Misconceptions of increasing accounts receivable Part 2

Misconception #2 It doesn't matter if the patient pays the copay at the time of service.

It actually makes a huge difference if the patient pays their copay at the time of the visit. Copays are supposed to be paid at the time of service and the patients know this. The whole point in developing copays was to make a set amount that the patient paid at the time of service. This avoids the need to wait for the insurance carrier to make payment before the patient amount can be determined and billed.

The chance of collecting the copay if it is not collected up front is greatly diminished. If you are a specialist the patient may be seen only one time. If they are not coming back to your office, if is harder to collect that copay. The patient may move out of the area. There are a lot of things that could go wrong.

Of course there is always a patient that has a very good reason for not being able to pay the copay. There is an exception to every rule. If you have a patient who comes in regularly and pays their copays regularly but for some reason is unable to pay it at this visit, it is very likely that they will pay the copay.

Copays should be collected before the patient is seen. If the patient has to wait before seeing the doctor they may be in a hurry to get out of the office once the appointment is over. Also if they receive news during the visit that is upsetting they are not going to want to stop and pay their copay. The person at the front desk should ask for the copay when the patient checks in.

Some may think that the copay doesn't add up to that much but in today's insurance world, copays are getting larger and larger and they do add up. We were in an office once where the doctor saw an entire family of five. None of the family members ever paid their copays. The doctor was not aware of this and the office manager only sent out patient bills every six months - which the family ignored. They owed the doctor over $5000 in copays and that was just one family.

Make sure your office is collecting the copays up front. It can make a big difference in the bottom line.

Medicare Credentialing - How Long Does it Take?

Many providers call me to ask how long it takes to become credentialed with Medicare. The problem is the process can vary based on a lot of things. For one, it varies from carrier to carrier. Each Medicare region has a different carrier and those carriers can switch if the contract gets awarded to a different carrier.

Our area, upstate NY had the same carrier for over 14 years and credentialing only took about six weeks. But on September 1^st, 2008 the carrier changed and now credentialing takes more like 10 weeks. Part of that is due to the transition.

There is no way to give an exact time on how long it will take, but one thing that greatly affects the time is if the correct forms are filled out right the first time. If the correct form isn’t used then the form will be returned to the provider that is applying and they have to start from scratch. It could take them up to 120 days just to return the form so four months was wasted on nothing.

If the correct form is used but it is not completed correctly then they have up to 120 days to request the corrections. They usually allow 30 days for the corrections to be submitted. Once they receive them the clock starts over. If you are applying to Medicare and you want it done quickly you need to make sure you complete the correct form and complete it right. For more information on which form you need and how to complete it correctly visit http://www.medicalbillinglive.com/medicare-credentialing.shtml .

The good news is that when you complete the form you tell them when you wish to have your participation to start. So if you are submitting a credentialing application in December to begin seeing patients in January, but they don’t approve you until March, the participation date is still for January. That means that you can see patients but you must hold the billing until the application is completed. So at least you can treat the patients and you will be paid, you just have to wait for the process to complete.

There is no way to ever be sure the form is completed 100% correctly but if the person completing it has experience with these CMS forms it is more likely to be correct on the first submission. This will cut down on the time it takes for the application to be completed.

Out of Network Coverage for Drug & Alcohol Rehab

We have gotten many phone calls from people who have had a family member that was in an inpatient drug and alcohol rehab facility that didn’t accept their insurance. Of course when the family member was admitted it was a crisis situation, and there was little choice as to what options were available. In many cases it is actually life or death. They certainly can’t be driving around looking for a participating facility.

The problem is that these out of network facilities require payment for the services up front. Since they do not participate with the insurance, they need to make sure they will be paid. The only real way for them to ensure payment is to get it in advance. Again, due to the situation, the family has no choice so they borrow, or charge, or whatever they need to do at the time.

A lot of times their insurance will have out of network benefits available and the patient (or family member with the insurance) can get reimbursed. The problem is that the facility doesn’t submit the claims. They usually provide the patient with a ‘walk out’ statement, or some other form that shows the charges.

The insurance companies usually require that the charges be submitted on a UB04 form, which is the universal claim form for facility billing. It isn’t that they don’t want to pay, but the information that they require is not on the walk out statement that the facility has provided to the patient. The facilities don’t know how to complete these UB04 forms, and they’ve already been paid. Many times they truly want to help the patient get reimbursed but they simply don’t know how.

We have found a way to help out both the patients and their families, and the facilities. Solutions Medical Billing Inc has teamed up with Xena health to provider a service of taking all of the necessary information from the facility and putting it on to a UB04 form to submit to the insurance carrier. Now patients have a way to get the proper forms filled out and submitted to their insurance carrier so that reimbursement can be made promptly. For more information on how this service works, visit www.facilitybilling.com

Misconceptions of Increasing Accounts Receivable

Misconception # 1

Alice and I had the honor of speaking at the Mid York monthly billing meeting in Syracuse last week. Our topic was “12 Misconceptions of Increasing Accounts Receivable”. We decided the topic was a good one and have decided to share the presentation in it’s entirety over the next couple of newsletters.

Since Alice and I are in a lot of medical offices we see a lot of different situations. Most providers are looking for ways to increase their accounts receivables. Whether they are just looking to make more money, or if they plan on expanding, or if they are not bringing in enough money to cover the expenses of the office, they all are looking to bring in more money. The problem is most of them have the wrong ideas on how to accomplish that.

The very first misconception we spoke on is one of my personal favorites. Many doctors will say to us “If I want more money, I need to see more patients.” What I say to them is that if they want more money, they need to make sure they are getting paid for all the patients they are already seeing and all the services that they are performing.

Many doctors are not even aware of how many patients they are seeing, how much is being billed out, how much is coming in, and how much is being written off. Are the write offs due to contractual adjustments? What percent of claims are being denied? Is their staff taking care of the claim denials, or just writing them off. A survey was done by the Medical Association of Billers in 2004 and they found that only 45% of respondents had ever appealed a denied claim. That means that 55% of respondents do not take care of denied claims. That can be a huge money loss for the provider.

Is your staff running and working regular aging reports? This is another area that much money can be lost. Are copays being collected? Is patient billing being done? If your claims are being submitted electronically, are the electronic reports being downloaded and handled.

As you can see there are many ways that money can be lost in a medical office. If a doctor wants to increase his/her accounts receivable they should first look into if they are collecting all they should be on the patients that they are currently seeing. If they are not collecting all that they should, bringing more patients into the system will just make it worse.

Coinsurance Uncovered

Now we’ve covered copays and deductibles, that leaves coinsurance. Coinsurance is a term used by the insurance carriers to refer to the amount that the patient is required to pay for a medical claim.

If a patient has an indemnity insurance plan then they would not have a set copay or a set amount that they are responsible for. The amount the patient will owe will be determined when the claim is processed.

For example, if the patient has an 80/20 indemnity plan, then the insurance carrier will pay 80% of the allowed amount and the patient is responsible for the remaining 20%. So if a provider bills $120 for an office visit and the insurance company allows $100, then the insurance would pay the provider $80 and the patient would owe $20.

The problem this presents for the provider is that the patient cannot be charged for their portion at the time of the visit. Since the amount the patient owes cannot be known until the claim is paid, the provider must wait until the insurance carrier processes the claim before they can bill the patient.

Many times with indemnity plans the patient also has a deductible that must be met first. After the deductible is met then the insurance carrier will begin to make their payments. Again, even when you know the patient has a deductible you can’t charge them up front. You must wait to find out what the insurance carrier is going to allow for your services. You can only charge the patient the allowed amount, not the billed amount.

Coinsurances can vary depending on the plan. They are not a set amount like 80/20. They can be 70/30, 90/10, etc. You should call when the patient comes in initially to find out what type of insurance plan they have. Just advise the patient that they will be billed for their responsibility as soon as their insurance carrier makes payment.

This is a good example of why it’s important to make sure your claims are being submitted and processed timely. If you are billing a patient for their portion 2 weeks after their visit instead of 6 months, you are more likely to get paid.

Medicare Applications – Which Form Is Used To Become A Medicare Provider

Medicare requires that you complete specific forms put out by CMS when applying to become a Medicare provider. Sounds easy enough but have you seen the list of forms that they have? How are you suppose to know the correct form to complete and once you figure that out, what fields on the form do you need to fill out?

If you are a solo provider, can you bill under a tax ID number (EIN number) or do you have to use your social security number? Is it necessary if you use a tax ID number to apply for a group Medicare number? And why would you need to reassign benefits to yourself?

Well it’s really not as complicated as it seems. If you are a solo provider and you are using your social security number for your tax ID number then you need to complete an 855I, 588 EFT, and a CMS 460. The CMS 460 is the participating provider agreement. You only need to complete this if you choose to be a participating Medicare provider. The 588 EFT is the Electronic Funds Transfer form. Medicare requires that you accept EFT and they will transfer your payments directly into your bank account. The 855I is the individual provider application.

If you are a solo provider who is going to bill under a tax ID number but you are a sole proprietor you also would need to complete the 855I, 588 EFT and the CMS 460.

When applying for a group, you will need to complete an 855B, an 855I for each provider in the group, an 855R for each provider in the group, a 588 EFT, and a CMS 460. The 855B is the group application and the 855R is to reassign the benefits of each provider to the group. If you are a solo provider but you have formed a corporation, you need to apply for a group application for the corporation.

The forms are available on the internet. You must complete the appropriate forms and send them in to the Medicare carrier for your area. It is crucial that you complete the forms correctly to avoid delays. If your application is not completed completely or correctly the carrier will request the additional or corrected information from you. If you do not respond or respond timely your application may be closed.

Deductibles in Depth

Last month we explained in detail all about copays. Now we are going to cover deductibles in depth. A deductible is a set amount of medical expenses a patient must pay to become eligible for insurance benefits under an insurance program.

What does that mean exactly? It means that before an insurance company begins to make payments for a patient, the patient must meet their deductible. How does a patient meet their deductible? Many people get very confused over how this is actually accomplished.

In order for a patient to meet their deductible claims must be submitted and processed by the patient’s insurance carrier. When the claims are processed, the amount that is applied to the deductible is the allowed amount for the services being billed. So for example, if the claim is for an office visit, 99213 for $80, and the insurance allows $55 for a 99213, then $55 will be applied to the patients deductible, not $80.

Deductibles can vary anywhere from $50 to $5000. If it is a private plan purchased by the patient the deductible depends on the plan the patient purchases. Plans with lower deductibles cost more than plans with higher deductibles. If the insurance plan is thru an employer then the deductible is determined by the employer and how much they pay for the insurance plan.

Some people mistakenly think that the patient has to pay them the amount of the deductible and then the claims that are submitted will be paid by the insurance carrier. They don’t realize that the insurance carrier must actually receive claims for the patient in order to apply them to the deductible for the deductible to be met.

The best thing to do is to call the insurance carrier before the patient is seen and inquire as to the amount of the patient’s deductible and if any of it has been satisfied yet. You must also remember, you don’t know which other providers the patient may have seen and whether or not a claim was submitted for those services.

Usually you will need to submit the claim and wait for the insurance carrier to process it and apply it to the patient’s deductible before you can bill the patient. Many providers like to charge the patient up front when they know that the patient has a deductible that hasn’t been met. This isn’t always the best thing to do since there are many factors that can affect the amount the patient owes.

For example, if you call when the patient comes in and are told they have a $200 deductible and it hasn’t been met yet, and the patient is being seen for an office visit and a urinalysis. The office visit is $80 and the urinalysis is $15 for a total of $95. You make the patient pay the $95 since the deductible is not met. However, you submit the claim and the insurance company allows $60 for the office visit and $12 for the urinalysis. That is only $72. If you participate with that insurance carrier then you can only charge the patient $72 or you are breaking your contract. You’ve already collected $95 so now the patient has overpaid.

Another problem with collecting up front is that a claim by another provider may beat your claim in. If you call when the patient comes in and they tell you the deductible is not met, you charge the patient up front. Then your billing person is out sick for a couple days, or gets busy doing other jobs and the claim doesn’t get submitted for a couple weeks after the patient’s visit. (Trust me, this happens a lot.) In the meantime the patient goes to Urgent Care where they submit their claims electronically the same day the patient is seen and their claim beats yours. Now the patient’s deductible is suddenly met, and the insurance carrier makes payment on your claim. Again, another overpayment.

If a patient has a deductible then usually once the deductible is met the insurance carrier will pay a percentage of the allowed amount and the patient will have a coinsurance. (We’ll talk about coinsurances next month.) Many plans today are getting away from the deductible/coninsurance and moving more towards the HMO/PPO plans that have set copays. However, it is still crucial that you understand exactly how the whole deductible thing works. There are still several plans out there with deductibles, including traditional Medicare plans.

Medicare Changes Carriers

On September 1, 2008 many of the Medicare contracts across the country changed carriers. In some areas it went very smooth and most providers didn’t even notice, but in some areas it wasn’t quite as smooth of a transition. Our local Medicare Carrier, Upstate Medicare, was changed, but I have to say it was a fairly smooth transition. Although I think a lot of that is due to the fact that the new carrier NGS, is subcontracting many of the processes to the old carrier, HealthNow.

I happened to be submitting a Medicare application for a provider in Northern California right around September 1^st though and the carrier for Northern California Medicare also changed. The problem that I had there is that no one seemed to know who the new carrier was, including CMS. After doing many web searches I was finally able to find a new phone number, but when ever I dialed it was busy. Several days of busy signals made me realize that I wasn’t going to get thru, so I went back to searching the web. Finally the new carrier was able to get the website updated to include the new address for provider enrollment.

In any case, if you have been suddenly having trouble with your Medicare carrier, it may just be that your carrier is no longer who you thought it was. By now most of them have worked the bugs out, but if not give it a few more days. Unfortunately dealing with these types of changes is all part of the game.

The Truth About Copays

Many people get very confused by all the different ways that insurance companies process claims and how they calculate what the patient owes. It is crucial that the providers have someone in their office or a good billing service that knows how to read the eobs and that they are billing the patients correctly.

Many plans today have a straight copay that is due at the time of service. Sometimes the copay is different for the patient’s PCP than it is for a specialist, but it is still a straight copay. For example, if a patient goes to their regular doctor for an asthma check or a physical, they pay $15 but if they go to a podiatrist or a chiropractor the copay is $25. In either case the patient is usually accustomed to and willing to pay the copay at the time of their visit.

A lot of the insurance companies print the patient’s copay information right on their ID card. It will say PCP copay $15 Specialist copay $25, or whatever. Some do not print the copays on the card. Usually the patient knows what it is, but some patients do not realize that they have a higher copay for specialists. It is a good idea to call the insurance carrier to verify a copay if it is a new patient. Especially if you are billing for a specialist.

Most offices will ask for the copay when the patient checks in which is a good idea. There may not be a good opportunity to get it on the way out. For example, if the patient doesn’t need to be seen again they may not even need to stop back at the desk. Or if they don’t feel well and they spend an hour and a half in the office, they probably just want to get out of there. It’s just a real good idea to collect the copay when the patient checks in. It eliminates the need to bill a patient later if they get out without paying the copay.

Sometimes patients do not want to pay the copay. Copays are due at the time of service according to most of the contracts that insurance companies require the provider signs to be in their network. It is not the providers who set that rule. If the patient truly just doesn’t have the money, then it’s ok to cut them a break and let them bring it in at another time or bill them. I went to urgent care once with a urinary tract infection. I was in agony and when I got there I realized I had forgotten my purse. They were nice enough to see me even though I couldn’t pay my copay and I didn’t even have my insurance card. I stopped by later that day with the card and the copay.

Since it is better to collect the copay up front, you should definitely try to get it then. But if you are going to allow the patient to be seen without paying the copay, you should let the patient know that you are doing them a favor. If you have pre-printed envelops with the office address on them, it’s a good idea to give one to the patient for them to send the copay in. They are more likely to stick it in the mail if they have a pre-printed envelope.

Many providers don’t realize that they are actually breaking their contract with the insurance carrier if they DON’T charge the patient the copay. If a provider is regularly not charging for copays and an insurance carrier finds out, they can terminate the provider’s contract. This is actually a great tool to use for patients who try to get out of paying the copay. The provider can tell them that if he gets caught not charging the copay he can be thrown out of the patient’s plan.

If you have a patient with a hardship case and the provider is going to forgive a copay, or forgive all copays for a period of time then the patient’s file should be well documented. For example - a patient’s husband was in a bad automobile accident and is out of work for a period of time and the provider decides to forgive her copays while the husband is out of work. The patient’s file should clearly indicate exactly why the copays aren’t being collected. Give details, such as “Pt’s husband in auto acc on 8/3/08 and out of work indefinitely. Only collecting 50% pay. Have 5 children.” Or whatever the case is.

Of course there are always the patients that don’t have to pay their copays. The patient’s wife’s cousin, the son of the doctor’s college roommate, etc. Most insurance companies will allow a couple of cases without getting too upset, but they definitely frown at skipping the copays on too many patients. Providers need to be particular at who they give breaks to.

Bottom line, copays actually work out best for a provider since they know up front what the patient’s responsibility is going to be and can collect it prior to seeing the patient. It is always easier to get paid up front than to have to bill the patient. Make sure the person checking the patient in is consistent about collecting the copays.

PT/OT caps exception process extended to 12/31/2009

When Congress passed The Medicare Improvements for Patients and Providers Act of 2008 on July 15^th not only did it stop a 10.6% pay cut for most medical service providers. There were other provisions as well.

One of the other provisions was to extend the exceptions process of PT and OT therapy caps. Claims for outpatient therapy with dates of service on or after July 1^st that exceed the current cap can be submitted using the KX modifier. The KX modifier indicates that the therapy cap exception has been approved or it meets all the guidelines for an automatic exception. In order for claims to be paid specified required documentation must be on file.

The current caps are $1810 for physical therapy and speech therapy combined and $1810 for occupational therapy, for the 2008 calendar year. Deductible and coinsurance amounts as well as paid amounts count towards the cap. If services meet the exception criteria and are billed using the KX modifier they will be paid beyond the cap.

Prior to Congress passing this new legislation providers were instructed not to submit claims using the KX modifier for any services after July 1^st. Claims that were already submitted for dates of service after July 1^st without the KX modifier that are over the cap will be denied. The claims need to be resubmitted with the KX modifier.

Remember, in order for claims to be paid with the KX modifier they must meet the exception criteria. The exception must either be an automatic exception or be approved by Medicare after the appropriate documentation was submitted for review. The list of ICD-9 codes that qualify for an automatic exception can be found on the CMS website.

If you have a patient who doesn’t qualify for the automatic exception but you feel they need additional therapy you need to submit a request to your Medicare carrier. You should include an evaluation and certified plan of care, Physician approval, clinician signed interval progress reports, treatment encounter notes, and records justifying services over the cap.

The legislation has extended the exceptions process for the therapy caps until December 31, 2009.

What Should Your Billing Service Be Doing For You

Many providers today are choosing to outsource their billing. The billing process has become much more involved over the past few years and for many it makes sense to outsource. Between the software updates, required electronic filing of claims, NPI numbers, and other changes, it has become nearly impossible for providers to keep up.
However, if you've only ever used one biller, or one billing service, then you might not really know what you should be expecting from them. We have providers who use other services ask us sometimes "Should my billing service be doing this for me, or is it something I need to do in my office?"

It is good to clearly know what your billing service should be doing, and what your office will be responsible for. That way you can keep things running smoothly. Not all billing services do things the same way and that's ok, as long as you know what yours is doing and it works for you. We actually provide different services for different accounts depending on the needs of the office. For example, we don't normally get involved with obtaining authorizations, however we have a couple of clients who cannot handle getting them from their office so they pay us extra to take care of that for them.

But there are some things that all billing services should handle. Billing is not just the act of submitting the insurance claims and waiting for payment to come. A good billing service will submit the claims, electronically whenever possible, check electronic reports for denials and bad batches, and follow up on unpaid claims. They should also take care of any denied claims.

If they are not checking electronic reports and doing regular follow up then you are losing money and so are they. Electronic reports will notify you if there are issues with any of your claims or with entire batches. If they are not reading them then they are not fixing those issues. For example, an electronic report will return a claim if the ID number is not right. Maybe it's a simple typo, two numbers got transposed, but if the electronic reports aren't being read it could be a big problem. What if it's a patient that comes in once a week? None of the claims are going thru because the ID number wasn't fixed.

Many insurance carriers today have time filing deadlines. Some are very short, like 60 days from the date of service. If regular follow up is not being done then money can be lost due to timely filing. Follow up reports should be run every 4-6 weeks and all claims over 30 days should be checked on.

There are other things that billing services can do to keep your accounts receivable running smoothly, but those are the basics. If you feel that your accounts receivable is not what it should be you might want to consider meeting with your billing service and asking what can be done to improve the situation. Tell them you would like a report of your accounts receivables. What are your figures over 30 days, over 60 days? They should be willing to provide you with reports of what's outstanding and why and it shouldn't take more than a couple of days for them to make the reports available. If they are unwilling to provide you with this information then you need to consider why.

I'm not trying to rat anybody out. I'm just trying to make us all accountable to providing the best service possible so that billing services don't get a bad name. We hear too many stories of bad services and it makes providers leery of outsourcing when it is a viable option.

The Centers for Medicare and Medicaid Services (CMS) Placed 10 day Hold on All Medicare Claims

On July 2^nd all Medicare Contractors were instructed to hold all Medicare claims for services dates July 1, 2008 or later, for 10 business days. This hold was placed to allow Congress more time to consider legislation related to the Medicare payment cuts that were scheduled to take effect July 1, 2008.

In December 2007 Congress had passed a law to postpone the cuts scheduled for January 1, 2008 for six months which went thru June 30, 2008. The new law contained a formula which reflected an increase of about 0.5 percent from the 2007 reimbursement rates.

This new halt will only last until July 15^th. If Congress fails to come up with a new law before July 15^th health care providers will see about a 10.6 percent cut from the 2007 rates.

There is a law pending called The Medicare Improvements for Patients and Providers Act which would postpone the steep payment cuts for an additional 18 months. This Act includes a 1.1 percent increase for 2009. However the law hasn’t made it out of the House of Representatives yet.

In the meantime there is nothing that we providers/billers can do but sit and wait to see what Congress ends up doing. It is such a huge cut that it greatly affects all health care providers. Rumors are that up to 60 percent of Participating Medicare Providers plan on dropping out of the program if the cuts are put into place.

It is understandable why they would want to drop out. However the problem is that by dropping out they are really only hurting the Medicare patients and the providers who stay in the program. There is no good outcome if the cuts are put into place.

Hopefully Congress will do the right thing for Medicare and come up with an alternative to the 10.6 percent cut in reimbursement rates.

Medicare “Cleaning Up” Providers with Tax ID vs. SS Numbers

Medicare is cracking down on providers who do not have their information recorded properly with Medicare. For example, if a provider signed up with Medicare under his/her social security number, but now uses a tax ID# for claims, his/her claims are being rejected by Medicare stating “NPI/Tax ID number not on crosswalk.” Medicare is requiring that your NPI number, your EIN or Tax ID number, and your LBN (Legal Business Name as registered with the IRS) all match up. If you tax id number is registered to John Smith MD but you call your practice Centertown Medical Office, Medicare must have you on file as John Smith MD. Their name for you must match what is on file with the IRS. Also, your NPI number must also match up with the IRS information. So if you are receiving strange rejections from Medicare, or if you have received a letter from CMS stating that your information doesn’t match, you need to straighten it out.

If you don’t have any idea what part is not matching, your best bet is to call your Medicare carrier and verify your information with them. They usually can direct you as to what information is not matching up.

Congress passes law to halt the 10.6% Provider Reimbursement Cuts in Medicare

Congress voted today, July 15^th, and passed a law that not only stops the 10.6% Medicare cuts, but it also includes a 1.1% increase for 2009. Today also ends the 10 day hold CMS had instructed Medicare carriers to impose on all claims with dates of service after July 1^st. This means that Medicare health care providers will not have to take a substantial pay cut for servicing Medicare providers.

New ABN (Advance Beneficiary Notice) for Medicare

CMS released a revised ABN or Advance Beneficiary Notice of Noncoverage (CMS-R-131) on March 3,2008 but providers and suppliers will be required to begin using it by September 1, 2008. This new form replaces the General Use ABN (CMS-R-131-G) and the Lab ABN (CMS-R-131-1) that were previously available. The new form and the instructions can be found on the cms web site at the following: www.cms.hhs.gov\bni

The ABN is a notice given to Medicare beneficiaries to advise them that Medicare is not likely to pay for a service or supply. Providers and suppliers must complete this form before providing services or products that are subject to this notice to the patient. The ABN must be explained to the patient or the patient’s representative and then the patient must sign the form.

One of the key features of the new form is that the title of the form, “Advance Beneficiary Notice of Noncoverage” more clearly conveys the purpose of the form. The new form replaces the need for two separate forms needed in the past. Also, this new ABN can be used for voluntary notifications instead of having the use the old separate form, the Notice of Exclusion from Medicare Benefits (NEMB).

The new ABN has a mandatory field for cost estimates. The provider or supplier must complete this field with the estimate of the cost of the service or good which may not be covered under Medicare. There is also a new beneficiary option on the new ABN form that allows a patient to choose to receive an item or service, pay for it out of pocket, and not have the claim filed with Medicare.

If you are providing services or supplies to patients that may not be covered by Medicare and are subject to the ABN you must make sure you are using the new ABN form before September 1^st. Make sure that the ABN is explained to the patient and have the patient sign the ABN. The patient should receive a copy of the ABN and a copy should be kept in the patient’s file. It is important that you have followed these steps when providing non covered services to Medicare patients.

NPI # Only Causes Claim Denials By Medicare

On May 23, 2008 insurance carriers were suppose to accept NPI only on all paper & electronic claims. Not only were you required to include the NPI number, but you were required to EXCLUDE the legacy numbers. Some insurance carriers were not ready for the deadline and applied for an extension (like NYS Medicaid). But Medicare was ready and if you include your PTAN (legacy) number on your claims they are being rejected.

For the insurance carriers who were ready for this deadline, you must make sure you do not have the legacy number in the shaded area of box 24J or box 32A & 33A. If your software is set up to automatically print the legacy number in this box you need to remove it. If you submit claims electronically, make sure your vendor has it set up to exclude the legacy number.

For the insurance carriers who were not ready and applied for an extension, you will need to continue including the legacy number until they have complied. This makes things a little messy. You need to make sure you are submitting the claims that require the legacy number with it, and the ones that don’t allow it, without. Crazy, but it’s what we billing people have to do to make sure the money keeps coming in.

Another little crazy thing to worry about is the NPI number entered in 24J. If you are set up with Medicare as an individual provider (not a group) and you only have a type I NPI, you must leave the NPI part of box 24J blank. You cannot include the individual NPI number here. If you are an individual provider and you put your NPI number in 24J, Medicare may reject your claims.

If you are a group with Medicare then you need to continue putting the rendering provider’s individual NPI in box 24J and the group NPI (type II) in box 33A. If you are not sure if you are an individual or a group you can tell by your PTAN number. If you only have one PTAN number then you are an individual. If you have a PTAN for the individual provider and a separate PTAN for the practice name then you are a group. Just when you thought it couldn’t get much more confusing!

If you want to keep your cash flow steady it is important to make sure you are submitting the claims correctly. If you have any question as to what a particular insurance carrier requires, give them a call. Better to have it right the first time than to have to resubmit!

Insurance Companies Downcoding Your Claims

Ever wonder why sometimes when you get reimbursed for a claim, the insurance company has ‘changed the code to a more appropriate code for payment’? You submitted the claim as a 99214 but they paid you for a 99213 or even worse, a 99212. This practice is called downcoding.

Do you have to accept it? Well in some cases you do. A lot will depend on the contract that you have with the insurance carrier. Some contracts will only allow providers to bill certain cpt codes. In that case, they can change a billed code to one of the allowed codes. Or the contract may specify that you can only bill a certain number, or percentage of claims at the higher codes.

But sometimes an insurance carrier will just downcode your claim and it is not due to contract specifications. In that case you can appeal it. We recently had a claim that the insurance carrier downcoded a 99214 to a 99213 and told us that they only allow a provider to bill a 99214 every 6 weeks for a patient. That is ludicrous. How can that guideline apply to any patient?

Sometimes we just have to remind the insurance carriers that the doctors are the ones who determine the patient’s needs. In this case we sent in office notes and a letter advising them that we were appealing the processing of the claim. The doctor had met the requirements to justify the billing of a 99214 and their ‘guidelines’ were inappropriate. We received payment for the difference about 10 days later.

So if you are having problems with your claims being downcoded, and they are not due to contract specifications, you should appeal. Don’t just accept what the insurance carrier does. That is what they are counting on. Just think of how much money they save on the providers that don’t do anything about it.

Mental Health Billing Made Easy

We're just putting the final touches on our newest e-book "Mental Health Billing Made Easy" A Complete Guide to everything you need to know to submit your claims and get reimbursed properly for your services. Whether you are a psychologist, psychiatrist, social worker, or a psychoanalyst, this book will walk you through the entire billing process and more. We cover everything from participating with insurance companies, credentialing, authorizations, referrals, copays, deductibles, coinsurance,codes, completing insurance forms, insurance denials, insurance appeals, practice management systems, and more. This e-book also contains our entire e-book "How To Complete A CMS 1500 Form Completely and Correctly - Line By Line, Box By Box".

Ask the Biller Questions

Just wanted to make sure everyone knows that we are still answering any medical billing questions you send us. We haven't updated the "Ask the Biller" page but we've moved many of the questions to our new medical billing forum. All the new questions are now posted on the medical billing forum. You can now help us answer problems that come up with others and put your experiences on the pages, too. We've got 108 new members this month alone. Be sure to sign up and check out all the messages.

New Fill and Print Software

If you haven't read about it yet, be sure to read about the new "fill and print" software for small offices that can't print cms forms on their computers. This seems to be a great and inexpensive solution to many small medical offices.

Deductibles Influence Cash Flow

This time of year many of our doctors find their receivables down. Most of this is directly because of the deductibles that kick in with the new year. Instead of receiving Medicare checks in January and February, many providers receive eobs stating payment was applied to the deductible. Medicare may have forwarded the claim to the secondary, or you may have to submit the claim to the secondary, or the patient must be billed.

The effect this has on the office is a definite drop in the income for the first few months of the year.
Offices should learn to be prepared for this.

Medical Billing Newsletter

Just wanted to make sure everyone got the March issue of our Medical Billing Newsletter (you can sign up for it here) we sent out this week. If you haven't signed up for our free newsletter yet, make sure you do now. This month we wrote about "Reading EOBs Like A Pro", "Don't Put Your NPI Number In Box 24J", and "Overcoming Coding Issues".


We also announced our new Medical Billing Forum (you'll have to sign up) and the latest e-book we've released - "Take Your Medical Billing Business To The Next Level"

We've also gotten all our Medical Billing E-Books organized with some special discount coupons. Be sure to check them out.

New Medical Billing Forum

Hi Everyone,

Sorry I haven't added to my blog in awhile but we've got some exciting news. We've been working on a HUGE project to improve our Ask the Biller page. The page has gotten so big with medical billing questions and answers that we really wanted to organize it.

So we built a forum. We are in the process of putting all the questions into categories so you can find what you are looking for easier. You'll need to sign up and choose a password, but it's free and easy.

We've just gone live and adding to it every day. Now you can add your 2 cents, too. Here's a link http://www.medicalbillinglive.com/members/

Please let us know what you think.

Michele

NPI Number - Using It Properly For Billing

Everyone seems to be adjusting well to the use of the new ‘here to stay’ NPI number. People don’t act like they don’t know what you are talking about at least! Now there just seems to be some confusion over which NPI number goes where when you are billing.

There are several places on the CMS 1500 form for NPI numbers. Box 17b is for the referring provider’s NPI number. If there is a referring provider in box 17, then you should enter his/her individual NPI number in box 17b. (If the provider is part of a group and the group has a Type II NPI number, you do not want to enter the group NPI in box 17b.) Entering the individual NPI number in box 17b is important because the purpose is to identify the individual provider who referred the patient for the services.

Box 24j is for the individual NPI number of the provider who rendered the services that are being billed. For example, if you are a physical therapy group, you would put the individual NPI number for the therapist who worked on the patient. This box is used by the insurance companies to identify the provider who performed the service, it is not used for payment purposes. Meaning that payment will not be issued to the owner of the NPI number in box 24j.

Box 32a is for the NPI number of the provider/facility entered in box 32. This would be the provider’s office or facility where the services where rendered. If you are a group with several individual providers, more than one location, you would enter the NPI number for the location that the services were provided at.

Box 33a is for the NPI number of the provider/facility entered in box 33. This is the provider/facility’s billing location. The NPI number that is entered here determines who payment is made to. Payment will be made to whoever the NPI number in box 33a is assigned to.

If you are a solo practitioner with one individual NPI number (no group NPI), one location you would enter your individual NPI number in box 24j, 32a and 33a. If you are a large group with multiple locations and one central billing office, then you would enter the rendering provider’s NPI in box 24J, the group NPI for the facility where the services were rendered in box 32a, and the central billing’s group NPI in box 33a.

If a provider works for more than one group, or works for a group but also does private practice on the side, it is important that they enter the NPI’s correctly. Their individual NPI would go in 24j to identify who performed the services. The entity that they are working under when they perform the services, or that they want the payment to be made to, goes in box 32a and 33a.

Now that everybody seems to have their NPI numbers, they just need to know how and when to use them. It may seem confusing but it’s really not too bad. You just need to take the time to understand what each box on the CMS form is used for.

EFT Vs Electronic Remits

Everything about insurance billing today is electronic. Electronic medical records, electronic claims submissions, electronic funds transfers, etc. It can all get a little overwhelming.

Not only do insurance companies want you to submit your claims electronically, but they want to reimburse you by transferring your funds to you electronically and stop sending you paper eobs in the mail.

EFT, or electronic funds transfer, is now being mandated by some carriers such as Upstate Medicare in New York. EFT is when the insurance carrier transfers funds (or your checks) directly into your bank account instead of sending you a paper check.

Electronic remittances is when you receive your eobs via the internet instead of on paper. In some cases you can still receive paper eobs even if you have your funds transferred electronically.

In any case it is important that you understand the difference between EFT and electronic remittances. Insurance companies will be contacting providers trying to get them to enroll in both of these services.

Both EFT and electronic remittances are big money savers for insurance carriers. It cuts costs in paper, postage, printing, employee wages, and much more.

EFT and electronic remittances can also be a savings for the provider as well. When funds are transferred electronically, they usually are deposited into the bank account a day or two before the check would have arrived. There is no chance of the check being lost or stolen if it is electronically transferred.

When you receive your eobs electronically you can store them on your hard drive and not have to store the paper copy in a file cabinet. This can cut down on space needed for filing. With Medicare eobs you can print out the eob for the secondaries for each individual patient. This saves you from having to block off the other patients information and photocopying the eob.


Technology just keeps on going and we have no choice but to go along with it. The best way to deal with it is to understand what each choice offers. My advice is to educate yourself on what's out there and make it work for you.

Anesthesia Billing

Here's a question on anesthesia billing we received

Regarding billing for anesthesia services:

Some insurers seem to want the start and stop times in Box 19 (Medicare, for example) while others want it in the shaded area above Date of Service. Is there one place it can go that will make everyone happy?

Box 24G seems like it should always be minutes of anesthesia, except for special cases (such as 99140, etc.), but some examples online show people putting units in that box (15 min = 1 unit). Can you confirm that it should almost always be actual minutes?

Thanks.

Michele answered:

Hi,

I checked with several insurance carriers including Medicare, Wellmark, and Aetna. They all state that anesthesia minutes are reimbursed under units. If you submit the claim with the actual minutes they convert them into units. Some carriers have specific requirements regarding including the start & stop time as well in specific boxes on the CMS (like box 19). Unfortunately there is not one standard that you can follow for all companies. If you want to get reimbursed you must follow their requirements. I hope that helps.

Medicaid Billing

With all the Medicaid HMOs Medicaid billing has become very confusing. In NY many Medicaid patients have two ID cards but show only one when they come in the office. This results in many questions and incorrect billing. We recently received this question.

My question is in regards to Medicaid. I live in Nevada and one of our Dr's does a lot of Medicaid patients. They come in several forms First health (mdc)BXBS (mdc) and Smart Choice. (mdc) The cards all look the same Medicaid Nevada Medicaid Check up. Are they all billed to the same place with the same payor ID # which is in Reno? Thanks for your help. Linda

I answered her as follows

I am not extremely familiar with NV Medicaid but it sounds to me as if it is the same as here in NY. Medicaid offers Managed Care Plans in place of straight Medicaid that the patient chooses. They are offered thru other commercial insurers. Those managed care plans are billed individually to the insurance carrier that sponsors it. For example, we have a Blue Choice Option Medicaid plan which goes to BCBS, there is a United Health Care option which goes directly to UHC. Then if the patient just has straight Medicaid (didn't elect a managed care plan) the claims are billed to Medicaid. You can probably get a list of plans and addresses from the Medicaid office.

Hope that helps,

Chiropractic Coding

We recently had a question on billing codes 95851 &/or 95832 in a chiropractic office. My advice to this office was:

Well, for chiropractors, in my experience, most insurance carriers only allow the manipulation codes (98940-98943) or they have a global allowance for a chiropractic visit. However, there may be some commercial carriers who do allow for chiropractors to bill for modalities and/or range of motion testing. I can’t really tell you for sure when it will be covered. What I would recommend is including on bills for patients when the testing is performed, (you may want to use the 59 modifier to indicate distinct procedural service) in addition to the other codes (exam or manipulation). The best way to find out is to bill it. Another option is to contact provider reps for your largest insurance carriers and ask them if you are allowed to bill those codes.

Ionic Detox Foot Bath Billing

We ran into another question that we haven't had any experience with yet. Thought someone might have an idea to share. Here's the question.

Hi Alice.

I was wondering if you happen to know what the appropriate way of coding an Ionic Detox Foot Bath? I haven't been able to find a CPT code for it and although I'm pretty sure it's a non covered service, I'm being instructed by the Chiropractor I work for to bill it as a 99211. Is this correct? My understanding of that E & M code would not include using it to bill a service such as the Detox Foot Bath, nor do I think that it is an appropriate substitution. If I am correct in my assesment, is there an appropriate code that it should be billed under?

Thanks!


Michele answered this one as follows:

Hi,

I tried to find an appropriate code but didn’t have any luck. I do know that the 99211 is not appropriate since and E&M code is for an office visit for the evaluation and management of a patient’s condition which requires that some decision making is made. The following description is for the 99211 and is only regarding the E&M componenet:



• An E/M service must be provided. Generally, this means that the patient's history is reviewed, a limited physical assessment is performed or some degree of decision making occurs. If a clinical need cannot be substantiated, 99211 should not be reported. For example, 99211 would not be appropriate when a patient comes into the office just to pick up a routine prescription.



In my opinion the Detox Foot Bath doesn’t meet that criteria, unless more is being done than you indicated. However, I would look at the modality codes to see if there is one that more closely describes.the foot bath, or you could use the unlisted modality code, however that is not usually covered.



Hope that helps.

Michele

Tier Billing - Can you help?

We recently received this question.

Do you know the term tier billing and what it is ? The doctor that i work for says we can use this with Medicare billing but i have not been able to find any information on this.

We couldn't find any information on this. Can anyone else explain tier billing?

Thanks for your help.

DME Claims Denied For NPI Issue

Many providers are experiencing strange denials on their Medicare DME claims and when they call to check on them, they are being told to call the EDI department - even if they aren't submitting the claims electronically. Seems strange, but it's actually accurate.

The problem begins there. The customer service people with Medicare DME do not explain why the denials are occurring very well and you end the call scratching your head still not sure how to get the claims paid.


If they would just tell you in plain English what the problem was and how to fix it, it wouldn't be so bad. Well after my staff made several phone calls I finally picked up the phone myself and made a call to Medicare DME Region A. I finally figured out the problem after a hunch I had which was a complete miracle that I could piece this together. It certainly was not because they were explaining it well.

The problem is that the provider's national supplier number must be linked to the NPI number. This can be done fairly simply by going to the NPI enumerator web site, logging in, and adding the supplier number as one of the identifiers. It's a simple enough solution.

If you are receiving these strange denials I would recommend not even calling the DME carrier at first. I would check to see if you have your supplier number linked to your NPI number and if not, do so. If it already linked then you are having a different issue. Otherwise, once it is linked, just resubmit your claims!

Charging Patients For Deductibles, Copays, and Coinsurance Amounts

Many offices lose money by not collecting all of the money that is due to them from patient responsibilities. Some do it by choice, and others because they don’t have a system for their patient billing. They don’t even realize that the patient’s aren’t paying the portion they owe.

In any case, it is important to know that you could get into trouble. With Medicare, it is illegal to not bill the patient for their portion, whether it is the deductible or the coinsurance. It is also illegal to bill for more than Medicare allows you to, so you must make sure you understand what the patient’s portion is. If Medicare finds out that you are billing Medicare for services, but not billing the patient’s for the patient responsibility, you can be investigated for Medicare fraud.

Of course there are exceptions. If a patient has a financial hardship you can waive the patient responsibility, but you must document this in the patient’s chart. And you can’t claim that every Medicare patient that you treat has a financial hardship. There are also other ways around this. You must bill the patient for their responsibility, but there is no law on how far you have to go to collect it. So if you send them a patient statement and they do not pay the bill, there is nothing that says you have to send a second one. As long as you can show that you billed them.

With commercial insurances, there is usually a clause in the contract that you sign that states you will bill patient’s for all copays and/or any other patient responsibility. If the insurance carrier finds that you are not charging the patients, they can consider it a violation of your contract with them and terminate your participation. They do not usually go any further than that, such as investigate for fraud, unless there are other violations going on as well.

If you have a couple of patients, friends, relatives or people with true financial difficulties that you are not charging that will probably not hurt you. But if you pretty much across the board don’t charge your patients, you could get into some trouble. Some people have a difficult time charging their patients. These laws are a good excuse for them. “I don’t want to have to charge you, but if I get caught I could be removed from the insurance carrier’s panel or investigated.”

If you have not been charging your patients, you will be surprised how much your receivables can go up when you do. It doesn’t seem like much, but it really adds up.