Overcoming Challenges in Medical Billing - The Appeals Process

Appeals are a normal part of the medical billing process, but that doesn't make them less frustrating or time-consuming. There are steps you can take, however, to make the appeals process much smoother and more profitable for your practice.

First, take a bird's eye view and review your most commonly denied claims, prioritizing both for volume and dollar value. You want to use this information to focus your attention where it's going to benefit your practice the most. You should also know the cost of appealing claims-that will help you prioritize those claims that will net the most for your practice and will also help everyone in your office understand the importance of eliminating denials before they occur whenever possible.

Be sure your appeals process also addresses priority by payer deadlines:

Prioritize by shortest deadlines, then by largest amount due. Draft and distribute a list of payer deadlines to insure your appeals are filed in a timely manner.

Next, develop a standard process for addressing the most common denials that represent the most revenue for your practice:

Develop a letter template that can be quickly generated and sent for each appeal. Consider designating specific staff members to handle particular denials so that they can develop expertise in that area and learn to expedite the appeals. Make sure your staff is cross-trained so that denials aren't delayed by a staff member's absence.

Each appeal letter should include key information:

Patient name and demographics, insurance account numbers and employer information Date of service The CPT and ICD-9 codes A short, clear explanation of what you are appealing (denial, underpayment) and why (explain medical necessity, authorization received, etc.)

Use your template or a checklist to ensure you include all of this key information-it's easy to leave an item off in the rush of the business day. Make sure you scan supporting materials so that you can easily find and attach them to the appeal letter.

Of course, one of the key steps in the process is to evaluate your most common denials so that you can eliminate them before they occur, as mentioned above. You will want to evaluate your report of most commonly denied claims to make sure you are addressing root causes and avoid the need to appeal to begin with.

In most medical billing software packages, you can generate denial management reports that group your denials and rejections by reason and dollar amount, trended over time. This helps you identify frequently recurring denials and rejections that can be addressed through process changes in your practice. For example, if you're routinely receiving denials because the patient is ineligible for insurance coverage, then you may want to begin verifying each patient's insurance eligibility prior to scheduling appointments.

But regardless of how you do it, spend time organizing your claims appeal efforts to insure you:

Eliminate root causes of denials wherever possible. Prioritize your appeals to insure you are pursuing the highest dollar return. Standardize your process so that it is as efficient as possible.

These steps will enable you to improve the productivity and profitability of your appeal processes, your medical billing, and ultimately your practice or billing service.

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Huge Medicine Bills? Choose the Cost Effective Part D Plan

Suppose, Greg counts his annual drug cost for the regular medicines which comes out to be $9200. Greg decides to sign up for a Medicare Part D Program in which offers low premium, no deduction and no coverage in Donut Hole period. The working for a plan if the annual drug cost is too high and the total drug cost calculation can be understood with reference to the following Example:

Costing chat for Greg will be: • As there is no deductible cost, Greg pays 25% of the total cost of $2830 [amount set for entering coverage gap for the year 2010]. This means in this level Greg pays $708.

• Now, Greg enters the Donut Hole period. Here he will have to pay the 100% amount for the drugs till he reaches $4550 [Amount to be paid to exit coverage gap for the year 2010]. As Greg already made a payment of $708. So, to exit the gap, he will have to pay another $3842

• By the time Greg exits the Donut Hole period, the total amount of $6672 is already paid by Greg and the Insurance Company [$2830 before entering donut hole and $3842 during the donut hole]. So the remaining cost of $2528 is still to be paid. But Greg is now entitled to pay only the 5% of the remaining cost only and the rest will be paid by the insurance company i.e. Greg pays only $126.40 more.

As we know, without the Medicare plan Greg was to pay $9200. But, using the Medicare Part D Plan, Greg pays: $708 + $3842 + $126.40 = $4676.40 and the fixed low premium every month for the plan. So, you can easily figure it out that how cost efficient is using Medicare Part D plan. You can make the calculations easily and check out what amount wills you have to pay for the Part D plan and how cost effective will it be for you.

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Medical Insurance For a Secured Future

Increasing cost of medical treatment is creating a lot of problems for consumers. Every year, salaried people have to spend a large part of their salary on medical bills. According to a recent survey, medical bills are the biggest reason behind the bad credit history of people. Medical expenses have touched the sky and keep on increasing day by day.

It is no longer for an ordinary citizen to afford normal medical expenses. Nowadays, maximum people prefer to go with medical insurance to eliminate the risk of huge expenses up to a certain extent. These insurance programs provide almost complete coverage regarding the health problems. By adopting the health insurance, you make sure that none of family member will face any problem at time of health disorder.

Even though the market of this kind of insurance is quiet big in United Kingdom and there is a huge demand of such services. Still few people do not feel comfortable to buy medical insurance programs, as they find the premium quiet expensive. But, it does not mean that all companies offer the same program with same premium amount. It is huge market where you can find good number of companies with different kind of policies. Individuals can purchase the policy as per their need, requirement and pocket. It is advisable to choose the cost-effective policy providing the maximum coverage for your health. In current scenario, absence of health insurance policies can be a biggest mistake of your life. It is not something which can be ignored easily.

Absence of medical insurance simply means that you will be in great financial trouble at a time of emergency. By taking insurance policies, you not only cover yourself but also save your family from any future disaster. These programs help you a lot at time of medical emergency. You are not required to spend even a single penny from the pocket. At time of emergency, individual needs to choose the nearest hospital and get admitted as soon as possible. These insurance companies takes care all of your expenses and medical bills.

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How to Start a Home Based Medical Billing Company

If you have decided that starting a home based medical billing company is the best move for you, you are approaching a great opportunity to cash in on a high demand market. With physicians finding it harder and harder to collect on invoices, they need medical billing companies that are able to efficiently manage their billing and ensure that there is appropriate payment and claims filing for the revenues to be generated more effectively. There are some insurance companies that can send physicians for the ride of their life, and there are some medical programs that make it quite difficult and timely to collect payments. Most of this has to do with the billing process, and that is why you can be a very beneficial asset to many health care facilities and physicians in your community or service area.

Why Home Based?

A home based medical billing company is a great option for those that have daily lives, but still wish to enter the workforce with a strong head. There are more and more businesses these days going into internet based servicing and medical billing is a great industry for that move. Not only are most of the billing processed completed through computer software, but there is no need for excessive costs on building space if you aren't going to be seeing any clients or managing staff. You can definitely hire staff that works through a network, giving you an efficient team at less than half of the cost.

All the Necessary Software and Hardware

You want to get all your materials and tools together when starting a home based medical billing company. As the company is home based, you definitely want to have the appropriate communication portals open, whether through web conferencing, phone conferencing, or any other method that uses today's technology to avoid the need for physical presence. You will also need many other tools such as:

• Appropriate billing and invoice forms • Fax and printer • Appropriate accounting software • Business licensure and registration

Having the right tools and materials will ensure that you are able to adequately perform the functions of the medical billing profession through your own home based medical billing company. Physicians will count on you to provide a steady cash flow, and with a home based company, you can provide this function for only a fraction of the costs of regular medical billing companies.

No matter which way you look at it, having an office is just an added expense that could be done without. With the great technology of the internet, you don't have to be bound by an office building that increases your service charges and causes your clients to pay for it in the services the obtain from you. You want to provide the most cost-efficient services which is possible by cutting your own costs and taking your business to the comfort of your own home, where you are known for your best ideas anyway.

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Medical Billing Outsourcing Empowers Doctors & Levels the Playing Field Against Insurance Companies

Insurance companies are definitely in a stronger position in the 'payer payee' relationship shared with healthcare providers. They have the advantages of scale, power and a large claims database. The complexity of billing procedures further tips the scales towards them. Technology and the internet come to the aid of medical providers through medical billing networks, promising to level the playing field between the two players.

Insurance carriers benefit from complex medical billing process. Changing codes, rules, and procedures make filing claims tortuous and error-prone. Insurance companies pick on these errors to reject claims. Sometimes this happens repeatedly till the medical provider caves in and forgoes the claim. Medical practitioners lose out on a significant chunk of revenue because of this tactic.

Common tactics used by insurance companies to delay payments

Insurance companies take advantage of the intricacies of billing procedures. Some of the common strategies used by them to delay payments of medical claims are:

Picking out bureaucratic errors to reject claims

Most medical practitioners do not have efficient and reliable billing processes. Insurance companies pick out errors and omissions in the submitted claims to reject them. Almost 20% of medical claims go unpaid as a result of claim rejections and unaggressive follow-up. This cut in revenue can seriously setback the operations of a medical practice.

Low allowable amount

Insurance companies take advantage of their large size by concurring on low allowable amounts to medical practitioners. Medical providers are left with little choice but to go with the low sums of money as competing insurance companies also offer the same amount.

Post-payment refunds

Insurance firms conduct post-payment audits to correct mistaken payments and redeem them. They have access to a vast claims database and can verify records to demand post-payment refunds. This further depletes the revenue of medical practitioners.

Insurance companies have an efficient billing system that allows them to reduce payments to healthcare providers. The added advantage of scale makes them a tough proposition.

Medical billing networks reinforce the medical billing process

Medical billing networks consolidate the claims database of various healthcare practitioners. Medical billing service providers provide the means to facilitate this network. The information of clients is combined into an efficient and accountable automated system that also offers effective records management and efficient processes. Medical providers can leverage the economies of scale to their advantage, as insurance providers have been doing since years.

Advantage of medical billing networks

Independent medical practices cannot do much on their own, but collectively they can build an effective system to combat the obstacles in getting payments from insurance payers. Billing networks enable medical providers to do business with large-scale insurance companies on an equal footing. The networks offer the advantages of improved collections, effective revenue management, lower audit risk and added revenue sources.

All medical practices should use medical billing network services to combat large-scale insurance company tactics to deny and reject claims. Healthcare providers can use network services to maximize revenue and streamline revenue management processes.

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How Good is Your Claims Scrubber?

The best way to reduce outstanding receivables in a medical provider's office is to make sure that claims being sent out are clean. Clean claims require less effort in collecting payment and result in faster payments. Claims with errors come back as denials and then need to be corrected, resulting in a delay in payment for services, and possibly no payment at all. After all, 42% of denied claims are never appealed or corrected.

Most provider offices do not have the time or the manpower to take care of denials in a timely fashion and it is one of the largest sources of lost money in a medical office. Sending out clean claims results in over 90% being paid on the first submission, leaving less than 10% of claims to be denied. By eliminating the avoidable errors, the real issues can be addressed and less money will be lost. One good way to ensure clean claims is by having a good claim scrubber in place. Many billers do not even know what a claims scrubber is but it actually influences your receivables in a huge way.

A good scrubber analyzes the data that is on the claim and compares the data to its rules engine before the claim is submitted. There are several levels of scrubbing and good claim scrubbers will analyze data on many levels. The most basic scrubbing function is to make sure that all required data is present. For example, it will check to make sure a name, valid date of birth, insurance information and id number are present. It will also verify that there is a date of service and a procedure and diagnosis code. But it may not verify if the data is accurate. For example, a basic scrubber may not notice if a date of service entered was mistyped and is for an obviously incorrect date, such as 04/01/2001. To a biller it is obvious that the entry person made a typo, but a basic scrubber may not catch this.

Another example is if an invalid insurance identification number is entered. Medicare identification numbers are a social security number followed by a letter, sometimes also followed by another number. If the person entering the claims makes a mistake and misses one number, a basic scrubber may not notice. But a good claim scrubber would pick up that there were only eight digits instead of nine, giving the user a warning that the claim may have an error.

Today claim scrubbers come with many more capabilities. They not only verify required data is present, but they also analyze icd-9 and cpt codes. They use rules from CMS and other major insurance carriers to detect mismatches and invalid combinations. Warnings will be given if data does not appear to meet carrier guidelines.

Now with web based software the claim scrubbers have improved even more. With the use of data mining a claim scrubber can build on its own knowledge base by continually reevaluating the adjudication rules of different payers. The claim scrubber is constantly improving its own quality of scrubbing capabilities. With this type of scrubbing capability a provider can reduce the percentage of human error and greatly improve the number of clean claims submitted.

Most practice management software systems with electronic claims capabilities come with some form of a claim scrubber. It is important to know how complete the claim scrubber that you are utilizing is. A good claim scrubber can have a huge effect on the accounts receivable of an office.

When we switched from a server based practice management system to a web based system we found that the claims scrubber on the web based Xena Health system caught up to 50% more errors that would have caused denials. The claims scrubber on our old system would have allowed those errors through creating much more work on the back end.

Some of the features in a product like the Xena Health's inbuilt claims scrubber include

• Required field checks • Required format checks • ICD-9 checks and specificity • E & V code checks • CPT validity • HCPCS validity • The CMS Correct Coding initiative • Local and national coverage determinations where appropriate • Payer specific requirements

Copyright 2010 - Alice Scott - Solutions Medical Billing Inc

Medical Coding Specialist - How to Become   Things to Know About Medical Billing Programs   Avoiding "The Tempest" of Investigation   Insurance Coverage for Mental Health Issues   Medical Billing Advocacy Services Expand Focus to Attorneys, Businesses, and Physician Practices   Courses For Medical Insurance Coding