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Sunday, December 9, 2012

Hospital Bills - Plan Ahead to Avoid Costly Mistakes

Understand your insurance policy terms and hidden rules before choosing a hospital for an upcoming medical need. If your circumstances dictate the need for an out of network hospital understand the practices behind usual customary and reasonable charges - or you may find yourself in the poor house.

I recently underwent a surgery that required a five night hospital stay. The final bill from the hospital sheds light on an often misunderstood and potentially crippling aspect of medical billing: usual customary and reasonable charges. If you are considering being treated at an out of network hospital, make sure you understand your possible financial obligations.

Many insurance plans provide in network and out of network reimbursement. The typical plan pays a higher percentage of charges for in network hospitals, and a lower reimbursement percentage for out of network providers. What many people fail to realize is that reimbursement levels are based upon usual customary and reasonable charges. If your hospital bills you above these standard rates you may be left with a big problem.

My surgery was performed at an in network hospital, and my insurance paid 100% of the "allowed charges", after I made a daily co payment. The total hospital charges were $61,000, while the allowed charges were only $13,000. The hospital credited a $48,000 contractual adjustment - that's a 78% discount off the retail cost!

When you use out of network providers you lose cost containment: the contractual rate. If this hospital was out of network my insurance would have paid 80% of the allowed charges - or $10,400 leaving me with an unpaid hospital bill of over $50,000. The contractual rate is equivalent to usual customary and reasonable fees and medical providers are free to charge and collect on any differences. In many cases the difference can blow your mind and your budget.

For many, an out of network hospital may be the best option for a healthy outcome. Make sure you know the real cost before making your choice. Hospital indemnity insurance can help as well, and long as your coverage begins before you need it.

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Section 111 Reporting - Special Issues in Mass Tort Claims

Section 111 of MMSEA Reporting Requirements

With Mandatory Insurer Reporting set to finally take effect on January 1, 2011, the insurance industry, litigants, beneficiaries and legal practitioners continue to face uncertainty regarding Medicare, Medicaid and SCHIP Extension Act (MMSEA) Section 111 Reporting Requirements.

This is particularly true in mass tort litigation. Unlike a more standard tort claim, mass tort litigation presents unique challenges from both a practical and Medicare Compliance standpoint. Clearly, the burden on the parties to comply and cooperate with the mandatory insurer reporting process impacts all facets of mass tort litigation as it does all tort litigation.

No Section 111 Resolution Section 111 reporting issues have not, by any stretch of the imagination, been resolved with respect to standard tort claims. Despite ongoing testing and receipt of data, CMS continually reworks the technical requirements of the reporting process and periodically clarifies critical elements of the reporting obligation such as the Ongoing Responsibility for Medical Care and what insurance products may be considered "no-fault" insurance.

Some unique issues raised in mass tort claims include proper and timely identification of Medicare status of class members, uncertainty regarding a specific product or products at issue in the litigation and the use of settlement funds or trusts.

Trusts sometimes make it difficult to identify the final recipient of funds and the amount ultimately received. Even less guidance has been provided by Centers for Medicare and Medicaid Services (CMS) regarding mass tort claims. CMS has been accepting comments and suggestions for revision of the "Product Liability" reporting fields including limiting the level of detail required and revising the term "Product Liability" itself to more accurately reflect the underlying legal issues.

We eagerly await the release of User Guide (now anticipated in July, 2010) which, CMS promises, will clarify their policy decisions and provide practical guidance on reporting for mass tort claims. They will include information on bankruptcy and insolvency, as well.

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Take Medical Coding Or Medical Billing Training Online Or On Campus? - And Know These Job Secrets!

If you're thinking about going to school online or on your local campus to get trained in medical billing and/or medical coding you'll find you have many options. There are many medical billing schools, trade schools, colleges and universities that advertise training online and offline. It may seem simple enough but it's important to look at all the ways you can get educated if your interest is in either medical billing or medical coding or both.

Medical billing and medical coding are two separate functions. You can be an expert in billing or coding or both but the training for each is quite different and usually people specialize in one or the other. Those who choose to be educated in both fields are usually known as medical insurance specialists. Most often though you would find yourself employed in facility such as a billing service or large doctors clinic or hospital and be hired to do just billing or just coding.

First of all you want to research all the schools online that offer specifically programs in either medical billing or medical coding and find out exactly what these programs cost and what classes they consist of. You need to know if you're required to take every class offered or if there is a bare minimum of classes you can take. Many schools add on classes you don't need. Many of these schools offer a graduation certificate but this is not the same certificate that the national associations offer if you decide you want to take a national exam to be certified. You may find some of these schools can be expensive. Make sure you get all the financial details.

Then the next step is to contact all your local schools, trade schools, college and universities and find out if they have any medical billing or medical coding programs set up or if they have any classes specifically meant to train you in these fields. Some schools have programs set up and you need to find out exactly what the program consists of and the cost or classes and the cost.

The most important thing is to know that you'll be able to get a job in your city or town after your medical billing training or medical coding training is complete. The education won't make a bit of difference if you can't get a job after you're done. So make sure to call the human resources department at local billing services, large clinics and hospitals and find out what the job opportunities are for medical billers and medical coders. But do all your online research first so you know whether or not you can afford to go to school or not. There is plenty of federal money available for online classes as well as for on your local on-campus training.

Medical Reimbursement is All About Follow-Up

So here's how it works: You see a patient, your biller submits a claim, and you get paid. Right? The answer, of course, is "no." The ugly truth is that many claims are never adjudicated. Why not? The claim was never received, it was sent back to the plan for pricing, the hand-off from one clearinghouse to another didn't happen, the gatekeeper computers rejected it, it's being held for additional funding from a self-insured employer, the carrier changed its "edits" so their computer now rejects claims that it used to accept, and oh, this network no longer handles those claims.

Because the claim doesn't get adjudicated, you don't receive a denial, and you don't know there was ever a problem. Meanwhile, most billers are so busy submitting claims and posting payments, that as long as you're not asking about missing revenues, those lost claims stay lost forever. Granted, some billers faithfully hit the resubmit button every 30 days for unpaid claims, but if they didn't uncover and address whatever issue prevented adjudication in the first place, those resubmitted claims fall into the same black hole until the timely filing limits expire.

Which brings us to this: The three most important things about medical reimbursement are follow-up, follow-up, follow up.

If you want to get paid for those "lost" claims, your biller has to read reports and work the phone. Someone has to ask, "did you receive this claim, and if so why hasn't it been paid?" Unfortunately, most billers focus on writing appeal letters for denied claims-after all, having a denial in hand is a great impetus to action. However, if billing is done correctly, appeals should be rare. The bigger problem lies beneath the surface of unpaid claims, and here's how to follow up on those lost and unpaid claims:

Start with an insurance aging report. If your system allows it, select only claims older than 45 days, because anything newer may be either in the adjudication process or the payment could be in the mail.

Prioritize your work. Act on claims that are nearest their timely filing limit first, and act on large claim amounts before doing small claims. Just in case your biller cannot complete the follow-up, you shouldn't forfeit reimbursement to a missed timely filing limit, and if your biller runs out of time, it's better to let the small claims slide than lose payment on the big dollar claims.

Check your claims acknowledgment files. If you use a clearinghouse or submit directly to carriers, you may be able to check on an individual claim manually. Often electronic feedback that a claim had a problem is sent to you automatically. Sadly, most billing software is unaware of these claim acknowledgment files, and many billers simply ignore the files that are available. Some medical billing companies use sophisticated custom software to parse acknowledgment files daily so that they can act to identify and correct a problem claim as quickly as possible.

Make the call. If the clearinghouse or acknowledgment files don't provide the reason a claim has not been processed, it's time to call the insurance carrier. If the response is, "we have no such claim on file," your biller should verify both the mailing and electronic addresses for the claim. Otherwise, find out what went wrong, and ask as many question as it takes to fully understand what needs to change to get the claim processed. Simple fixes can often be made over the phone and the claim can be sent back for reprocessing. Other fixes may require more work. You might even find out that the claim was paid to another provider or a lost check needs to be reissued.

All of this takes time and the right personnel. Think of follow-up as an investment, and the payoff will be the difference between a practice that's just doing okay and one that's truly profitable.

A Dozen Steps to Successfully Appeal Denied Claims

Appealing denied claims used to be a simple process. A biller working with a physician's office would stamp "APPEAL" in big red letters on a photocopy of the claim, and mail it back to the insurance company. These days, you'd be wise to put the cost of that postage in the bank, and throw away both the APPEAL stamp and its red ink stamp pad. This sort of knee-jerk response won't even make it past the insurance company's initial computer screening; they'll likely toss such "appeals" into the trash and you'll never hear anything back from them.

To successfully appeal denied claims, you need to get your "A-game" on; otherwise, you won't see a penny for your efforts.

Follow these steps to effectively appeal denied claims.

1. Recognize denials. Insurance companies don't print the word "denied" in big letters across the top of the claim form. In fact, the word "denied" may never appear at all. The insurance company simply declares the reimbursement amount to be "$0" and enters an adjustment reason code next to the amount paid. The key is to identify it as separate and distinct from a contractual adjustment, which is - and should be - a write off.

2. Understand why the claim was denied. Before you pick up the phone and demand to speak to the claims representative, determine the root cause of the denial. You can't effectively appeal until you know why payment for the service was denied. In addition to the reason code, there is a remark code. Look up the insurance company's definition of that code to get details about the reason for the denial. WPC maintains a complete listing of standard reason and remark codes, available on their website.

3. Don't procrastinate. There is often a timeframe in which you can resubmit a claim after it's been denied. Pull the record, research the code, call the patient, etc., but don't delay: most insurers only allow a few months to resubmit a claim for reconsideration.

4. Follow the insurance company's rules. Each insurer has an appeal process. The Centers for Medicare and Medicaid Services (CMS), for example, has a form to complete when appealing the denial of a Medicare claim called the "Medicare Redetermination Request Form". Get familiar with the insurer's protocols to understand your options if your first appeal is turned down. Don't give up; most insurers have multiple levels of appeals and even a grievance process if you disagree with the outcome after you've exhausted the appeals process.

5. Make a compelling case. An appeal means that you disagree with the insurance company's decision, so put your debate cap on and gather supportive evidence to present your case. Perhaps the most important aspect of your claims letter is the content. The letter should go well beyond stating, "please pay my doctor." Build a compelling case for why the claim should be paid:

Develop a professional letter that begins by referencing the claim number, date of service and patient; then, briefly describe the particulars of the service in question. Use the insurer's own language if possible. For example, to appeal a claim denied because the insurance company claims the treatment was experimental, quote from the insurer's own marketing materials where it declares it seeks to provide the best medical care for its beneficiaries. When the insurer questions the necessity or separate payment for a distinct service, the physician should type or dictate a paragraph or two about the benefits of the service to the patient. Seek objective evidence to support your case from your specialty society and medical literature. Look to see if Medicare or Medicaid pays for the service; if they do, you can argue that even the government has determined that payment is appropriate. Copy and attach sections that support your case from coding manuals, including past issues of the American Medical Association (AMA) CPT Coding Assistant, a periodical that the AMA publishes to clarify CPT codes. For appeals that concern clinical issues (for example, medical necessity), send the appeal to the medical director of the insurance company. Look at the class action settlements between several large physician organizations and a number of national insurance companies; review those settlements to see if anything in there can support your position. See the HMO Settlements site for up-to-date compilation of the settlements, as well as a list of pending lawsuits.

6. Confirm receipt. Don't just send the appeal and hope for the best. Review your submission online, or call the insurance company to confirm that they received your appeal, noting the name of the operator, extension number, date and time. Place a tickler in your practice management system or Microsoft Outlook to follow up in 30 days.

7. Set boundaries. Although it might make you feel better to fight for every dollar, it doesn't pay to prepare a third-level appeal of a $2.41 service, particularly if you only perform it once a year. Establish protocols for dollar thresholds that you'll appeal only once, twice, etc.

8. Don't go overboard. Avoid fighting for a claim that should have never been submitted in the first place, such as an undocumented service. Your physician may have provided the service and feels there should be some way to get paid, but - as the saying goes - if it wasn't documented, it wasn't done.

9. Carbon copy stakeholders. Your appeal to reverse a denial is a matter between you and the insurance company, but sometimes pulling in other key stakeholders helps. Your first, and most important, advocate is the patient. Although patients may never be held responsible for payment if a denial is ultimately upheld, news of payment disputes certainly get their attention. And the patient's attention is just want you want. Prompting the patient to contact the insurance company directly to encourage payment doesn't guarantee payment, but it certainly helps.

10. Develop supportive language in your contract. Your contract establishes the relationship between you and the insurance company. Even though the insurer is the party that typically presents the contract to physicians for their signature, it's every bit as much your physician's contract as it is the insurer's. Proactively negotiate the inclusion of language that supports your efforts to appeal claims. If you're frustrated by the appeals process itself or if you keep running into certain problems, such as unfair bundling denials, seek to include clearer definitions of these processes in the contract.

11. Compile appeals. Appealing claims one-by-one may get the results you need, but it is laborious. If you've seen the same service denied for the same reason multiple times - or your insurer hasn't paid in a timely manner, according to your state's prompt payment law - compile your appeals and present them together for reconsideration.

12. Maintain a hassle folder for each insurance company. Keep a record of denied claims - by dollar and type. Measure and compare the data on a quarterly basis. If you negotiated a good reimbursement rate with an insurer, but all of your claims get denied, the "good" rate is meaningless. It pays to maintain a record of reimbursements and denials in order to effectively review your contract for its strategic contribution to the practice's bottom line.

Preventing denied claims is a key skill of successful billers. But getting some denials will always be a fact of life in today's complicated physician payment system. Appealing denials is your right: it pays to exercise it.

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Tips For Improving Productivity in Your Billing Process

Apart from the patients, billing is the lifeline of the medical office. Whether your medical office's billing is done in-house or you've outsourced it to a medical billing company, there are specific things you should do that are crucial in maintaining a smooth billing process.

• Train the front desk staff. It is imperative that staff at the front desk has some type of introductory insurance and/or billing training. Make certain your staff is verifying insurance benefits prior to patients' appointments. Be sure to train new employees on the various types of health insurance; indemnity plans, HMOs, PPOs, and POS plans. Educate the front desk on authorizations and referrals. Explain the difference between 'Original Medicare', 'Medicare Advantage', and 'Medigap' in order for the correct co-payment/co-insurance to be collected and the correct health insurance cards to be copied for billing purposes.

• A thoroughly completed patient registration form is crucial in the billing process. Nothing frustrates a medical biller more than a missing insured's date of birth, a suffix missing from a Medicare HIC number, or a missing home phone number. Train your front desk staff to keep a watchful eye on the registration form to make certain all fields are completed! This tip not only helps with initial claims submission, but also assists in future collection procedures.

• A biller and only a biller! If your billing is done in-house, your billing should be designated to specific person/persons whose only job is billing. When the same person who is manning the front desk, putting patients in rooms, and answering all telephone calls is also the employee who is doing your billing-mistakes are bound to happen. These mistakes may be the very reason a provider will make the decision to outsource the practice's billing.

• Using a web-based application is especially helpful in improving billing productivity because it allows the provider and billing service to stay connected. For one thing, the medical office has access to patient accounts, which can be helpful in collecting outstanding patient balances during an encounter. On the other hand, the biller has real-time access to any patient demographics, diagnoses, insurance, or any other pertinent information needed to prepare claims for submission.

• Maintain your accounts receivable. Many a provider would be shocked if they knew the dollar amount in their 90+ column on their insurance aging report! Each state has prompt payment statutes which give the timeframe in which both paper and electronic claims are to be paid. If your billing is done in-house, take the time to ask your biller to print an A/R report. If you are unhappy with what you see, find out the exact problem. Is it that your biller does not have enough time to post charges, post payments, submit claims, and maintain the A/R by themselves? Are you the owner of a billing service whose billers are in charge of their own accounts for the entire life cycle of the claims? In either scenario, listen to your biller(s) and if they need help, hire a separate employee whose only job is maintaining the accounts receivable.