ANSWERS TO YOUR BILLING, CODING QUESTIONS

by Elizabeth W. Woodcock, MBA, FACMPE, CPC

Every once in awhile, a coding or reimbursement question comes along that causes even the best billing professional to reach for the jumbo-size bottle of Excedrin.

Here’s a sampling of typical questions – along with answers that will help you optimize your revenue, while maintaining full compliance with Medicare and other regulations.

QUESTION: Is there anything I can do about an insurance company that is not making a decision about a pre-authorization?

ANSWER: The National Committee for Quality Assurance (NCQA), which establishes requirements for most large insurance companies, sets a standard of 15 calendar days for response to a non-urgent request. Contact the NCQA about a noncompliant company, and report it to your state insurance commissioner’s office. You also can file a formal complaint, going through the channels outlined in your provider manual.

But before you take these steps, consider calling your provider representative at the insurance company and outline your intentions. This alone may motivate them to be more responsive.

QUESTION: It’s not uncommon for patients to ask us to resubmit claims that their insurance company denied for non-coverage. They want to see if the claim will be paid on the second pass. These patients often ask us to change the diagnosis code as well. We spend precious time resubmitting these claims – which rarely get paid. What should we do?

ANSWER: This is an unfortunate, but common, occurrence for most practices. Patients make these requests, particularly regarding preventive services, because they are not familiar with the benefits of their health plans. They just assume that all services rendered by a doctor are covered.

First of all, do not change the diagnosis code just to get a claim paid. The only exception is when the service was coded incorrectly, or when a covered diagnosis was documented but simply wasn’t coded. To avoid this problem, make sure that you code everything correctly in the first place and that providers routinely list all documented diagnoses.

If patients still want to repeat a process that you’ve already performed correctly, then it’s only fair to ask them to pay a modest reprocessing fee. The fee is intended to cover the additional work performed by your billing staff and to account for the fact that reprocessing will delay receipt of the patient’s balance by at least a month.

Notify patients in advance that you will be making this charge. List your reprocessing fee decision in your practice’s financial policy. When patients who have been notified of the new policy ask you to reprocess a claim, remind them of the charge. Be sure to collect the fee before reprocessing. Practices implementing a reprocessing fee typically charge between $15 and $25 per request.

QUESTION: How should I code school and camp physicals?

ANSWER: It depends. School and camp physicals typically do not require a complete preventive exam – and few, if any, health plans cover these short encounters.

When patients or parents call for an appointment for one of these physicals, advise them that this is a non-covered service and quote the expected payment. Tell them the service will not be billed to their insurance company and that you will require payment at the time of the visit. Establish a special procedure code for internal use and link it to your chosen charge. Most practices charge between $25 and $50 for these short physicals.

If your patients raise concerns about paying for school and camp physicals, you can certainly encourage them to schedule their annual preventive visit about the time that the forms are needed. Then, you’ll be in a position to complete the forms as part of the annual complete preventive exam. Some practices charge a nominal fee to complete these additional forms. Before implementing such a charge, however, consider whether or not it would have a disproportionately negative effect on customer relations. In addition, check the terms of your insurance contracts to ensure you are allowed to bill the patient in these instances.

QUESTION: I’m transitioning to a new billing system. What should I do with my receivables?

ANSWER: This can be tricky. Unfortunately, many physicians follow the wrong advice and make the switch even more complicated. First of all, refrain from attempting a “balance forward” transfer (unless you’re simply upgrading your system with the same vendor). A balance transfer can cost a lot of money. A programmer has to write a one-time interface between the old and new systems, and there’s still a high potential for something to go awry (e.g., a past-due account from guarantor Ms. B. Jones gets allocated to Mr. B. Jones).

Instead, keep the old system around for at least four months so your staff can query it when needed. Then, “work down” the accounts receivables (A/R) that were entered on the old system, while sending out new claims through your new system. Ideally, staff should be able to toggle between the two systems from their computers.

After four months (or maybe six, to be safe), transfer old A/R to a collection agency. Alternatively, print out a report of outstanding monies and key them into your new system. For example, if guarantor Ms. Smith still owes $200 from her child’s office visit six months ago, record what she owes and a few details about the service. The cost to manually key in a few old accounts will be faster, cheaper and cause less confusion than attempting a balance transfer of all accounts when the new system goes on line.

Elizabeth Woodcock is the founder and principal of Woodcock & Associates, with 15 years experience in medical group operations and revenue cycle management. A speaker, trainer and author, Ms. Woodcock has led educational sessions for the Medical Group Management Association, the American College of Obstetricians & Gynecologists, and the American Medical Association, and has consulted for clients as diverse as a solo orthopedic surgeon in rural Georgia to The Mayo Clinic. She is author of Mastering Patient Flow to Increase Efficiency and Earnings, and co-author of The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid and Operating Policies and Procedures Manual for Medical Practices.

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