Taking control through self-audit

A medical business should always be making steps toward improvement.  That is how we retain clients in all businesses.  Have you ever thought, “Every worker is busy. The appointment calendar is full.  The piles of work get bigger, but the money is shrinking.  It feels like everything is out of control.”  

These are common thoughts for many executives and employees when a business has grown to capacity.  How can we find areas that need improvement?  Self-audit is a tool that will help answer those questions.

The television show “Undercover Boss” depicts corporate executives in disguise traveling to different locations of their business. They want to discover the real truth about flaws in their company’s workplaces. Many are surprised by the loyalty of the employees who try hard and care about the company. Yet many employees feel disconnected from the ‘top’ because they have ideas about how to improve their jobs and their company that go unheard.

The owner of a company need not go undercover to get into the real workings of the business. Business owners should be encouraging employees to improve workflows and outcomes. Self-audit is a simple and proven method for finding better ways to work. Sometimes it takes another set of eyes to see obvious flaws in a workflow. Maybe it means giving an employee permission to take the time to stop and take time to reflect upon their work.

It is always better to find your own mistakes and correct them before an outside auditor comes in to point them out.  Set aside a small period of time daily or weekly to conduct a self-audit. Look over the goal of the project, and then get into the details.  Ask others to look over the work and give feedback.  Swap files and audit one another’s work.  If self-audit is done frequently, it need not take hours or days.  Learn to budget your time and include self-audit on your task list.  For instance, in our practice, I budget fifteen minutes a day to review charts and to compare treatment data to the charges billed. It keeps the files from piling up on my desk and helps me catch billing errors when they are fresh.

The first question to ask during self-audit or internal audit is “Why”.  Why did the biller choose that code?  Why did the treatment course change mid-stream?  Why does it take so long to answer the phone?

The second and most important question to ask is “How”.  How can we make our processes better?

Self-audit gives everybody power and control over their own work. The practice of self-audit will give employees confidence that their tasks are being completed with integrity as they see flaws and improvements that can be made in their own work practice.  It also gives employees proof of their abilities to manage their job duties, especially when they correct problems as they arise. Self-audit also gives the owner or CEO confidence that everything is under control.

I have received claims denials, now what?

Set aside a specific amount of time to work the denials received. The practice will be better off for this approach, because consistent data entry problems or billing errors can begin to show a pattern in poor workflow or training needs. Insurance companies also have time limits on adjusting and reviewing appealed claims, so time is of the essence.

When we receive a denial on a claim, we can use a logical approach to resolve the problem. Here are a few common reasons for denials and the steps toward resolution:

Eligibility or Coordination of Benefits –locate a copy of the patient’s insurance card and compare it carefully to the information coded in the system. Make sure data entry has been performed correctly for patient demographics including the spelling of name(s), birth date, etc. Compare the eligibility dates with the dates of service being billed. Check the insurer’s eligibility information by contacting the insurance company online or by phone. If you cannot resolve the problem, call the patient and ask them what information they have received from the insurance company regarding the denial. Sometimes the patient has the responsibility to clear up the issue.

Timely Filing - make sure the claim reflects the correct date of service. Call the insurance company and ask what the timely filing rules are for your practice (rules vary by state and contract). If everything is verified as correct, ask the insurance company to adjust the claim. They may ask for a timely filing report. If it was a paper claim, ask the insurance company if they accept a screen shot of when the claim was filed for proof.  Your billing system should be able to produce an EDI document of timely filing if you bill electronically. If there were extenuating circumstances that resulted in late filing, resubmit the claim with an appeal asking for leniency.

Bundling - check to confirm if billing was done correctly. Check NCCI (National Correct Coding Initiative) edits to see if another procedure was billed on the same day that superseded or included the procedure being denied.  Check also for whether a modifier should (or should not) have been added. Decide if the claim should be billed as a correction, appealed for special circumstances, or accepted as bundled.

Medical Necessity - insurance companies have system edits that alert staff to the necessity of further review. Many ICD 9, CPT, and HCPCS codes are programmed to stop during processing to allow review of the claim by the insurer’s staff. Some codes may automatically reject.  Make sure the billing submitted is correct, including the diagnosis. If necessary, correct the claim and re-bill according to that insurance company’s rules on corrected billing. If the insurance company is asking for medical records, send all documents asked for; especially anything that supports the decision to provide the treatment. Act on this as soon as possible, because most appeals take up to 60 days.

Not a benefit – as always, make sure the diagnosis and procedure codes are billed correctly. If the insurance company has ruled a service as not medically necessary, there is no benefit available to anyone under their membership. If an individual policy does not offer the benefit (such as maternity, elective surgery, etc.) then the patient’s specific policy is the determining factor. Either way, the service will not be paid. Review previously billed services to detect any errors on the insurance company’s part. If it was a benefit last week, it should be acceptable this week. Call the insurance company for an adjustment to their error. If a call or online review reveals the patient does not have coverage for that service, accept the denial and make a note for the future. Be sure to alert the physician and staff as well to prevent future denials.

Duplicate-review  the patient’s charges to identify a duplicate billing, previous payment, or if the claim has been submitted more than once. Pay attention to professional, technical, and global fees for the same code.  Look for any other diagnosis that the patient could have been billed under. If there is nothing to indicate a similar charge was billed, check the insurance company records to see what they have that could be bumping against the service. Perhaps they just paid on another claim and the denial reached the office before the check did. If you cannot find a duplicate, ask an insurance representative to check other providers on the same date. If nothing can be resolved, ask the representative to prove that the charge is a duplicate by researching further and either adjusting the service to pay, or sending a letter in writing explaining why the service cannot be paid.

It is easy to make mistakes in data entry and billing, even when we are taking great care. Sometimes there are many different elements in decision making, or possibly several people are entering data on the same chart. Once a claim has been sent, it has moved on to other systems outside of our control with the potential for additional mistakes in data entry or guidelines.  Being diligent in following up on claim denials can teach us a lot about best practices in our own office.

How to handle secondary insurance denials

Secondary insurance plans often pay deductibles, co-pays, or coinsurance that is due after the primary insurance plan has paid on the claim. Secondary claims process through the insurer’s regular claims progression, so it may be somewhat of a surprise when a denial EOB shows up for a secondary claim. Remember, a patient’s secondary insurance plan has its own benefits and coverage policies that cover that member.  So, for example, while a patient may have coverage for a certain procedure under their primary insurance, that procedure might not be included in the patient’s benefits under the secondary policy.

Let’s examine a recent claim for radiation therapy that crossed over from Medicare to a secondary insurance company and was denied by the secondary payer for “place of service incompatibility”. Radiation therapy is routinely performed in free standing facilities and in this case was billed as such, per Medicare coding guidelines. Upon phoning the secondary insurer to point out a possible denial error, it was discovered that this particular patient’s plan falls within a small group for which radiation therapy is only payable as an inpatient procedure.  Therefore, in this instance the denial is correct since the treatment was performed as an outpatient procedure, disqualifying it from secondary coverage for this particular patient.

However, secondary insurer denials often prove to be an error on the payer’s part and an adjustment to the claim is warranted. The accounts receivable manager’s first step is to compare the service line to other claims that have already processed. If the same procedure code has been paid by the plan in the past, a quick phone call to point this out will often result in an adjustment to the denied service. Sometimes an accounts receivable manager has to be confident and persistent to get a denial error reversed. Your persistence may cause the insurance company to retrain its claims processors or may result in the correction of an error in their system so that future services are not denied improperly.  It is always worth pursuing secondary denials that you believe are erroneous.

The importance of a good medical claim scrubber

Coding claims is tricky. Radiation oncology is especially difficult because of the planning and staging processes that occur prior to treatment. On a bad day a coder can create future problems that are difficult to remedy.  Fortunately, Iridium Suite offers a safety net to help you avoid the pitfalls of improper coding.

A claim scrubber is a built-in editor, like spell check, except it is automatic. Iridium Suite features a scrubber that has many capabilities, so if a biller is having a bad day coding, he or she can rest assured that many billing violations will be caught by the claim scrubber before the claim is generated.  The claim scrubber is present and active in the background during billing work, whether during the importing of charges from outside systems (such as record and verify systems or EMRs/EHRs) or while manually coding charges.

Here are a few examples of the functions of Iridium Suite’s claim scrubber:
The claim scrubber offers suggestions for converting old, outdated codes to newer ones, or requests permission to add a modifier to an E & M (evaluation and management) code that conflicts with other codes billed the same day, such as 99204 with 77263.  The biller has the option of re-evaluating the code and overriding the warning edit or allowing the scrubber to change it.

The claim scrubber sets a warning status on service lines that may be correctly coded but which conflict with other services according to NCCI (National Correct Coding Initiative) edits. A pop-up window shows the NCCI conflict and rule regarding the services billed. The biller has the option of choosing to override the warning status or the biller can change the date on the service that is being billed to avoid the conflict. The service line may also be deleted and a more appropriate service can be coded.

PQRI/PQRS is a potential ‘miss’ on any patient having Medicare or Medicaid.  If a medical practice activates the PQRI scrubber, then the scrubber is configured to automatically request that the physician sets up PQRI measures for each patient whose treatment qualifies for PQRI. The claim scrubber also recognizes which billing codes are potential PQRI denominators and automatically suggests the PQRI numerator codes that should be added to the claim. The biller simply accepts these suggestions and the claim scrubber automatically adds the proper PQRI charge codes to the claim.

In addition, the Iridium Suite claim scrubber makes every radiation oncology biller’s life better by automatically adding up the patient’s daily treatments and applying the management code 77427 with its corresponding dates. This feature is a fantastic time saver and ensures that this often-forgotten code is billed out properly.

Iridium Suite’s claim scrubber is without a doubt the most helpful tool for a biller coding for a radiation oncology practice. It saves time and money and prevents potential errors that cost further time and money to remedy.

Billing Claims to Secondary Insurers

After those payments come in from primary health insurers, it is imperative to have a reliable system for billing secondary insurers. Staying on track with sending secondary claims can be a challenge.  Consider that using a manual process to bill secondary payers requires pulling patient charts, making copies of primary Explanations of Benefits (EOB), generating secondary claims, attaching all the required documentation together and mailing to the appropriate secondary payer. The most efficient way to create secondary claims is to use a computer database that automatically files the claim electronically with the secondary insurer, attaching an electronic version of the primary explanation of benefits. This establishes a smooth work flow and saves valuable time and money. Accounts receivable aging also benefits from the rapid billing of secondary claims.

 Iridium Suite automates this process, including account notification of an electronic secondary claim.  If the secondary insurer is not set up for EDI transmission, then the claim is automatically sent to a queue to be printed with the next batch of paper HCFA 1500s, along with a system generated copy of the EOB from the primary insurance payment.  No interaction is required on the part of a biller, other than monitoring aging as a regular part of the accounts receivable process.

Processing secondary claims is a vital part of medical billing, whether done manually or automatically. Having the tools and organizational skills to control this process is vital to accounts receivable aging.  Iridium Suite automates the process for you.

How do insurance companies process medical claims?

COMPATIBILITY IS THE NAME OF THE GAME IN INSURANCE BILLING

Have you ever wondered what happens to your claim once it has been sent, either electronically or by mail? An electronic claim is sent directly to the insurance company’s computer system to begin a series of compatibility checks. A paper claim is always scanned first and may be manually entered into the insurance company’s computer system if the system cannot adjudicate claims from the scanner.

After the insurance company receives the claim, it begins a series of checks and cross-checks with the information already in their system. As a first step, patient and provider eligibility is checked against the enrollment identification numbers.

Next, the date of service is compared to eligibility; again, the patient and provider enrollment dates are considered. The system will reject any service line that does not fall within the patient’s insurance contract, and the claim determination is based on in-network or out-of-network provider status with the insurer.

The service code (CPT-4, HCPCS, etc.) and place of service are the next matching criteria. An inpatient visit that is inadvertently billed with an outpatient place of service is incompatible coding and will be rejected. Codes that are paid as stand-alone procedures may ‘bump’ against one another, causing a reduced payment or non-payment for certain codes if billed on the same service date. Additionally, insurance company systems are programmed to automatically stop or ‘suspend’ a service code that is considered by their standards to be experimental. These claims must be manually adjudicated by a claims processor. A claim also is compared against the patient history for duplication of services, and if a previous claim has been entered that matches, it may reject as a duplicate billing.

The diagnostic code is matched with patient contract benefits. A diagnosis of ‘Family Planning’ may not be a benefit covered by the patient’s plan, so a service line billed with this as the diagnosis would be rejected. The diagnosis must also match the patient’s age and sex type. For example, a prostate exam will not be reimbursed if the claim indicates that the exam was performed on a female.

Next, the billed amount is compared with the provider’s contract and may be adjusted to an allowed amount. For instance, if a provider’s contracted rate with an insurance company is 120% of Medicare’s allowed amount, then the service line would be paid at that rate.

A service line that has passed each of these criteria is then checked against the patient’s coordination of benefits information to determine if the insurer in question is the primary payer of benefits. If it is, then the claim passes through the patient history of all other claims of this type for application of deductible, co-pay, or coinsurance. Those patient responsibilities are subtracted from the allowed amount before the service line is paid. If a patient has not met his or her annual deductible, the allowed amount is applied to the patient’s deductible history and the charge becomes the patient’s responsibility. Additionally, if the insurance company is secondary to another insurance company, that primary insurance company’s EOB is sought. Any denials, payments, and benefits from that policy are applied to the claim before payment is considered. The absence of a primary EOB will cause the claim to reject.

If the claim was considered previously, it will be rejected as a duplicate claim. If the claim is being disputed or re-billed for additional units of service, a previous payment by the insurance company may result in an adjustment to the claim amount.

Finally, the claim is analyzed for age. If the claim has been unpaid, residing in an insurance company’s system for longer than allowed by regulatory guidelines (usually 30 days), interest may be due to the provider. On the flip side, if a provider did not bill the claim in a timely manner, the insurance company may charge a Late Filing Charge or may reject the claim outright due to timely filing issues.

Claim status is available on most insurance websites, and if an accounts receivable manager is paying attention, making the calls, and checking online, many claims processing mistakes can be corrected quickly. No system is perfect, and knowing how claims are processed by insurers is helpful in fighting for additional consideration. To keep your accounts receivable aging under control, it is a good idea to stay abreast of how each of your claims is progressing through the insurer’s claim processing system.

EHR Reimbursement Deadline Rapidly Approaching

Through the course of time, we have seen advancements in electronic claim submission, responses, and reimbursements. Now comes Electronic Health Records (EHR).

Medicare, Medicaid, and other insurance companies first required electronic transmissions in the big move in ‘going paperless’.  As more providers enabled their claims transmission capabilities, the question became how to handle the exceptions as well as provide documentation. The subject of medical records and document sensitivity came under scrutiny because of HIPAA laws, but the fact that the National Health Information Network is on its way into the nation’s medical system forces the requirements for compliance to be pushed into place now. It’s only a matter of time, and all communications and reimbursements will be structured around the ability to generate and accept electronic medical information. It is now widely thought that electronic health records will improve physician decisions and patient outcomes.

The Stimulus law was signed by President Obama in 2009, and the Health Information Technology initiative (HIT) is a part of that. The initiative set aside 19 billion dollars to be used in reimbursement grants to medical providers who are on board with the 2014 target date for Electronic Health Record compliance.

Are you planning to participate in the reimbursement program? If you have a computer system that is certified EHR compliant (or becoming so), it may translate into an amount between $44,000 (Medicare) and $63,750 (Medicaid) that you are eligible to receive. But you MUST start in 2011 to be eligible to receive the full reimbursement amount, as it is dispersed over a 5-6 year period. 

Also coming into the limelight is the catchphrase “Meaningful use”. Meaningful use of EHRs is a goal and requirement of the adoption of EHR compliance, “…that is, their use by providers to achieve significant improvements in care. The legislation ties payments specifically to the achievement of advances in health care processes and outcomes” (Blumenthal & Tavenner, 2010).

For detailed information on the reimbursement programs, please visit https://www.cms.gov/EHRIncentivePrograms/

Reference:

            Blumenthal, D.  & Tavenner, M. (2010).  The “Meaningful Use” Regulation for Electronic Health Records.

New England Journal of Medicine. 2010; 363:501-504. Retrieved from

http://www.nejm.org/doi/full/10.1056/NEJMp1006114