Call me crazy, but it is always exciting to me when I assist a practice in getting reimbursed on unpaid or delinquent claims. Claims that were denied, viewed as uncollectable, past filing deadline, or a multitude of other reasons. I even have a little dance that I do! Why not? We need to get excited about our jobs, and in these times of decreasing health care reimbursement, it is crucial that we push forward and adopt a motto of “NO CLAIM LEFT BEHIND”! Here are a few tips to help you become persistent in your reimbursement efforts for your practice.
First and foremost, don’t get behind. I know it seems elementary, but it is very important to have solid Billing Processes. Set goals and tasks that need to be met daily, weekly, and monthly, and mark them on your calendar to ensure you comply.
Resolve payment denials and other claim related requests as they come in. Don’t let them stack up.
Communicate denial trends with your provider or other appropriate staff. There may be coding, office policy, or even staff issues that need to be addressed. Resolving the issue quickly can help avoid future denials and possible compliance risks.
Identify your delinquent claims on your Aging Report monthly. Most Practice Management Systems can easily compile this report. Go through each claim to follow up to see why the claims has not been paid.
Record detailed account notes on what you have done on each claim. Include dates, contact names, and other pertinent details. This proves vital when you need to access the account again and take further action on a claim.
Know and understand all of your top Payer guidelines for appeals, reconsiderations, and resubmission of corrected claims.
Develop a QRG (quick reference guide) for all of your payers that includes required information when working your claims.
Finally, take action on every one your delinquent claims and follow through to resolution. In most cases, persistence will lead to positive results.

Author: shannon bosley

– Source: http://www.codapedia.com/article_552_No-Claim-Left-Behind.cfm#sthash.CY2tZxXr.dpuf

Accounts Receivable benchmarks are measures of how successfully and how quickly the practice collects their revenue for services provided.
These measures include the gross collection ratio, the net collection ratio, aging report and day in receivable outstanding.
Physician practices should make a special effort to collect revenue and cash from patients with past due balances who are being seen in the practice, patients who have a budget plan and patients who have high deductible plans or no insurance. The longer the time between the date the service and the collection effort, the lower the chance of collecting at all.
Measure each of the AR benchmark data monthly and track your results on a monthly and year to date basis. Use external data to compare your specialty to other specialists. The key data are at least: gross collection rate, the net or adjusted collection ratio, an aging report, or an aged trial balance and the total days in accounts receivable outstanding.

Author: Sally

- Source: http://www.codapedia.com/article_81_Accounts-Receivable-Benchmark-Data.cfm#sthash.H8aHLa0W.dpuf

For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following:

• There must be written documentation in the chart from the physician practice requesting the consult. You can have them fax a request or the patient can bring it with them, but as the physician billing the consult, you have to make sure you have the request in writing.

• The written report that must be sent to the requesting physician is the most often overlooked component of a consult code. This report does not have to be a full copy of the history, exam, and decision making but can be a summary of your opinion and recommendation for treatment. Most requesting providers would prefer not to have the full consultation note; it’s too much reading; duplicates information they already have in their own history, and takes up too much space in the chart. Make sure you maintain documentation in your chart that shows that the opinion was sent either by mail or fax or email.

• Primary care or cardiology physicians who are asked to clear a patient for surgery can bill a consult code, even if the clearance is for an established patient. Remember that for Medicare patients, surgery clearance is only covered for patients with an underlying medical condition such as hypertension or diabetes that must be managed to safely perform surgery. Most carriers suggest the use of V72.83 diagnosis code for pre-operative surgery clearance. Remember that the requirements for written request from requesting physician and the need to send back your opinion to the requesting physician still apply.

• Medicare has made it very clear that consults CANNOT be shared between non-physician practitioners and physicians. If a non-physician practitioner performs any of the key elements of the consult, then the consult cannot be billed under the physician NPI. For commercial carriers, be sure and find out if these visits can be shared–don’t just assume that they can.

Once you get your processes in place to ensure you are following the rules for consult coding, you can put more energy into patient care. Happy coding!

Author: Kay Stanley

- Source: http://codapedia.com/article_321_Consult-Documentation-Guidelines.cfm#sthash.Jh37oADa.dpuf

Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure?
In many cases outpatient procedures and surgeries do not require pre-authorization or precertification, but that does not guarantee payment by the insurance company. Insurance companies frequently require patients to meet criteria prior to having surgery. What is the difference between pre-authorization, pre-certification and pre-determination?
Pre-authorization is getting approval or permission for the procedure or surgery. Without the permission, the insurance company may not pay for the procedure. This may include learning the patient’s benefits or allowances for such procedures.
Often, physical therapy, occupational therapy and chiropractic services require approval prior to beginning of the services. An MRI or CT often requires approval from the insurance company. Without the prior approval when required, the insurance company won’t pay. As physicians staff members, it may be our responsibility to gain the approval.
Pre-certification is the gaining of approval from the insurance company by proving medical necessity. Often this is done by having the insurance company review documentation and medical records regarding the treatment to date of the patient. The goal here is for the provider to prove that the procedure is medically appropriate and needed. Insurance companies are looking to save money by requiring more conservative treatment prior to surgery.
Spinal and fusion surgeries are one of the procedures that insurance companies are looking to have patients do more conservative treatments prior to undergoing surgery. When a policy reads that the patient must undergo 6 months of physical therapy and a provider chooses to perform the surgery after 4 months of therapy, the insurance company most likely won’t pay for the surgery. Simply stated, the patient did not meet criteria. It does not matter how much pain the patient is in. Nor does it matter how many pain medications the patient takes during the day; the patient did not do what the insurance company required. Physician practices should fight on their patients’ behalf for the precertification when indicated whether or not the criterion has been met. They also need to be prepared to have some requests denied.
Who is left with the unpaid balance? More than likely the practice would not be paid. Most patients do not have the money to pay out of pocket for surgeries. We often forget that it is not only our bill that isn’t paid; the hospital, the anesthesiologist and all other bills will be denied by the insurance company.
Patients need to meet “medical necessity.” For most medical procedures, meeting medical necessity should be straightforward with proper conservative treatment and documentation provided the patients and providers follows the insurance guidelines and requirements. The most difficult (if not impossible) cases to prove medical necessity are for cosmetic surgeries.
For questionable coverage of a procedure or surgery, a practice may request a “predetermination of benefits” from the insurance company. What you are asking for is a written verification of the policy benefits and whether a specific procedure is covered by a patient’s insurance. Often this is done for procedures that may be considered experimental or not proven. A surgery does not need to be experimental for a carrier to label it as such. Knowing what is covered allows a patient to maximize their benefits and know up front what should or should not be covered.
Predetermination also allows the insurance company (most often by a physician) to review the patient’s records to determine whether the insurance carrier considers the requested procedure to be medically necessary.
Failure to do your due diligence prior to a procedure will often result in non-payment. Precertification, pre-authorization, predetermination and benefit verification will allow for better reimbursement of the procedure or reimbursement at all. Providers as well as patients need to be aware of their contractual agreements with the insurance carrier for the best opportunity for reimbursement.

Author: Donna Weinstock

- Source: http://codapedia.com/article_727_The-Benefit-of-Checking-Benefits.cfm#sthash.t1945K8w.dpuf