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.

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.

What are the Medical Billers?

What are the Medical Billers?

by | Nov 12, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Software

Medical insurance billers (MIBs) are the lifeline of a well-funded practice and the connecting link between patients, practitioners and insurance companies.

Billers affect the lives of hundreds of people each week and are an essential link in the reimbursement process. They collect payments for clinicians and ensure that insurance companies pay their portion of the costs for their clients’ healthcare expenses.

medical billerMedical billers perform a variety of functions, from entering the alpha-numeric ICD-9 and CPT codes that tell insurance companies the treatment a practitioner provided to interacting with patients on the balances they owe.

Medical billing staff works with sensitive data each day that requires confidentiality, integrity and ethics.

First Step — Data Collection

An MIB often functions as a coder and a biller, though the jobs can be exclusive of each other. Medical billers gather all the information associated with a patient’s encounter with their healthcare professional.

That information provides the documentation that will be used to support the payment requested from insurance carriers.

They decipher the data to determine the patient’s complaint and the appropriate CPT code to reflect the treatment provided.

Medical Billers Should Have Good Communication Skills

Medical billers spend a considerable amount of time interacting with others as part of the data collection and payment process. Clinicians must be queried to clarify patient encounter information and patients contacted about their payment obligations.

Medical billers also interact with insurance company representatives on reimbursement issues.

MIBs Must Always Verify the Facts

Medical billers are responsible for verifying patient insurance information, the correct billing format for each payer, and assigning the codes and modifiers that result in the practitioner’s payments.

They work with hard facts about patient policies, physician services and insurance company protocols.

Medical billers may also transcribe a doctor’s dictation about the patient encounter. Billers are knowledgeable in medical terminology, which helps them in assigning diagnosis and procedure codes.

Medical Billers Must Have Computers and Integrated Software

Medical billers spend a majority of their time behind a computer screen, ascertaining the facts of each patient encounter. They work with specialized billing software, like In Touch Biller Pro,or electronic medical record (EMR) systems, like In Touch EMR, that assist them in coding correctly, meeting the many submission demands made by payers, and transmitting claims electronically.

Consistent in Following Up Funds

Medical billers track and monitor each claim to determine its position within the reimbursement process. medical billers' software

They submit claims to clearinghouses where they’re examined for mistakes, errors and inconsistencies.

Clean claims are forwarded on to payers for reimbursement.

Medical billers track and monitor each claim to determine its status, ensure payments are made in a timely manner, and deposited in the practitioner’s account.

They work with clearinghouses and carriers if a claim is denied to obtain payment, and interact with patients on co-pays, deductibles and balances owed.

IMPORTANT:  Medical billers ultimate responsibility is to ensure that clinicians collect the maximum amount of money to which they’re entitled.

Medical billers wear many hats in their profession. They’re often one of the first and last individuals with which patients interact on financial obligations, and they comprise the key element in the reimbursement chain.

Medical billers document, code, transmit and follow payments to ensure their client’s financial status remains in the black.