PQRI- Streamline Your Process

PQRI is the Physician Quality Reporting Initiative created by the federal government.  As with most government programs, especially those offering financial incentives, filing PQRI can be difficult to navigate.
You could spend hours combing through the 318 Reporting Measures for 2012 to figure out which ones apply to your medical practice.  Then additional hours completing all the questionnaires for the applicable patients.  Don't forget to file the measure(s) code(s)with the qualifying code on your Insurance claim forms or it will all be for nothing.
Even though none of this sounds like fun, an advanced medical billing software like Iridium Suite can take most of the work out of PQRI.

Five Ways to Improve Reimbursement of Medical Claims

Often the handling of accounts receivable is considered distasteful, something that can be ignored or should be handled by somebody else.  Too often the calls don’t get made to insurance companies, the appeals don’t go out, or the resolution of denials is put off.  Even though it may be difficult to find time to perform these tasks, they are an integral part of every successful medical practice.
It is crucial to have a plan for working your accounts receivables.  Follow these suggetions below to get your cash flow going:                                           

• Setting aside the time and assigning the accounts receivable task to one person is the most logical option.  This assures a focused attempt to resolve problems and may reveal erroneous patterns in billing that are missed by several people handling the receivables ‘on the fly’ or ‘when they have time’.
• Most insurance companies have made information quickly available online through their secure websites.  Often an EOB or check that has been missed may be found online and entered in the accounting software without picking up the phone.  The website can also offer more detailed information regarding claim denials.  Additionally many insurance websites offer direct email to quickly access customer service with any questions.
• Each insurance company has an appeal process that must be adhered to in order to get the attention directed to your claim. Keep an appeal file with details (also available on websites) so that the information is quickly available. When an appeal letter is written, keep a copy on the computer and use it to easily change only the patient information and date, thereby saving additional time and keeping the format needed by the insurance company.
• If there is no other way around making the occasional phone call to an insurance company, they often have an IVR (Instant Voice Response) telephone number where you can retrieve all the information needed regarding claims and eligibility. To accomplish this task quickly, make sure all the details are at your fingertips prior to making the call. If you must speak to a ‘live’ person, get as much information as possible at the time of the call to avoid repeat calls.
• Finally, if there is no time to squeeze these tasks into any staff schedules, check into hiring outside personnel that will concentrate on this important job. Make sure they have the communication skills and availability to give feedback when necessary so that recurrent findings or problems can easily transfer back to billers or medical staff. 

Staying involved with accounts receivables is a win-win solution for medical offices, patients and insurance companies. The best medical billing software can help your practice stay organized and maximize claim reimbursement.

What are EOB Claim Adjustment Group Codes?

A Claim Adjustment Group Code consists of two alpha characters that assign the responsibility of a Claim Adjustment on the insurance Explanation of Benefits.

These 5 EOB Claim Adjustment Group Codes are:

CO	Contractual Obligation
CR	Corrections and Reversal
OA	Other Adjustment
PI	Payer Initiated Reductions
PR	Patient Responsibility

These Group Codes are combined with Claim Adjustment Reason Codes that can be numeric or alpha-numeric, ranging from 1 to W2. Claim Adjustment Reason Codes are associated with an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.

Top 5 examples of EOB Claim Adjustments are:

CO-45 indicates claim amount that must be written off based on payer contracted fee schedule.

CO-97 indicates the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

OA-23 indicates the impact of prior payer(s) adjudication including payments and/or adjustments.

PR-1 indicates amount applied to patient deductible.

PR-2 indicates amount applied to patient co-insurance.

For a complete list of claim adjustment reason codes, visit Washington Publishing Company's website by clicking here.

Let's look at Claim Scrubbers and how they function to optimize reimbursement of medical claims.

Let's look at Claim Scrubbers and how they function to optimize reimbursement of medical claims.

The best medical billing software will have a built in scrubber that analyzes the procedure codes on the claim for any conflicts to the NCCI edits.

If the scrubber finds no conflicts, then you can proceed with submitting your claim without any changes or corrections.  If the scrubber does show conflicts between two or more codes, then you now have the opportunity to review and adjust your claim before it is denied.

The billing software should indicate why there is a conflict and maybe all that is needed is a modifier.  For example, if it states one procedure is a component of the "larger" procedure, you know to not submit the component procedure.

When you submit a claim that is denied based solely on lack of a proper modifier, you then have to resumbit a "corrected claim".  Even thought they are indicated as a "corrected claim", you can now enter the duplicate claim denial loop. You may end up waiting months for reimbursement and wasting countless hours working with the payer to get the claim paid.  By taking a few minutes to "pre-check" the claim, all this would be avoided.

Investing in a medical billing system with an integrated claims scrubber you will see greater and faster returns in the reimbursement of medical claims.





Infrastructure is Key in Medical Billing Systems Software

Do you need have an Apple computer and require Mac medical billing software?

Do you want to get rid of that clunky server under your desk?

Do you want access to your billing system online from anywhere, even home, day or night?

Is having the ability to create workflow that fits your billing needs important?

Do you value real financial accountability?

If you have answered yes to any of these questions, then infrastructure is a driving factor when selecting the best medical billing software for your practice.

As you evaluate different medical billing systems software,  look for these key items:

• A web based system without special hardware requirements
• Compatible with Windows, Mac, Linux and other operating systems
• Remote servers maintained by the software provider
• A system truly designed around the biller's workflow
• Customization of reports and in-depth accounts receivable analysis

Finding medical billing software that offers these features will enable you and your staff to work at your highest efficiency.  You will also save money ordinarily spent on special computer hardware required by some medical billing software.

Understanding Medicare Fiscal Intermediaries LCD’s and How They Affect You

Each Fiscal Intermediary (FI) has the authority to produce their own “Local Coverage Determination” (LCD), based on national guidelines. The LCD basically defines under which circumstances a particular procedure is covered under the patient's Medicare benefits. As new procedures are developed, the FI will then set out to create an LCD. The FI will also review existing LCDs to see if changes are necessary based on treatment advances, statistical data, industry standards, etc.

How do LCDs affect you? If a procedure is planned, but the criteria of the LCD is not met, you will get a very swift denial, that turns into months of waiting for responses to appeals. If you are familiar with the parameters of the LCD, you may be able to avoid the denial or at least have the exact medical documentation needed that addresses the specific potential cause for denial. Most LCDs do contain the “Medically Necessary” clause. If your documentation can prove that the case is an “exception” to the rule and the procedure is medically necessary, you will likely be successful in your appeal.

The websites for all FIs include a search for LCDs. You can quickly and easily enter a CPT or HCPC code to get the most recent version of the LCD. Many times you can also enroll for automated email updates regarding new or changing LCDs. This also allows you to become involved in the creation/modification of the LCD, as the FI offers comment periods before making them active.

Why are Internal Chart Audits Important?

Many people are intimidated by the word “audit” and run in the other direction. Why should every practice do chart audits? It is important to inspect and verify your charts and billing practices before an insurance company calls for medical records. Doing regular chart audits sets you up for a sense of calm when the auditors do come knocking. Audits help you learn more about billing, the hierarchy of treatment, and what to expect from an insurance company before you send the claim.

When a patient is finished with treatment, the documentation needs to be matched up with the billing. It is not unusual to perform ‘spot’ audits during a course of treatment and helps the final audit process go very smoothly. A billing ‘roadmap’ or guideline is a handy tool to have available. If you use a billing guide, be sure to exercise flexibility in auditing, due to patient factors. There are no hard and fast rules when billing radiation oncology services, because every patient is different.

Steps:

First, read the original consult notes to gain understanding of the patient history, the current diagnosis, medications, and the treatment plan. You are going to use this information to form a logical sequence of events.

Next, sort the billed charges by date and read over the CPT codes. They should follow a pattern, such as pre-planning stage, treatment weeks, boost planning, etc. The dates in billing should match the documentation in the patient’s chart. Exceptions to this are acceptable (within a day or two), as long as the practice consistently bills the same way for all patients.

Pay attention to the units billed and match the number of beams or tangents with dosimetry charges, or the number of blocks with units billed for the immobilization device(s).

Count the number of treatments that were expected to be given, the number that were billed, and the number reported in the final completion note. In a perfect world, all should match, but patients get sick, discontinue treatment, or other events can change a treatment course. Just document on a checklist or in the final treatment notes what caused the discrepancy so you will remember later.

Verify that every weekly treatment management charge that you billed has a doctor’s report, and that the number of treatments divided by five equals the number of treatment management codes billed. However, keep in mind that you may have three or more additional treatment deliveries at the end of the patient’s treatment course that would result in one additional weekly treatment management charge.  The date ranges for your weekly treatment management charges cannot overlap.

Also count any port films and weekly physics codes and match them to your documentation and the number of treatments received.  Many of these documents may come from different departments. Check that all documents have been signed, initialed, or electronically signed by the doctor who is overseeing treatment.

At this time, I also like to look at the payments and/or denials that have been received in the patient’s A/R’s. This gives me an opportunity to share any research that can guide my A/R or billing person as to the reason why a service was denied improperly or should not have been billed.  It becomes apparent which services will always be bundled if billed together, or which services may require a modifier.  Refund situations can also be quickly identified and you will be in the good graces of any insurance company when you voluntarily send a refund for a billing error.

Basically, when you perform a chart audit, you are making sure that every billed charge has a document to support its existence. If you use a billing guideline or checklist, it can be included in the chart with notes or exceptions that you would like to remember later, such as why a code was not billed or why a patient did not receive the number of treatments originally planned. This way, if a chart does get pulled for an external audit, the internal audit checklist can really take the pressure off and you are not scrambling to find explanations for any inconsistencies.  A typical internal chart audit takes only 15 – 20 minutes and is well worth the time in the long run.