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I’m Just a Bill!
• Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow
• Gainesville, FL AAPC Coding Fiesta
• October 26, 2019
Overview
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•Who’s Got the Bill?
•What do They do with the Bill?
•Denied? What do you Mean, Denied?
•Getting the Bill Paid
Who’s Got the Bill?
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• Your clearinghouse
• Your payor
• Your patient
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Is Everyone on the Same Page?
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•Is your claim “bullet proof”?
•To your clearinghouse
•To your payor
•To your patient
What is a “Bullet Proof” Claim?
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•A clean claim is defined by Medicare as a claim which has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment.
•A clean claim is defined as one that does not require the payor to investigate or develop on a prepayment basis. Clean claims must be filed in a timely manner.
Terms
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• A rejected claim has been rejected because of errors.
• Denial of claim is the refusal of an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.
• In general, fraud is defined as making false statements or representations
• Abuse describes practices that result in unnecessary costs to a program or payor
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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What about Contracts?
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• A well defined contract does the following:• Defines the number of days after the encounter the provider has to submit the claim (timely filing)
• Specifies how many days after receipt of the claim the payor has to make payment
• Specifies which plans are included, the frequency of services that it will cover and the type of claim providers must submit
• Identified special circumstances, such as how unlisted procedures will be reimbursed, which procedures are carved out of the fee schedule, the number of procedures the payor will pay per encounter and how to apply the multiple procedure discount.
• Identifies the appeals process• Identifies cost intensive supplies or procedures
Why It’s Important To…
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•Understand the reasons why medical claims get denied
• Limit the number of denials your medical office receives
•Prevent them by being aware of what they are.
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PATIENT
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Vague:
• Do you have the same primary insurance?
• Do you have the same secondary insurance?
• No question asked about possibility of injury
Precise:
• Is Aetna still your primary insurance?
• Do you have a secondary insurance coverage with United Healthcare?
• Is this visit related to a work injury or an auto accident?
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Collecting Patient Information
Vague
•Are your phone numbers the same?
•Are you at the same address?
•Have you changed jobs?
Precise
•Please confirm your home and work phone number for me
•Are you still at 312 Windy Drive?
•Are you still employed by the City of Chicago?
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Verify Patient Demographics and Insurance Information – Collecting patient information
Verify Benefits
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•Don’t make assumptions
•Every visit!•Benefits can drop off and then be reinstated in the same month
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Your Clearinghouse – What do they do With the Bill?
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• Functions as an intermediary between the provider and the payor
• The clearinghouse also checks to make sure that the procedural and diagnosis codes being submitted are valid
• Each provider chooses which clearinghouse it wants to use for submitting claims
• Clearinghouses may submit claims directly to the payers, or they may have to send a claim through other clearinghouse
Why Your Clearinghouse is Important…
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Example 1:
• Provider Smith uses ABC billing software.
• Provider Smith then enrolls with XYZ clearinghouse. ABC software sends the claims entered into it to XYZ clearinghouse.
• Payer Gold is enrolled with the same XYZ clearinghouse. So XYZ receives Provider Smith’s claims and sends them directly to Payer Gold.
• This is a simple exchange, and the claim is paid fairly quickly.
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Why Your Clearinghouse is Important…
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Example 2:
• Provider Smith uses ABC billing software and enrolls with XYZ clearinghouse.
• Payer Gold isn’t enrolled with XYZ clearinghouse; it’s enrolled with JKL clearinghouse.
• So XYZ clearinghouse must send the claims to JKL clearinghouse before they can be sent to Payer Gold.
• This exchange takes longer to get the claim from the provider to the payer and may delay payment.
Assure Correct Coding/Meet Medical Necessity
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• Encoders are fine but books are sublime!
•Use certified coders• Support staff continuing education•Correct ICD‐10‐CM and CPT codes may appear appropriate but may not support medical necessity
• Link diagnoses and procedures• Educate your providers
Review Documentation
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Documentation that fails to concisely convey a patient's problem and the logic used to address that problem risks patient safety and obfuscates any effort to estimate the quality of the rendered care,"
‐James L. Whiteside, MD, MA, FACOG, FACS
• To identify a potential documentation issue, Whiteside recommends gathering an expert content team to focus on a measurable procedure. "Look at the documentation leading up to and after that procedure," he says, while suggesting the following questions be addressed:
• Did the documentation logically point to the need for the procedure?
• Was the procedure adequately described?
• Was the care following the procedure described properly to track the outcome?
• When deficiencies are found, if possible, revisit the EMR to program remedies, he says.
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Up Until Now…
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• After the initial paperwork is complete, the patient encounter with the service provider or physician occurs, followed by the provider documenting the billable services.
• The coder abstracts the billable codes, based on the physician documentation.
• The coding goes to the biller who enters the information into the appropriate claim form in the billing software.
And Then…
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• If everything goes according to plan, and all the moving parts of the billing and coding process work as they should, your claim gets paid, and no follow up is necessary.
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Where it Begins…And Ends
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Patient identifier informationa. Subscriber/patient name spelled incorrectlyb. Subscriber/patient DOB does not match the date in the plan’s systemc. Subscriber number is missing or invalidd. Subscriber group number is missing or invalid
Coverage? What Coverage???
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Coverage terminated or suspended
a. Terminated or suspended by insurer
b. Subscriber changes plans
d. Subscriber changes insurer
I Need An Authorization?
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Requires Prior Authorization/Precertification/Prenotification
a. non-emergencyb. some radiology servicesc. certain surgical proceduresd. inpatient admissions
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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More About Pre-authorization…
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•Prior authorization or pre-authorization is a review prior to the time a specified procedure is scheduled. This review consists of checking clinical documentation to verify the medical necessity for the procedure. A prior authorization is required for each different procedure, even if those procedures are performed on the same day. Failure to obtain prior authorization can result in denial of the claim.
And One More Word!
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•Another word about pre-authorizations/pre-certifications and denials in this category;
• Exceeded number of authorized services
• Authorization timed out
Pre-certification vs. Pre-notification
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• Preadmission certification or pre-certification is a process where a member must call and receive prior approval for an admission into any hospital. Failure to receive preadmission certification usually involves a penalty payment by the member of a specified dollar amount –varies by plan design.
•Pre-notification is a process where a member should call in prior to admission to an out-of-network hospital facility or a hospital outside the state of Arkansas to alert us of the admission. Pre-notification provides information helping to determine if case management would be an appropriate option for the member. Pre-notification is not required for outpatient treatment or any in-state, in-network inpatient admissions.
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Hmmm – It’s Not Covered?
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Services Excluded or Non-covered
a. Services excluded from the patient’s plan or coverage
b. Patient responsible!
What’s An ADR?
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Request for Medical Records
a. Patient medical history
b. Patient physical reports
c. Physician consultation reports
d. Patient discharge summaries
e. Radiology and laboratory/pathology reports
f. Operative notes
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I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Who’s On First?
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Coordination of Benefits
a. Other insurance is primary
b. Missing EOB/Remittance Advice
c. Patient/Member has not updated insurers with other insurer information
Third Party Carriers
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Bill Liability Carrier
a. Motor Vehicle or Auto Insurance
b. Missing EOB/Remittance Advice
c. Patient/Member has not updated insurers with other insurer information
Having the Right Stuff
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Missing or Invalid CPT or HCPCS Level II Codes
•Diagnostic (ICD-10-CM) and procedure code (CPT) are missing, incomplete, invalid or do not correspond to the treatment rendered by the provider – which results in:
•Failure to provide medical necessity
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Those Pesky Modifiers!
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Missing or Invalid CPT or HCPCS Level II Codes
•A word about modifiers•Specific to certain plans, certain modifiers do not require clinical
records
•Example: Cigna does not require clinical records for procedures with these modifiers:
•26, 52, 63 or 90
Timely Filing
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a. UHC: specified by the provider contract
b. Cigna: unless state law or other exception applies, participating providers have 3 months (90 days) from date of service. OON have 6 months (180 days) after date of service.
c. Aetna: unless state law or other exception applies, physicians 90 days from DOS, hospitals 1 year from DOS.
d. Tricare: within 1 year after DOS
First Coast
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• Claims must be filed with the appropriate Medicare claims processing contractor no later than 12 months (one calendar year) after the date of service (DOS).
• • Claims with a February 29 DOS must be filed by February 28 of the following year to be considered filed timely.
• • Electronic claims -- The electronic data interchange (EDI) system accepts claims 24/7; however, claims received after 6 p.m. eastern time (ET) or on a weekend or holiday are considered received the next business day.
• • Paper claims -- Timeliness is calculated based on contractor receipt date, not the postmark date when the claim was mailed, so please allow time for mailing.
• For claims with “span dates of service” (“from” and “through” date span on the claim):
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Referrals
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•Some procedures or services by another physician (specialist or consultant) requires a referral from the primary care physician prior to the services being rendered.
Of Course There Are More Than 10!
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• Other frequent denial reasons –
• The claim is lost
• Two services on the same DOS
• Patient changed plans
• Patient lost coverage or did not/late pay COBRA
• Wrong insurance company
• Location ineligible
• Provider ineligible
• Duplicate claims
• Patient has out of state plan
Government (Medicare/Medicaid)
• Four plans – A, B, C, D
• A: Inpatient hospital, inpatient SNF, inpatient rehab, hospice, some home health, inpatient mental health
• B: Medical services and preventive services, DME
• C: Medicare Advantage Plans (replacement plans) provided by commercial insurers under contract to CMS
• D: Prescription drug services
Commercial
• Many payers, each with different levels of plans
• Plans vary from comprehensive services to specific services only
• Many plans exclude certain services
• May require pre-authorization or pre-certification
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Government vs. Commercial Payors
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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A Bullet Proof Claim
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• One that can be processed without obtaining additional information form the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.
• Claims must usually meet the following criteria:• The health care provider is eligible at the date of service
• The patient who received the services was covered on the date of service
• The claim is for a service or supply covered under the health benefit plan
• The claim is submitted with all the information requested by the payor on the claim form
• The payor has no reason to believe that the claim has been submitted fraudulently
• The claim is submitted timely
Where It Begins – Patient Demographics
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Is There A Secondary Payor?
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I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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What Was the Service Provided?
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One More Thing
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• Electronic vs. Paper Claims
• The National Uniform Claim Committee (NUCC) and ANSI ASC XN 837P
• Initial claims must be submitted electronically – unless!
Unless What?
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• Small practices
• Any situation where a provider can demonstrate that the applicable adopted HIPAA claim standard does not permit submission of a particular type of claim electronically;
• Disability of all members of a provider's staff prevents use of a computer for electronic submission of claims; and
• Other rare situations that cannot be anticipated by CMS where a provider can establish that due to conditions outside of their control, it would be against equity and good conscience for CMS to enforce this requirement.
• See the Electronic Billing & EDI Transaction webpage and select one of the ASCA options in the left menu:
https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ASCAWaiver.html
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Bullet Proofing Your Claims
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•Verify patient demographics and insurance information
•Verify benefits
•Assure correct coding
•Confirm coding meets medical necessity
•Review documentation
•Confirm documentation supports medical necessity
Revenue Sourcing
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• Patients bring their consumer buying experience into your practice
• Set the expectation
• Pay on time, be creative!
• Fast reconciliation
• Simplify workflows
• Meet your staff and patient needs!
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Make Balance Due Easy to Understand
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•Who designs these statements?
•Move past confusing information
•Focus on how is key
Make Paying Easy
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•Deliver bills via email or text
•Easy to pay – from computer or mobile device
•Let go of portal log-ins or 20-digit passcodes or payment codes
Ask for Information!
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•Patients are comfortable with providing emails and mobile phone numbers
•Direct, timely access enables you to deliver a bill that will be seen
•Making it more likely to be acting upon
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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What’s Your Patient’s Payment Profile?
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•Understand a patient’s propensity to pay• Use credit bureau data
• What is your ROI (Return on Investment) ceiling?
• Prioritize your cash value
Be Proactive!
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•Use ageing reports
•Create payment plans
•Make yourself your patient’s ally
In Summary
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• Make the patient your partner• Assure they understand their responsibilities
• Do they understand what they see or read?
• Talk with your clearinghouse frequently• Utilizing new treatment modalities or initiating new procedures
• Forge relationships with your payors• They are your best asset when working with unpaid claims
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
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Thank You!Linda Martien, CPC, COC, CPMA, CRC
573.590.3617
I’m Just a Bill!
Coding Fiesta 2019 Linda Martien, CPC, COC, CMA, CRC, AAPC Fellow October 26, 2019
