Billing and Coding Errors – How to Minimize If Not Avoid

Billing and Coding Errors – How to Minimize If Not Avoid

The Affordable Health Care Act resulted in many changes for subscribers and alterations in the services carriers are willing to cover as part of insurance policies.

Those modifications directly impact how medical insurance billers (MIB) code claims. To assist billers in avoiding costly billing and coding errors, Nitin Chhoda examines the most common reasons for claim rejections and denials.

codingTo make payroll or purchase equipment and keep a practice operational, clinicians rely on MIBs to provide a steady stream of income in the form of reimbursed claims.

When the flow of revenue is interrupted with rejected or delayed claims due to coding errors, it can spell hardship for the practice and result in an investigation by regulators and law enforcement for suspected fraud.

Assumption of Coding

Every patient encounter is different and MIBs should never code on the assumption that “standard” treatment was provided. Billers need to consult with the clinician if they suspect missing information or simply can’t read the physician’s handwriting.

Documentation Problems

A number of documentation problems can arise when claims are filed, including missing or incomplete documentation that supports each item for which the practitioner is seeking reimbursement.

A criminal investigation could be done in the immediate future if a payer believes the MIB altered or recreated documentation to support a denied claim.

Mismatched Coding

The incidence of mismatched coding is a careless mistake and happens more often than one would imagine. It most frequently displays as billing a male patient for a treatment or procedure that is unique to female anatomy.

Important note: You can never overlook such simple mistakes because it can lead to claim denials.

Noncompliance

Each insurance carrier establishes its own set of rules and regulations governing claims. Billers can expect a denial if they don’t adhere to the payer’s specific policies, procedures and protocols.

Preapprovals

MIBs who fail to obtain the appropriate approval prior to treatment will find the practitioner’s claim denied. Payers are sometimes willing to make the approval retroactive in the event of an emergency when treatment was critical to save a person’s life.

Truncated Coding

Claims must include all three diagnosis levels for the greatest accuracy. Truncated coding may address the manifestation and episode of care portions, but not include the site of infliction.

Up and Down Coding

Coding at a higher level of treatment than was received exposes practitioners to fraud charges. Down coding is billing at a lower rate than appropriate in an effort to avoid denials. Payers who suspect this of happening can hold up claims for weeks or months.coding and billing

Unbundling

Coding is designed to include multiple actions as part of specific procedures and is billed as a whole. Unbundling bills those elements separately and could be viewed as an attempt at fraud.

Practitioners place their faith in MIBs to do their jobs quickly, efficiently and ethically. Mistakes in your physical therapy billing and coding can be easily rectified by simply double checking each claim before transmitted.

Being “creative” by unbundling or making assumptions about treatment that’s not supported by documentation can lead to charges, fines and litigation against both the clinician and the biller. Taking an extra moment to examine the claim will save days or even weeks in terms of delays and denials.

Healthcare Coding Basics

Healthcare Coding Basics

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.

healthcare codingMIBs 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.

healthcare coding basicsModifiers 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 Typical Insurance Claim Cycle

The Typical Insurance Claim Cycle

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.

claim cycleThe 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.

claims cycle process

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.

The Real World of Outpatient Claims

The Real World of Outpatient Claims

Medical insurance billers (MIBs) learn a wide variety of skills and obtain a diverse array of knowledge in preparation for a career as a biller. Conditions and protocols in the work environment can vary significantly from the educational arena, depending on the facility’s policies. In this informative article, Nitin Chhoda takes a look at the real world of outpatient claims.

outpatient claimsNew Beginnings

An appointment for a new patient begins with a comprehensive health form to collect as much information as possible about the reason for the visit, along with health concerns, conditions and ailments.

The outpatient claims process include obtaining a copy of the individual’s photo ID and insurance card to verify eligibility and that the policy is valid. Healthcare identity theft is an increasing problem and MIBs must be vigilant.

As part of the registration of the outpatient claims process, MIBs review the guidelines and specifics of the patient’s policy.  Exclusions, limitations and prerequisites may apply that can affect available treatment options and the timely collection of the provider’s revenues.

Co-pays and Deductibles

Patients are typically required to pay a portion of their healthcare costs through co-pays and most policies have a deductible that must be met. Part of the outpatient claims process includes collecting the required co-pay, preferably before the patient sees the provider. Insurance data is presented to the practitioner, enabling him/her to render care that meets with the carrier’s policy specifications.

Just the Facts

In the world of outpatient claims, the facts encompass the provider’s diagnosis and statement of services provided. MIBs assemble all the necessary data and documentation, assigning numerical and alphabetical codes that will be used for reimbursement purposes when the claim is transmitted to the clearinghouse.

Follow Up Visits

outpatient claims processContinuing care isn’t just for patients. MIBs monitor and track claims, outpatient claims included, to ensure they reached their destination and determine the payment status. If a problem arises, billers will need to conduct a follow up and revisit the claim to rectify any errors or obtain payment.

MIBs are also responsible for contacting patients for unpaid balances on their accounts. When patients have difficulty paying their bill, MIBs may be authorized to negotiate payment plans or turn the account over to a collection agency.

In the real world of outpatient claims, the expertise of the certified medical insurance biller is a key element in the financial success of a practice.

Medical billing people are the keepers of the data and outpatient claims procedures that facilitate the flow of revenues to practitioners, forging the essential monetary links between patients, practitioners and payers.

 

Bundled Medicare Payments with Obamacare?

Bundled Medicare Payments with Obamacare?

Bundled payments for Medicare patients is one of the big changes that comes with the Affordable Health Care Act, also known as Obamacare. The loss of revenue will be obvious for practitioners.

ObamacareObamacare places restraints on payments made for Medicare patients, cutting them by up to 20 percent, and bundles payments for treatments and procedures that were billed separately in the past.

Bundling For Savings

Approximately one-fifth of the funding for Obamacare comes from slashes to Medicare reimbursements to medical providers.

Obamacare removes the traditional fee-for-service payment model, replacing it with a bundled system for inpatient hospital services and post-discharge treatment, also known as episode-based payment.

The new system’s intended goal is to reduce the length of hospital stays and readmissions. When an individual is hospitalized, they will be treated by a team of healthcare professionals for a specific length of time.

The team can include medical professionals from multiple care facilities. The grand experiment in healthcare delivery to patients began in Jan 2013 and will operate for three years.

The members of a treatment team will be rewarded with financial incentives for getting Medicare patients cured/recovered quickly.

Unfortunately, the system opens the door to the potential of reduced quality of care and a temptation to cut corners.

Payments are fixed at a set amount. The fewer resources used on patients, the more money goes to the hospital.

Hospital At Home

As part of the Medicare imperative to cut costs, the Independence at Home initiative began in Jan. 2012. The program evaluates the profitability and outcomes of home monitoring technology to discover if costs are reduced and care improved.

The Medicare-related programs are based on a 2008 essay by President Obama’s healthcare advisor, Dr. Ezekiel Emanuel.

The doctor postulates that the rise in healthcare costs can be traced to patients who “overuse” the healthcare system. He advocates for the removal of “fluffy, self-indulgent excess” out of the system and giving doctors financial incentives to deliver less care to patients. Emanuel’s views may come to fruition with the Independent Payment Advisory Board (IPAB).

The IPAB Ingredient

Obamacare established the IPAB, whose sole function is to find more ways to reduce healthcare spending, specifically in the Medicare arena. The 15-member panel isn’t elected and can’t be replaced by the will of the people.

IPAD could mean radical cuts in the future for Medicare patients.

ObamacareThe panel will be responsible for evaluating available treatment options and deciding which treatments and procedures provide the best value for the money spent.

Their recommendations automatically become law unless Congress counteracts them with a three-fifths super majority vote. IPAB’s recommendations start in 2015 and will be implemented in 2018.

There’s no guarantee that bundling payments for care delivered to Medicare patients will improve quality of care or reduce costs.

To retain more of the fixed fees allotted for hospital care, Medicare patients could lose access to tests, treatments and medications that are considered too costly, while IPAB recommendations will hold more such cuts in the future.

Reimbursement Claims: How Can to Make Sure I Get It the First Time Around?

Reimbursement Claims: How Can to Make Sure I Get It the First Time Around?

Clean reimbursement claims are the bread and butter of the medical billing industry. They pass the scrubbing process at clearinghouses quickly and generate revenues faster. Billers can take a variety of precautions to avoid denied claims and in this telling article, Nitin Chhoda reveals the most common billing mistakes.

reimbursement claims The first rule of medical billing is never assume anything. If a medical insurance biller (MIB) has any doubt due to a practitioner’s illegible scrawls, the type of treatment received or procedure performed, it’s imperative to contact the clinician for clarification.

Coding Errors

Mistakes and oversights in coding represent the number one reason that reimbursement claims are denied. Electronic medical record (EMR) technology can identify potential claim problems and notify the user. Insurance carriers are constantly seeking ways to avoid paying reimbursement claims and examine coding closely for the following items:

  • Mismatched coding that creates inconsistencies in the claims. A good example is gender specific ailments.
  • Truncated coding doesn’t address all three levels of the practitioner’s diagnosis is suspect.
  • Up and down coding is a red flag for carriers. Trying to obtain higher reimbursement claims or coding at a lower level in an effort to avoid denials can result in penalties, or the carrier may decide not to do business with the clinician.

Document Everything

Clean claims provide the appropriate documentation for every item, from the patient’s identity to the treatment provided. MIBs must ensure that reimbursement claims contain complete and accurate information on all facets of the patient’s visit.

When claims are returned with a request for supporting data, insurance carriers can become suspicious and suspect the medical provider or the MIB of altering or recreating documents to support a claim.

Billing Blunders

Unbundling is the act of billing separately for elements that should have been claimed as a whole. Insurance carriers allow for unbundling under very specific circumstances, but MIBs should utilize caution when doing so. Coding is designed to cover an entire treatment or procedure and will single out a claim for closer inspection.

Complying with Carriers

There’s no standard procedure when dealing with insurance carriers. Each company establishes its own rules for reimbursement claims submissions. MIBs who don’t adhere to the carrier’s specifications will be deemed non-compliant and the reimbursement claims will be denied. That can also encompass failure to obtain a pre-approval prior to the patient’s treatment.

Clerical Oversightsreimbursement claims process

Correct coding and detailed documentation won’t avoid a denial if the reimbursement claims contain omissions, data entered in the wrong location or typographical errors.

Even simple items, such as misaligned paper in a printer, can pose sufficient reason for a clearinghouse to reject a claim.

Most mistakes can be identified and corrected prior to transmission to the clearinghouse. It takes only moments to double check a claim before it’s sent, but correcting and resubmitting reimbursement claims can take hours of work and severely disrupts the flow of revenue. Knowing where the most common errors occur is the first step toward filing clean claims.