With all the obstacles to reimbursement that managed care creates, your practice’s cash may be flowing at the velocity of water in a clogged drain. In our experience and that of other practices I know of, only about 70 percent of claims submitted are processed and paid on the first submission. That means an astounding 30 percent are unprocessed or returned unpaid. Now that Medicare reimbursement has been cut significantly for many of the evaluation and management (E/M) codes you use, it is even more important to check the efficiency of your billing system.
Consider this all-too-familiar scenario: You see a patient for an upper respiratory infection. The patient also has atrial fibrillation and is currently on warfarin therapy. You treat the patient’s URI and, when he reports that his gums have been bleeding when he brushes his teeth, you also do a PT/INR test in your office. You code the office visit (99213) and the lab test (85610). The billing clerk sends the claim in for payment.
Three months later, the billing clerk is posting another visit to this patient’s account and notices that the previous claim is still outstanding. She refiles the claim. Another three months goes by, and again she notices that the claim is still outstanding. This time she calls the insurance company to find out why the claim has not been paid. The customer service representative informs her that their office never received either submission. It turns out that the copy of the insurance card in the patient’s chart is old and the claim filing address had changed. “Fine,” the billing clerk says, “I’ll correct the address and resubmit the claim.” But there’s a problem. The customer service representative informs her that the insurance company has a 90-day filing deadline, so they do not have to pay. Furthermore, the practice’s contract with the insurer prohibits billing the patient for the balance.
This is just one example of how family physicians lose critical revenue. To help ensure that you receive full and timely reimbursement, follow these tips:
1. Read your managed care contracts and familiarize yourself with coverage terms. Be aware of any stipulations such as filing deadlines and make sure your office adheres to them. Go over the fee schedule for each plan and determine how much you’re being paid for each service. (If you didn’t receive a copy of the schedule with your contract, ask a provider relations representative to provide you with one.) Know which plans have deductibles, which have co-payments and which cover office visits for preventive care as well as illness.
2. File claims daily. It’s hard enough to get your claims paid when you send them in. They definitely won’t get paid sitting in your office.
3. Use electronic billing whenever possible. Your claims have a better chance of making it to their correct destination when submitted electronically than if you mailed them. They’ll be processed faster and you’ll have a printout that shows when you sent them and a confirmation report of when the insurance company received them. This information is vital when you have to fight for payment. If you can produce the report that shows you sent that claim within the time limit, they have to pay your claim, even if the filing deadline has passed.
4. Establish a system for checking open claims each month. Whether you keep track of this information manually or with a computer program, routinely check your list at least once each month and either resubmit claims or contact insurance companies to track down your payments.
5. Call about claims that have not been paid within 60 days. One phone call is worth a thousand re-submissions. I had an office manager tell me once that she would flood insurance companies with copies of the same claim. She said she did this because one claim had to eventually make it through the system. That may seem logical, but what if the claim has an error, or the patient’s insurance changed? Eventually all these claims will be denied as duplicates, and you’ll have wasted a lot of time – the insurer’s and your own. When you talk to someone in customer service, your call gets logged by the insurance company, which shows you are making an effort to get your claims paid. Sometimes one phone call is all it takes to get these claims released and paid. If your claim has truly never reached its destination, a call to the insurance company may get you a customer service representative who will have you fax your claim directly to him or her for processing.
6. Always document the name of the customer service representative you are speaking with and the details of your conversation. This information is vital, especially if you end up having to file an appeal to get your claim paid.
7. Make sure secondary insurance is billed. Most Medicare patients have secondary insurance to pick up the Medicare deductible and 20 percent co-payment. Even when the Medicare explanation of benefits states it crossed over the patient’s claim to the secondary insurance, don’t believe it. If the claim is still in your system after 90 days, it didn’t cross over. Submit a hard copy and don’t forget to attach the Medicare explanation of benefits.
8. Collect co-payments at the time of service. It costs between $6 and $12 to send monthly statements to patients, so if you don’t collect it at the time of service, you may as well forget it.
9. Update and verify each patient’s insurance coverage. At each visit, copy both sides of the patient’s insurance card to ensure that you get the correct claims filing address as well as other important information. If you have any doubts, call to verify the patient’s coverage. (Some insurance companies also have Web sites where you can easily check eligibility as well as claims status.) This may take you five minutes, but that’s less than the 90 days that will lapse while you try to collect payment from a patient who has presented you with invalid insurance information. Be aware that even if the patient hasn’t changed employers and the employer hasn’t changed insurers, the contract may have changed. Most employers renew insurance benefits annually, and changes are common. A difference in the alpha prefix or suffix of the patient’s identification number might signal that the employer’s coverage has changed. Be sure to check these numbers carefully.
10. Go over explanation of benefits with a fine-tooth comb. Don’t just use the explanation of benefits to post payments; use it to make sure you are getting paid what you are due. Look for unnecessary downcoding, bundling and denials, and investigate.
11. Assign one staff member exclusively to billing. Make sure this individual is up-to-date on all the current modifiers, and codes. You should also have this person attend provider meetings offered by the major insurance companies at which plan representatives explain changes that may affect your billing practices.
When it comes to billing, follow-through and persistence are a must. If your cash flow remains stagnant, so will your practice.