Claim — How to Appeal and Handle When Denied

Claim — How to Appeal and Handle When Denied

by | Jan 17, 2014 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

When a reimbursement denial is received, medical insurance billers (MIBs) may need to initiate an appeal process to collect disputed funds for practitioners. In this informative article, Nitin Chhoda reveals the most common reasons for denials and the best strategies for handling claim disputes.

claimEach claim goes through an adjudication process at a clearinghouse to check the data for errors before forwarding it to the appropriate insurance carrier.

A claim examiner conducts another exploration of the claim and renders a decision. The examiner can choose to pay the billed expenses, reimburse at a reduced rate, or deny the claim.

Insurance carriers usually deny payment for one of seven typical reasons. Some of the factors are the following:

  1. Carrier’s procedures
  2. Medical necessity
  3. Inactive policies
  4. Out-of-network
  5. Level of care
  6. Pre-existing conditions
  7. Pre-authorization

Unknown Carrier’s Procedures

MIBs should be aware of each payer’s procedures and policies for handling claims. Each insurance company has its own hierarchy and protocols for reviewing a claim. MIBs should also check the contract between the clinician and the insurance company to determine that all conditions have been met.

Medical Documentation is Necessary

When a claim is denied on this basis, it’s up to the MIB to provide documentation that the appropriate diagnosis and procedural codes were employed. Sometimes a coding change and resubmitting the claim will result in a satisfactory resolution.

If the codes are accurate, a letter must be provided that clearly states why the treatment was necessary, along with any extenuating circumstances.

Patient’s Insurance Policy is Now Inactive

It’s essential that the MIB has proof that the patient has an active insurance policy at the time treatment was provided. This can be accomplished through a copy of the individual’s medical card, a letter from their employer, or a statement from the insurer.

Out-of-Companies-Network of Physicians

Some carriers require patients to only see practitioners within the company’s network of physicians, but situations arise when an in-network clinician isn’t available.

A simple letter explaining, in detail, why the patient didn’t have access to the carrier’s network of clinicians can easily turn a denial into a payment.

Having Too Much Level of Care

Claim examiners may determine the level of treatment that was billed exceeded the usual care for a particular ailment. The culprit in these situations is usually a lack of physical therapy documentation that fully explains why additional treatment or procedures were required. Providing supporting documentation usually takes care of the problem.

The Most Common – Having Pre-Existing Conditionsclaim

Most insurance policies won’t cover treatment for conditions and diseases that patients were afflicted with prior to when their policy became active.

If treatment can be linked to any prior health problem, the need for an appeal is negated.

If it wasn’t related to a previous health issue, MIBs should provide a written explanation as to why the ailment wasn’t related to a pre-existing condition.

Unable to Meet Pre-Authorization

A wide variety of treatments require pre-authorization for reimbursements. MIBs can reverse a denial if they provide proof the treatment would have been approved, as in the case of an emergency. A convincing argument can result in full payment and waiving of penalties for not obtaining the pre-authorization.

A denial doesn’t always result in an appeal. Providing documentation and a convincing argument as to why the denial was in error is essential when disputing reimbursement rejections. Clear and concise communications are critical elements of strategies to obtain payment for denied claims.

 

Services Rendered: The Options to Offer as a Medical Insurance Billers

Services Rendered: The Options to Offer as a Medical Insurance Billers

by | Jan 13, 2014 | Electronic Medical Records, Medical Billing, Physical Therapy Billing

The future of medical billing is as bright and busy as billers want to make it. As various portions of the Affordable Health Care Act take effect, professionals and health care facilities will be serving an influx of new patients, requiring a variety of billing related services.

In this informative article, physical therapist and electronic medical record (EMR) specialist, Nitin Chhoda, examines services offered by medical insurance billers (MIB).

medical insurance billersCertified medical insurance billers provide a variety of services, from coding and transmitting reimbursement claims to accounting and tracking accounts, along with full practice management services.

Much depends upon the work environment. Those who work in medical practices and facilities may be tasked with simply coding and transmitting claims electronically.

Medical insurance billers working from home may choose to offer a la carte services to meet the specific needs of the client. Tracking accounts receivable and payable, and pursuing unpaid amounts owed by insurance companies and individuals are also part of a biller’s duties.

Who Are The Clients?

Most medical insurance billers think exclusively of medical practices when offering services, but any healthcare provider or facility is a potential client, from small clinics to practices with multiple clinicians. Hospitals, nursing homes and mental health professionals offer other options. Often overlooked sources of clients include dentists, pharmacies and social workers. Services can be adapted to meet individual requirements.

Customized Services and Specialties

Certified medical insurance billers always seek to bill accurately and quickly to increase the cash flow for their clients. They may also take on a multitude of other duties, including making referrals and recommendations within the field. Some medical insurance billers have taken their prior experience in marketing and other professions and applied it to billing to assist practitioners promote their products and services.

Medical insurance billers have their finger on the financial pulse of practices. They can determine when a client’s finances are faltering and offer consulting services. Some medical insurance billers specialize in services to physicians just starting out who can’t afford an in-house biller, as well as medical professionals who are closing out their practice.

Others have found their niche by working with rural providers who don’t have access to medical billing services or by handling non-insured patients.

EMRs and Portability

EMRs are an essential element for medical insurance billers, allowing them to perform their tasks quickly and efficiently, with clean claims that approved the first time. Built-in functionalities meet HIPAA security standards and EMRs provide alerts if claims contain potential problems or if a security issue is present. medical insurance billers with EMR

An EMR also provides medical insurance billers with portability, allowing them to offer services from multiple locations and take the job to the client.

The software systems are capable of producing graphs, reports and charts to keep practitioners informed of how they fare financially.

Multiple opportunities exist for medical insurance billers and those who are willing to offer specialized, customized services are indispensable. Billers who offer the little “extras” are in high demand, but medical insurance billers should never lose sight of their most important goal – quick and accurate billing that produces a steady monetary flow for clients.

Understanding the RAC Audit Process

Understanding the RAC Audit Process

by | Jan 11, 2014 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Software

One of the greatest challenges facing practitioners is a potential investigation by a Medicare Recovery Audit Contractor (RAC). Medicare estimates that there is a sixty two percent error rate among reimbursement claims in which documentation doesn’t match the billed expenses.

Private practice marketing expert, Nitin Chhoda, says that when services, fees and documentation don’t match, it increases the possibility of a RAC audit. The good news is that there are concrete steps clinicians can take to reduce the risk. And he shares that information in this article.

RACEven with the best coders and billers, errors can occur and it’s ultimately the responsibility of the practitioner to ensure that records match.

Knowing how the RAC process works allows clinicians to develop measures and install appropriate software systems to minimize risk factors that lead to an audit.

Medicare RAC auditors examine reimbursement claims after payment has been made, using methods similar to those employed by commercial healthcare insurance carriers.

The practice is known as pay and chase among industry officials. They look for inconsistencies in the billable services and submitted documentation.

RAC auditors utilize methods that comply with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.

Determining the Two types of Audits

There are two types of audits – automatic and complex.

  • An automatic audit seeks easily identifiable errors in payments, but doesn’t require human intervention or medical records to determine a problem exists.
  • A complex audit addresses improper payments through a manual evaluation and a request for extensive supporting documentation. Medical providers have strict and definite timelines in which to request an extension, comply with producing the appropriate records, and make appeals.

The process doesn’t stop there. Practitioners singled out for a RAC will be reported to CMS for potential fraud. If the RAC determines the problem is a potential quality issue, they report the provider to the state’s Quality Improvement Organization.

Initiate Self-Audits in order to Minimize RAC Interventions

Conducting self-audits will help minimize RAC interventions, but the best way clinicians have of avoiding an audit is to ensure their flow sheet, plan of care and billed expenses all match. If they don’t, it’s a problem and the responsibility of the practitioner.

Integrated electronic medical record (EMR) software is a critical element and provides the first line of defense toward that goal of avoiding an audit.

RAC auditorsEach EMR differs slightly, but systems such as the In Touch EMR, and In Touch Biller Pro, have capabilities specifically designed to assist coders and billers.

When data is entered, it prompts and advises the user for information and data to ensure all the components match and support each other.

It’s a crucial feature that offers a greater level of compliance and minimizes the probability of an audit.

Knowing how and why a RAC audit is conducted provides clinicians with the necessary information to help them avoid the experience. Confirming that the flow sheet, plan of treatment and documentation are all in agreement is the first step. The second is implementation of an “intelligent” integrated EMR physical therapy software system.

An audit isn’t desirable, but instead of living in dread practitioners should look upon a RAC audit as an additional way to maintain compliance.

Medical Billing Basics, Rules, and Regulations

Medical Billing Basics, Rules, and Regulations

by | Jan 5, 2014 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

A medical insurance billing (MIB) specialist is one of the most trusted individuals in a practice. Clinicians trust billers with the personal information of their patients, to obtain the largest revenues to which they’re entitled and to do so in a manner that’s accurate and legal. Nitin Chhoda discusses why integrity is one of the greatest assets a medical billing staff must have and why it should never be compromised.

medical billingCertified MIBs are specialists in their field and must conform to accepted coding practices and standards.

They have a moral, ethical and legal responsibility to code each reimbursement claim accurately, and deal fairly with patients, providers and payers.

Medical billing people are legally accountable for maintaining compliance and confidentiality, even if encouraged by unscrupulous individuals to “bend” the rules.

Ignorance is Never an Excuse

Coding regulations and requirements for submitting claims can change quickly. The onus is on the medical billing staff to remain informed and current, whether it’s a coding change or the manner in which clearinghouses accept reimbursement claims.

Always Keep it Private

Many billers are required to sign a confidentiality agreement and it’s becoming standard procedure in many practices. Confidentiality is more than a suggestion. It’s the law as outlined by HIPAA.

IMPORTANT: Patient information is to be protected at all times and there are stiff criminal penalties for those guilty of violations by word or deed.

Mistakes Cannot be Avoided But Should Never Be a Habit

No one is perfect and mistakes will occasionally be made. If there’s doubt about data contained in any portion of the patient encounter, obtain clarification from the practitioner before coding. When a medical billing staff makes a mistake, they’re obligated to report it to the payer and correct it.

No to Fraudulent Billing

There are many ways in which medical billing may be considered fraud. Over billing or unbundling to obtain more money, and under billing to get claims approved quicker, hurts the financial well-being of the practice and is illegal.

Routinely forgiving patient balances or failing to collect co-pays may run the practice afoul of anti-kickback statutes.

Insurance carriers are always seeking ways to avoid paying claims. Double billing and claiming for unnecessary procedures are red flags for payers, who have the option of initiating an investigation into the clinic and its medical billing practices.

Maintaining complete documentation that supports each medical billing reimbursement is critical.

Being Compliant is a Must

Medical billing staff must work within the dictates of the National Correct Coding Initiative edits to provide ethical, accurate and honest cost accountings to which practitioners are entitled. medical billing software

To maintain compliance, MIBs are charged with providing documentation that supports a diagnosis or procedure, and to explain costs that exceed the expected norm.

Compliance also extends to the methods by which patient information and reimbursement claims are transmitted.

The Affordable Health Care Act has mandated that billers and any entity or facility that transmits a patient’s personal data must do so through electronic medical record (EMR) technology that provides the appropriate security and safeguards.

As certified medical insurance billers, medical billing staff must have an ethical and legal responsibility to code correctly and accurately. They must maintain compliance within the confines of state and federal law, and be cognizant of the numerous requirements of insurance carriers.

Doing so will increase the number of clean claims that are paid promptly and ensure that the medical billing staff and practitioner’s reputations remain above reproach.

Insurance Claim: How to Handle and Appeal

Insurance Claim: How to Handle and Appeal

by | Dec 30, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

When a reimbursement denial is received, medical insurance billers (MIBs) may need to initiate an appeal process to collect disputed funds for practitioners. In this informative article, Nitin Chhoda reveals the most common reasons for denials and the best strategies for handling claim disputes.

insurance claimEach insurance claim goes through an adjudication process at a clearinghouse to check the data for errors before forwarding it to the appropriate insurance carrier.

An insurance claim examiner conducts another exploration of the claim and renders a decision. The examiner can choose to pay the billed expenses, reimburse at a reduced rate, or deny the insurance claim.

Insurance carriers usually deny payment for one of six typical reasons. Some of the factors are the following:

  1. Carrier’s procedures
  2. Medical necessity
  3. Inactive policies
  4. Out-of-network
  5. Level of care
  6. Pre-existing conditions
  7. Pre-authorization

Unknown Carrier’s Procedures

MIBs should be aware of each payer’s procedures and policies for handling claims. Each insurance company has its own hierarchy and protocols for reviewing an insurance claim.

MIBs should also check the contract between the clinician and the insurance company to determine that all conditions have been met.

Medical Documentation is Necessary

When an insurance claim is denied on this basis, it’s up to the MIB to provide documentation, physical therapy documentation for example, that the appropriate diagnosis and procedural codes were employed. Sometimes a coding change and resubmitting the claim will result in a satisfactory resolution.

If the codes are accurate, a letter must be provided that clearly states why the treatment was necessary, along with any extenuating circumstances.

Patient’s Insurance Policy is Now Inactive

It’s essential that the MIB has proof that the patient has an active insurance policy at the time treatment was provided.

This can be accomplished through a copy of the individual’s medical card, a letter from their employer, or a statement from the insurer.

Out-of-Companies-Network of Physicians

Some carriers require patients to only see practitioners within the company’s network of physicians, but situations arise when an in-network clinician isn’t available.

A simple letter explaining, in detail, why the patient didn’t have access to the carrier’s network of clinicians can easily turn an insurance claim denial into a payment.

Having Too Much Level of Care

Insurance claim examiners may determine the level of treatment that was billed exceeded the usual care for a particular ailment. The culprit in insurance claim denial is usually a lack of documentation that fully explains why additional treatment or procedures were required.

Providing supporting documentation usually takes care of the problem.

The Most Common – Having Pre-Existing Conditions

Most insurance policies won’t cover treatment for conditions and diseases that patients were afflicted with prior to when their policy became active.

If treatment can be linked to any prior health problem, the need for an appeal is negated.

If it wasn’t related to a previous health issue, MIBs should provide a written explanation, accompanied in the insurance claim, as to why the ailment wasn’t related to a pre-existing condition.

Unable to Meet Pre-Authorizationinsurance claim

A wide variety of treatments require pre-authorization for insurance claim reimbursements. MIBs can reverse a denial if they provide proof the treatment would have been approved, as in the case of an emergency.

A convincing argument can result in full payment and waiving of penalties for not obtaining the pre-authorization.

An insurance claim denial doesn’t always result in an appeal.

Providing documentation and a convincing argument as to why the denial was in error is essential when disputing reimbursement rejections. Clear and concise communications are critical elements of strategies to obtain payment for denied claims.

Medical Coders – What are they?

Medical Coders – What are they?

by | Nov 15, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Software

Medical coding is often associated with medical billing, but the two are entirely different career paths. Coders use the information provided by the medical provider for treatment rendered and assign the appropriate codes for billing purposes.

The duties of a biller and coder may be combined in smaller practices and performed by the same individual. Nitin Chhoda shares the main responsibilities of medical coders and the attributes that they must have.

medical codersEducation Always Counts … Of Course!

A thorough knowledge of medical terminology and anatomy is essential for a medical coder. The average medical coder’s course is 15 months long and costs approximately $2,000.

Online training is available from a variety of professional organizations and at multiple colleges throughout the country.

A prerequisite is college-level human anatomy and physiology.

Students will learn how to assemble documentation and interpret guidelines for accurate coding. Courses will address the upcoming transition to ICD-10 codes, along with maintaining compliance and the ethical and professional standards required of a certified coder.

Medical Coders Must Be Familiar with Legalities

Remaining in compliance with government rules, regulations, guidelines and laws will play a major role in a coder’s every day duties.

Medical coders are in contact with confidential information that’s protected through regulations established by the U.S. Office of the Inspector General (OIG).

The OIG rules are designed to prevent fraud and abuse in billing.

Medical coders must also maintain compliance in the usage, dissemination and transmission of patient information as set forth in the Health Insurance Portability and Accountability Act (HIPAA). Known as the Privacy Act, it dictates how to handle sensitive patient data.

Medical Coders Know the Requirements and Compatibilities When Coding the Bill

An extensive array of data is collected during each patient encounter and it’s up to the coder to decipher any clinician notes and gather the documentation necessary to accurately code the reimbursement claim.medical coding

This is where knowledge of anatomy and medical terminology comes into play.

Medical coders are responsible for assigning the appropriate alpha-numerical CPT and ICD codes to reflect the practitioner’s diagnosis and subsequent treatment.

Medical Coders Should Be Familiar with an Integrated Software Technology

All the assembled data must be entered into a specialized medical billing software program or an electronic medical record (EMR) system in preparation for billing.

In practices that employ a single individual who acts as both the coder and biller, he/she will transmit the claim electronically to a clearinghouse for examination before being sent to the payer.

Show Me the Money …

Medical coders who undertake both coding and billing duties will be required to monitor claims to ensure they’re paid, follow up on late or denied claims, and interact with insurance carriers to collect the clinician’s fees.

Certified medical coders also work with patients on their portion of healthcare costs and file appeals with payers when required.

Medical coders hold considerable power within a practice and are professionals in a specialized field. They use their knowledge and ability to keep the flow of funds coming into a practice. They hold the financial keys to enable clinicians to plan, expand and pay the bills.