Claim Appeals 101

Claim Appeals 101

Reimbursement claims can be denied at any time and for any number of reasons. Most problems can be remedied easily, but when talking fails to facilitate a desirable outcome it may be necessary to file an appeal. In this revealing article, Nitin Chhoda addresses the basics of filing an appeal.

clearinghouseMost appeals in the billing process, physical therapy billing included. will involve commercial insurance companies.

How a clinician approaches an appeal has a huge impact on how quickly and smoothly the process is concluded.

Unfortunately, the onus is on the practitioner to prove why a claim wasn’t processed properly for payment. That requires knowledge of the payer and the terms of the contract that was signed with the insurance provider.

Provider Relations

Many contracts include a prompt pay clause that can cost the payer fees and interest on late payments if they didn’t file or process the claim according to the terms of the contract. The first point of contact when filing an appeal will usually be provider relations to ascertain if the claim was received and how it was processed.

A phone call can be all that’s needed to quickly remedy the situation. Some payers provide online reconsideration forms that can be submitted, while others require a formal written appeal. It’s critical to maintain complete documentation of all verbal and written communication associated with the appeals process.

Provider Representative

If the claim wasn’t processed due to the contract loading incorrectly in the payer’s software system, the next step is to speak with the provider representative. This individual is charged with ensuring the contract between the medical provider and payer is correct and loaded in the claims processing software system.

Expect to be vetted and answer specific questions about the claim. The provider representative may be able to locate the problem and solve it.

Representatives also have the power to send the claim back to the payer for reprocessing.

Written Appeals

If a phone call fails to resolve the issue, a written appeal must be submitted. It should include all the pertinent information about the claim and clearly state the expected outcome for settlement. Explain why the actions are being sought and further steps that will be taken, such as referring the matter to the practice’s attorney.

Exercise Control

Appealing a claim rejection is time consuming and frustrating. It’s critical to exercise control and professionalism at all times. claim submission

The appeals process relies on facts for resolution and it’s important to clearly state the problem and the payment expected. Refer to specific clauses in the contract to prove points.

A denied or rejected claim delays payment and appealing the decision can require considerable time and effort.

The process is sometimes necessary to collect the fees to which clinicians are entitled and it’s important to keep a cool head throughout the process.

Most disputes with commercial payers can be solved if practitioners approach the situation armed with the facts and the terms of the payer contract.

Insurance: The Rules, Regs and Who Makes the Decisions

Insurance: The Rules, Regs and Who Makes the Decisions

The rules governing healthcare insurance procedures are as varied as the companies that offer policies. Payers may choose to follow the same regulations as government backed insurance plans, while others have developed their own unique set of parameters.

It’s essential for billers to be familiar with them all and electronic medical record expert (EMR), Nitin Chhoda, has released new data on who makes the rules that govern reimbursements.

insuranceWho Controls The Purse Strings?
When it comes to clinicians being reimbursed for the services they render, practitioners should never forget that insurance companies are firmly in control of the entire process.

Each payer has its own set of policies, procedures, manuals and submission requirements. The payer establishes the rules and regulations that medical billers and coders must follow to ensure clinicians are reimbursed.

Practitioners typically contract with commercial insurance companies to reimburse them when one of their covered clients seeks medical attention. Most individuals have insurance through their employer and the payer underwrites the plan, complete with financial caps, treatment limitations and the need for prior authorization and referrals.

Networking Opportunities
Insurance companies control access to providers through the employment of networks. The insurance company maintains a network of medical providers with which it has a contract. The arrangement ensures a steady stream of patients for practitioners.

In return, the clinician agrees to receive specific reimbursements for services to limit outlays by the insurance company.

Contract Specifics
Contracts define time limits for submitting claims, how long the insurance company has to pay the claim, and the type of plans included in the agreement. Fee schedules, procedures that require preauthorization or referrals, and the appeals process are clearly spelled out.

Other payers choose to adhere to the fee schedule set forth by Medicare, modify the fees to pay 110 to 125 percent of what Medicare reimburses, or even pay less. Even though the medical provider may receive less than the Medicare fee, insurance company executives know that patients covered under their plans represent a substantial client base.

The Path to Payment
Most claims result in prompt payment, but the potential always exists for the payer to repudiate a reimbursement. Practitioners must use caution when negotiating contracts with payers, be cognizant of the terms, and long-term implications. Appeals can be filed when necessary.

Much of the reimbursement process relies upon the medical billing and coding specialist entering the correct codes, and ensuring documentation complies with the payer’s submission specifications.

insurance guidelines

Payer-practitioner contracts should be loaded in the practice’s EMR software to facilitate clean claims.

Insurance companies call all the shots when it comes to reimbursements. Clinicians must be vigilant when negotiating contracts with payers to ensure they’re receiving the best return for their services.

A great many payers exist, each with its own set of rules, regulations and requirements, but with a good billing and coding department, participating in a network of insurance providers can be a good investment for the practice.

The Life of a Claim: How You Get Paid

The Life of a Claim: How You Get Paid

The clock starts ticking on the life of an insurance claim the moment a patient makes an appointment and doesn’t end until the practitioner is paid. To better understand the life cycle of an insurance claim, Nitin Chhoda offers a first-hand look at the process.

claimFirst Contact
When clients contact a practice, it sets in motion a process in which it can take up to three months for the clinician to be paid.

Before patient arrives at the office, staff should already have obtained and verified the individual’s healthcare insurance information to ensure the policy is in force, hasn’t lapsed and who is covered, along with any limitations or restrictions.

Insurance benefits can be tricky to navigate. Clinicians must ascertain exactly what’s covered under the patient’s claim insurance, their deductible and co-pay when they make an appointment. It will impact the client’s available treatment options. Some individuals have coverage under more than one insurance provider. Both policies must undergo the same rigorous verification.

Patients will also be required to sign consent forms allowing the practitioner to bill the insurance company and be paid directly, release information for billing, and for the client to pay any amount not covered by insurance claim. A copy of the client’s identification and insurance card is required, along with a complete health and medical history.

Enter the EMR
All the client’s information must be entered in the practice’s EMR for medical billing. Incorrect or incomplete information will delay reimbursements to the clinic, as will failure to obtain an authorization for procedures. Insurance providers will deny a payment if the correct forms aren’t used, information is incomplete and for other breaches of the company’s particular set of rules.

To document the client’s visit, clinicians will create an encounter form that provides pertinent information about the patient’s complaint, exam, diagnosis and procedures performed. Any secondary problems that are observed must be documented and all the information entered into the EMR. Each diagnosis and procedure code must match or the claim will be denied.

Calculating Fees
Clinicians can now enter the cost of the visit utilizing their schedule of fees. Each procedure and all materials must be calculated into the final cost, from the use of the exam room to bandages. It’s also time for the patient to determine how they’ll pay for any portion of the cost for which they’re responsible.

That can take the form of cash, check, debit or credit cards, or a payment plan. Collect at least a portion of the payment before the client leaves the office.

Submitting the Claim
A reimbursement claim must be prepared and sent to the client’s insurance carrier, complete with documentation of the patient’s financial and clinical information from their visit. Each claim should be double checked to ensure that codes and patient information match, and that there are no omissions, or the claim will be delayed.

The claim will examined in extensive detail by the insurance company to ensure the client is covered, any restrictions and limitations were adhered to, accurate coding was included and information is complete. insurance claim

If a problem arises, the clinician will be asked for additional information or to resubmit the claim.

Practitioners can appeal the decision, collect any unpaid amount from the client or write off remaining costs.

It can take a typical claim up to three months to be reimbursed, even without any difficulties. Using an EMR ensures HIPAA compliance, protects against loss, decreases processing time and accelerates the entire process for quicker deposits and better cash flow.

Payer : Who Is It and Who Has the Money? Part 1

Payer : Who Is It and Who Has the Money? Part 1

Medical professionals collect reimbursement payments from a variety of sources. Known as payers, they encompass commercial insurance companies, third-party administrators and government-funded programs.

In part 1 of this revealing article, Nitin Chhoda identifies the major commercial payers and third-party administrators, and what clinicians need to know to obtain reimbursements.

payerA wealth of commercial insurance plans payer exists to help individuals pay for medical expenses. That includes preferred provider, point of service, health maintenance, and discount plans.

To ensure that services are paid for, practitioners must verify the client’s coverage each time they visit the office and ascertain any limitations as it will have a direct bearing on treatment options.

When contracting with a payer, it’s important for clinicians to know if the insurance company is the entity that actually sets the amount that medical professionals are reimbursed. Some participate in a payer network that determines how much practitioners are reimbursed for their services. Some networks pay better than others and clinicians should exercise due diligence in researching payers.

Commercial insurers
The most common form of insurance practitioners will encounter is the commercial policy, typically offered through the patient’s or spouse’s employer. This type of coverage will fall under one of the following:

•    PPO – A preferred provider network is a group of healthcare professionals and facilities that have agreed to provide services at reduced rates.
•    HMO – Health maintenance organizations rely on a network of healthcare providers, but clients are assigned a primary care physician and care must be accessed through that physician.
•    POS – Point of service coverage is a hybrid blend of a PPO and HMO payer. Patients who visit an HMO medical provider are covered under HMO benefits. If they see a PPO provider, they receive coverage through the PPO.

•    EPO – An exclusive payer or provider organization plan requires patients to select a primary care physician and obtain a referral before seeing a specialist.
•    High deductible plans – These offer patients low monthly premiums and deductibles that can begin at $4,000 or more.
•    Discount plans – These plans require patients to pay a monthly fee to obtain access to participating providers. They’re not true healthcare insurance plans.
•    COBRA – Coverage under a Consolidated Omnibus Budget Reconciliation Act plan is a payer that is dependent upon patients making their monthly payments on time. If a payment is late, claims will be rejected or the coverage cancelled.

A COBRA plan is interim coverage when an employee loses or leaves their job.

Third-party administrators
A third party administrator (TPA) or payer is the middleman of healthcare. TPAs are operated as an independent network, or price claims by accessing other networks.

They handle claims for employers who insure their own employees rather than participating in a commercial group program. medical payer

Reimbursement problems can arise for clinicians if the TPA prices the claim incorrectly or the claim isn’t paid according to the individual TPA agreement.

Before contracting with a payer, it’s essential for practitioners to determine which entity sets the cost of services and what those payments will be to the practice.

Different networks and commercial insurers for medical billing have their own set of rates and reimbursement requirements that must be met for clinicians to be paid and practitioners must conduct sufficient research to ensure they’ll be reimbursed appropriately.

Medical Billing — Its Role and What it Means to Your Office Structure

Medical Billing — Its Role and What it Means to Your Office Structure

A structured medical practice is essential to ensure that reimbursement claims are submitted in a timely manner.

Missing, lost, misplaced or improperly filed patient records creates unnecessary medical billing delays and interrupts the flow of funds into the practice.

billingOrganization is the key to a well-run practice that treats as many patients as possible and generates a steady stream of reimbursement claims for medical billing and coding specialists to process.

In the absence of clear cut rules, direction and procedures, waste and chaos results. Distracted billers can make costly mistakes.

Filing practices
Maintaining accurate and easy to access patient records is essential if a biller is to do his/her job. The information contained within the patient’s record is the basis upon which reimbursement claims are filed.

Incomplete, inaccurate or illegible records cause delays in medical billing and can easily result in a payment denial or rejection. The information needed to obtain payment must be maintained in a manner that allows billers to quickly access the information they need to submit claims.

Each to his own task
In smaller practices, staff members may be required to wear a variety of hats, including the clinic’s medical billing and coding specialist. While it’s possible for a clinic’s healthcare staff to multi-task by answering phones, looking up records, scheduling appointments and communicating with other healthcare facilities and pharmacies, it’s not conducive to medical billing practices.

Each team member should have set responsibilities and clear cut job descriptions to avoid wasted effort. That’s not to say that personnel shouldn’t be cross trained to handle other duties should the need arise. Clinicians need to plan for such contingencies and ensure staff has a clear understanding of what to do in specific circumstances.

Set office hours
Setting regular office hours allows patients to know exactly when the clinician is available and keeps practitioners from being pulled in too many directions at once. Scheduling appointments to see clients allows providers to best utilize their time and provides medical billing specialists with a steady stream of claims to submit throughout the day.

Some healthcare professionals prefer the walk-in method of seeing clients with no appointment necessary.

It eliminates the problems of cancellations and no-shows, but there’s no way to ascertain how many patients may or may not arrive.billing and documentation

Clinicians could find their medical billing specialists have few reimbursements to submit.

A well-structured office is one that operates efficiently and where every detail of a patient’s visit is carefully documented and filed for retrieval by the practice’s medical billing specialist.

Careful organization and an eye for detail ensures that billers have the information needed to process reimbursement claims to maintain a steady cash flow into the clinic.

Health Insurance and Its Top Three Mistakes or Issues

Health Insurance and Its Top Three Mistakes or Issues

There are three major mistakes within the office setting that are contributing to a loss of revenue through non-payment. The errors can easily be prevented and some can be eradicated before patients ever arrive for their appointments.

health insuranceClinics across the nation are feeling the effects of longer turnarounds on reimbursements and outright denials by health insurance companies to pay for services.

Verify Health Insurance Information Each Time Services Are Provided
The number one cause of denied reimbursement claims is a failure to verify health insurance information. Loss of employment and changes in insurance coverage can occur at any time. It’s essential that client coverage is verified for each patient anytime services are rendered.

Denials occur for any number of reasons, but the most common is the coverage has been terminated, followed by the patient being ineligible. Many health insurance plans require pre-authorization for procedures and have limits on benefits.

Failure to obtain permission or determine if the client has reached a maximum benefit amount will result in denial of payment. Practitioners should also ascertain if specific services are covered.

Current Patient Information Is Essential
They may seem like simple errors, but incomplete or incorrect patient information is the second most common cause of denials. Clinicians should ensure that the client’s name is spelled correctly and the date of birth is accurate, along with the address, complete contact information and gender.

Some patients have healthcare coverage through multiple providers, requiring clinics to perform additional checks to coordinate benefits. The policy holder and their relationship to the patient must be clear.

Each health insurance provider has its own set of rules for submitting claims and special attention should be paid to ensure those requirements are met.

Diagnosis, Procedure Codes and Sloppy Handwriting
Diagnosis and procedural codes provide essential information to health insurance companies about the patient’s condition, symptoms and treatment. Codes that don’t match the information provided can result in a denial on the grounds that the procedure wasn’t medically necessary or it doesn’t match an authorization.

Clinicians should ensure that their medical billing and coding experts are utilizing current codes and that they’re updated yearly. Another source of denials is poor penmanship on the part of the practitioner, a situation that is easily corrected with implementation of an integrated electronic medical record (EMR) system.

health insurance issuesNavigating the labyrinth of rules, regulations and requirements set forth by health insurance providers can be a daunting process.

Human error and failing to verify health insurance information complicates the process, leading to payment denials and loss of revenues.

Vigilance is the only cure for clinics still using paper records. Implementation of an EMR transitions clinics away from wasteful paper records and virtually eliminates the top three mistakes of health insurance claim submissions that rob practitioners of revenues.