communication systems
Increase referrals from other business in the community by creating and automating cross promotion marketing campaigns
Converting prospects to patients with done-for-you educational resources automatically distributed to patients
Diversification – The Way to Thrive in this New Economy
In this new economy, you don’t want to ‘keep all your eggs in the Medicare basket’. As patients see a decline in the quality of physical therapy, they will be looking for (and willing to pay for) options that make them healthier.
This is an unprecedented new opportunity, unlike anything we’ve ever seen before in physical therapy private practice.
That’s exactly where you come in.
Today’s patient is eager to partake of services and products perceived as “luxury” items. Known as cash paying services, they’re paid for at the time they’re delivered. Options include selling supplements, durable medical supplies and medical products to better serve patients and create multiple income streams.
Hiring the right staff to provide the services, and the right systems to be able to track these services is the first step towards diversification. Speaking of systems, nothing is more important than a simple, yet powerful electronic medical records (EMR) system for your private practice.
With the portability of EMRs, practitioners can expand their repertoire of offerings at the clinic and in other venues. Clinicians can feature a variety of different massage therapies, weight loss clinics and nutritional information, along with personal training,acupressure and wellness programs. Aquatic therapy, women’s programs, athletic training services and fall prevention offerings are also popular.
Your Action Plan with Obamacare
Strategies to maximize Medicare payments include:
Be more efficient with time spent with all patients, especially Medicare
Be more knowledgeable about the types of CPT codes and number of units billed
Here is how you can maintain (and even increase income) in the Obamacare economy:
Diversify your payer mix by having payers other than Medicare, preferably those who pay more than Medicare. Look at your payor contracts to determine how much you are getting paid and identify the ones where you are paid more. Reduce your dependence on Medicare patients. We can help you analyze this, as part of our coaching service in the Referral Ignition Elite program.
Setup different cash paying programs to increase income and increase lifetime value of each patient. Mobilize your staff, patients and referral sources to help you increase referrals and grow the practice. Diversify sources of income and services to serve patients better to make your business multi-faceted and diverse. You can get several free tips and tricks on how to market your private practice at our blog.
Clinicians must be more efficient in the time they spend with patients, from ascertaining the source of their ailments and creating documentation to preparing claims for billers.
Besides the clinician, the biller is the most important person in the practice. Here are some of the most time consuming aspects of billing:
Creating claims by copy pasting ICD, CPT, modifiers, supporting diagnosis data into the billing software
Editing and scrubbing this data before it is submitted to the payer
Manually batching claims and uploading them to the clearing house
Manually reviewing and posting ERAs to the patient record
Submitting secondary claims
Generating and mailing patient statements
Here’s the good news – EMR systems such as the In Touch EMR and the fully integrated In Touch Biller Pro automate all of these tasks for the biller. This allows the biller to focus on the things that drive revenue for the private practice such as:
Make sure all claims are submitted as quickly as possible
Identify reasons for denials and eliminate them
Provide simple guidelines to clinicians to maximize reimbursement and minimize denials
Call the insurance companies to follow up on claims
Make sure all EOBs are entered promptly
Write and mail appeal letters
Follow up with patients to make sure statements are paid
This makes things easier for the private practice owner, allowing him or her to plan and implement diversification endeavors.
Concierge Services – A Bold New Alternative
Concierge practices, also known as direct pay practices, are typically the bastion of primary care physicians, but the concept can work for physical therapists. In a concierge practice, patients pay a monthly or annual fee for enhanced services that can include same day appointments, email consultations, extended patient encounters and 24/7 access to their therapist, along with other perks.
Practitioners generally maintain a smaller roster of clients, but are paid better and work fewer hours. It’s a healthcare option that enables clinicians to practice in their own way, reduces staffing, compliance and administrative costs, and treats patients as individuals rather than part of an assembly line. Therapists can also continue to accept insurance payments if they choose.
Therapists don’t want to turn away any patient, especially those with Medicare who may need them most, even though they’re underpaid through Obamacare.
To combat the negative impact of Obamacare on patients and practitioners, clinicians must increase the efficiency level during the patient encounter.
Identifying cash paying services and products appropriate for the practice allows clinicians to attract a larger and more diverse clientele. Those services and products will establish multiple streams of revenue that ensures profitability through any economy and helps practices survive Obamacare.
