Denials disrupt a medical insurance biller’s (MIB) cash flow to their clients, but incurring exclusions from one of the government operated healthcare programs can cost thousands of dollars. Exclusions severely limit employment opportunities and in this revealing article, Nitin Chhoda examines exclusionary factors and what it means for billers.
There’s an extensive number of ways that billers can garner exclusions. The good news is that there are preventative measures that billers can take to protect themselves and their clients.
Keeping current on coding is essential for obtaining reimbursements and it helps MIBs avoid claim denials. CPT codes are updated annually and those using old, obsolete or defunct codes run the risk of having a claim reimbursed at a lower level.
At the payer’s discretion, the carrier may refuse to recognize the claim at all. When billers obtain a new client, it’s a good idea to take a look at their coding and forms to ensure they’re using the most current codes.
ICD-10 codes will soon replace the old system and updating to the new codes is critical for claims to be accepted. Healthcare practice management insurance carriers will reject and deny any claim that doesn’t employ the new coding system.
Current coding allows practitioners to be reimbursed at the highest level and provides proof to carriers that the charges are justified.
Attending seminars and conferences is a good way to stay up-to- date on the latest trends, laws and practices that relate to the billing industry. Many carriers provide free seminars and professional billing associations offer online webinars and resources. Subscribing to newsletters and bulletins from professional organizations is also a good source of knowledge.
Exclusions and Causes
There are two types of exclusions – permissive and mandatory – and they’re governed by the U.S. Office of the Inspector General (OIG). Depending upon the offense, those who have incurred exclusions will find their employment opportunities curtailed and they can even lose their license. Penalties are typically in effect for a minimum of five years. Mandatory offenses that require exclusions are:
- Conviction of patient abuse or neglect;
- Conviction of a program-related crime;
- Felony conviction relating to healthcare fraud;
- Felony conviction of a controlled substance.
Penalties for permissive exclusions vary from case to case, but are in effect for a specified amount of time set by the OIG. Permissive offenses that are at the OIG’s discretion include:
- Failure to provide quality care;
- Failure to repay college education loans;
- Some misdemeanor convictions;
- Lying on an enrollment application;
- Loss of state license to practice.
Billing with the latest codes facilitates claims that aren’t denied, while ensuring prompt payments and uninterrupted cash flow for clients.
MIBs that garner exclusions will be unable to work or contract with facilities or clinicians that participate in government healthcare programs, and will lose income should one of their clients incur exclusions.