My first post on obesity counseling can be found here. This is a very specific update to help you get paid a bit more.
I have been running into problems with certain insurances. They have been bundling and excluding my G0447 and 99401 codes even though I am following my own guide. Blue Shield Federal and some Aetna plans are the most common offenders. Lengthy and boring story condensed, and, it turns out, these plans have specific exclusions for the diagnosis of Z68.30 to Z68.45.
When I bill the claim with the Z code primary, the code gets denied stating the service is not a benefit. When I bill the claim with either E66.01 or E66.09 on the obesity counseling line item, and leave off the Z code entirely, those line items get paid.
I also really suggest that if your system has pop-ups, alerts, built in claims edits, or anything along those lines that you utilize those for these specific situations. I know, personally, there is no way that I will be able to remember which specific patients or plans need these special rules without that tool. I do enough follow up as it is, I am not trying to make more for myself.
One of the things that people often hire me for is an in-depth consult of an entire practice reviewing reports, procedures, and EOBs to help you make sure that you are keeping this type of money in your practice. I also have group and one-on-one training sessions to teach billers and managers how to do this themselves. Call me at (909) 610-9524 or email me at email@example.com if you want to set something up.
I was debating continuing the joke into inappropriate-land, but my professionalism got the better of me.
By “IT” I mean, no matter how careful the front desk is, the doctors occasionally see a patient that has an insurance the doctor is not contracted with. If you have a lot of non-contracted patients slipping through, please read my post on how to run a tight ship at the front desk. The purpose of this article is not to cast blame, but to help you deal with the inevitable insurance fight that will result when this does happen.
Just like all posts, this will have a detailed article and a summary wrap up at the end, and a downloadable guide. If you are looking for particular information, try pressing CTL + F and a little search box will pop up. Put a one to two word search query there and press enter. You should jump directly to the part of the post that applies to you.
The BEST case scenario when you end up with an out of network patient, is that they have a PPO, Managed Care (MC), or Place of Service (POS) plan with out of network benefits. The patient will end up paying more toward their coinsurance or deductible, which, you know, sucks for them, but the allowed amount for the provider will be the same as the in network rate.
If the non-contracted insurance is an EPO, the patient has no out of network benefits. No matter how much you appeal, you will not get any payment from this insurance. Now you have to break out your flow chart. If the patient doesn’t have anything secondary to their EPO, you bill them your cash price. Or the full price. Whatever. You do you. If the patient does have a secondary, you send a claim to the secondary with a copy of the primary denial and hopefully you are contracted with them.
Here is where it gets a little complicated. If the patient has a commercial HMO, there are a ton of rules the IPA will cite in order to deny your claim. And, if the patient does not have a secondary insurance, you can decide how much effort you are going to put in trying to get the insurance to pay your claim. You can bill the patient right away or you can appeal the charge to the non-contracted IPA. I, personally, will fight with the insurance company for a couple of rounds before I bill the patient. A patient who has insurance is very unlikely to pay your bill, even if they legitimately owe it. A patient who has an HMO generally has less money in their budget then someone who has a PPO or EPO and is even less likely to pay your statement. Here are your options with a commercial HMO patient.
You are a family practice/internal med contracted with the IPA, but you are not the PCP. Unfortunately, in this case, there is probably not much you can do. You can try sending a claim to the claims department with the medical records and a letter requesting retro authorization. Here is an example of a letter requesting retro authorization. You would update the letter to explain what happened in your case. I have not had much success in convincing the insurance to pay in this situation. Mostly because the IPA has ALREADY paid the other provider their cap for that patient for the month. They are not going to pay you another cap payment, and they REALLY don’t want to pay you fee for service.
You are a family practice/internal med and you are not contracted with the IPA. You have a better shot in this situation getting a retro auth from the insurance. You would use the same type of letter as in the above example. I have about a 70% success rate when this happens.
You are a specialist and you did not get an authorization. Whether or not you are contracted, you have about the same chance of getting paid if you did not get a prior auth or single case agreement. You write a letter to convince the insurance that the services were medically necessary, or urgent.
One of the most complicated situations arises when a patient comes in and hands you a Medicare card, but it turns out they actually have a Medicare Risk HMO plan. If the patient does not have a secondary, you would handle the charge in one of the ways outlined above. However, most of our patients with MR Risk HMO plans, also have Medicaid secondary (called Medi-Cal here in California). If your provider is contracted with Medi-Cal you are not allowed to bill a patient under any circumstances. It does NOT matter that the patient went to the wrong doctor, it does NOT matter that they gave you the wrong insurance, it does NOT matter that they specifically withheld information regarding a primary insurance, it does NOT matter that the insurance they became effective with on the first of the month when you saw them is not one you are contracted with, it does NOT matter that you requested an urgent auth and the insurance denied it. Medi-Cal does not care. My out of state readers will have to let me know if your Medcaid works the same way, but that is how it works here. Also, Medi-Cal has been forcing people into HMOs as well. So what often happens, is that a supposedly straight MR patient comes in, you bill MR and they deny it stating the patient has an HMO. You can’t send that denial to Medicaid because the secondary is also an HMO and you are not the PCP. And, unlike in the previous situations, you are not allowed to bill the patient.
Here is an example of a letterthat I have successfully used to get payment from an IPA in this exact situation.
I have added all the letters to the links and tools page, and I have created this Downloadable non-contracted patient guide, to help you easily determine what you need to send where in which situation. If you need help with your specific patient, and your specific situation, send me an email.
If your office needs training or consulting or an audit, or if you decide that all of this is too much hassle and you want to pay someone else to do it for you, you can give me a call (909) 374-5439. I am awesome at this stuff. All the partners in New Generation are awesome at this stuff, actually, and we will train, consult, or bill, well, awesomely.
Edit: Final status update at the bottom of the article 10/07/15
I am always telling my doctors and employees that in our profession the rules change around here every 10 minutes. We have spent the last two weeks finding out again how true that is. One of the providers we bill for is an ophthalmologist and he does a lot of Avastin injections. Blue Cross has recently started denying the CPT code J9035. They still pay the 67028, but they are stating that the code J9035 is not indicated for ophthalmological services.
And, I have to say, they kind of have a point.
The CPT book description of J9035 says Injection, bevacizumab, 10 mg. That means is code is for the full 10 mg of meds, notup to 10 mg. For macular degeneration (362.52) and diabetes with ophthalmic manifestations (250.52, 362.07) the typical injection is 1.25 mg.
We’ve been in contact with the American Academy of Ophthalmic Executives and they said that Blue Cross will not be accepting the J9035 from ophthalmologists any longer and that we have a few options.
1. Use the code C9257 which is injection, Bevacizumab, 0.25 mg and use 5 units of that.
2. Use the code J3590 which is just the unclassified biologics code, and then put the NDC in box 19. I know that most of you have practice management systems which puts the NDC number in the correct 5010 loop, but we were told that we also have to put that information in box 19.
3. Use the RT/LT modifiers on both the 67028 and J9035 with the NDC number in box 19. This suggestion was made on the AAOE message boards by another biller and I have not been able to verify whether or not this will work.
The issue with the first two suggestions is that the reimbursement amount is going to be significantly less than we are used to getting and the issue with the third suggestion is that it may not work. Personally, I am going to try the J3590 code with the NDC in box 19 and see what happens. I’ll keep you guys updated.
Edit 08/24/15: Hello everyone. We are still fighting this with Blue Cross. What I ended up doing was submitting one service with the new J3590 code and one service with the J9035 RT. Both of those were pended requesting a detailed treatment plan. I finally managed to drag out of Blue Cross what THEY want in terms of a treatment plan. And here it is
1. Clinical indication
2. A stated goal for the patient in terms of his condition
3. They want to know if the treatment plan is having the desired affect
4. They also said that if we have attempted any alternative treatments, we should indicate if we are going to be utilizing those concurrently or if we are discontinuing those
They didn’t say this specifically, but I got the impression that they want to know when the patient will be all better and they will get to stop paying for this kind of thing. I told the woman I spoke with, that for patients with macular degeneration “getting better” isn’t really a thing. The point of the injections is to preserve what eyesight the patient still has. She said “then that’s what you probably want to say in your plan.”
If any of you are having trouble getting the Avastin paid by Blue Cross try sending in something like this with the office notes. I’ll continue to update you as I get more information.
Edit 10/07/15: Finally! We just got the answers on our test claims back. The charge with the J9035 – RT was denied. The charge for the J3590 was paid, albeit at an allowed amount of $47.50. Blue Cross used to pay about $60.00 for the J9035, so we are taking a bit of a cut. We are sending all our outstanding Avastin claims to Blue Cross with the J3590. Please remember to put the NDC number in the proper box when you use that code though. Please be aware, Medicare also has some new guidelines for the Avastin starting 10/01/15. Anyone having issues with the Avastin injections for Blue Cross, go ahead and email or call.
Your front desk staff are the marines of your office. The doctor is the general, the office manager and billers are the lieutenant and sergeants, and you can’t run a successful campaign without them. But your front desk staff are the boots on the ground, first in, last out. Their actions represent the first impression patients get of your office, and they have the last interaction with patients before those patients leave. I know that mostly, by the time you come to this blog for help, the patient has already been seen and you need to know how to get the charge paid.
But I get your emails, I know what you really need.
In a perfect world, insurances would just pay what they were supposed to, patients would send in their checks on time, and we could all leave work at 5:00. This post will help you get a little closer to that perfect world, and it all begins with your front desk. Many offices, family practice and specialists alike, end up seeing patients with insurance that is not on file, termed, or non-contracted. This happens for a variety of reasons. New patient’s tell us they have PPOs when they really come in with HMOs. Established patients forget to tell us that they changed insurance 2 months ago. HMO patients forget that if they change their PCP, they can’t come to us anymore. Howeever, with the proper procedures, the number of patients with these issues that actually get in to see the doctor can be virtually eliminated. I recently had someone contact me to train their front desk, and this is the checklist that we put together to ensure that the doctor will be paid for every service he performs.
When a patient calls in to schedule an appointment…
New patients – Many offices send patients to complete their paperwork online. If you do this in your office, you only need to get the name and phone number when the patient is on the phone.
Name and phone number
Insurance name and id#
Date of birth
We have your phone number as (909) 555-5555, is that still correct?
And we have you with BlueCross BlueShield, is that correct?
The day before the appointment….
Call to confirm appointment
If your patient filled out their paperwork online, verify eligibility
If patient has not been seen within 30 days, verify insurance (eligibility, deductible, copay)
Call to confirm appointment
Also, please be aware you have a balance of $XX.00. See you on Friday!
When the patient checks in…
We still have your address as 1122 N. Del Sol Lane, is that correct?
Collect any copay/deductible. If you are collecting toward a deductible, charge $50 and tell the patients this will be applied toward their deductible. Anything over that the insurance applies will be billed to their account. Unless the patient is in for a post-op, blood draw, or follow up for an established condition. In that case, the service the doctor performs probably won’t end up with an allowed amount of more than $50.00. We want to be very careful that we don’t charge patient’s more than the insurance allowed amount when we collect toward their deductible.
Copy any new insurance cards
When the patient leaves the office…
Schedule any necessary follow up appointment.
Collect for any additional procedures performed (cash patients)
Put in for any referrals
I have included this Front desk checklist on the links and tools page for you to download. These procedures are small changes that can have a transformative effect on your office and allow your billers to concentrate on what you pay them for. Namely, fighting with the insurance companies. When your billers have to run around after the front desk and try to solve these issues after the fact, it’s too late. As always, call or email with any questions. I love hearing from you.
April 1st is the deadline to switch over to the new CMS forms. And that is today. I know that there are a lot of you out there following this blog, so I have a quick public service announcement.
Please make sure you have the new forms for your paper AND electronic submissions today. If you are not sure whether or not you have the new forms, call around. Call your clearinghouse! Call your software vendor! Call MY software vendor! Call support! You may need to upgrade your software or re-map your print image file and test everything to make sure it’s working properly.
If you need help today, and you can’t get hold of your support people, please do actually call my support people. I use Lytec and I get it from Advanced Data Management. If you have an older version of Lytec and you don’t want to upgrade, they can get you the new CMS form for your current version (back through Lytec 2006 I believe). Even if you don’t have Lytec, they might be able to help you. You can find them here at http://www.adm1inc.com or call them at (800) 888-2361. They have been busily helping their customers get ICD10 ready for the last three months (including me–thanks Jo-Ann!) and if you left it to the last minute, please don’t leave it any longer.
This is along the lines of the cash in the office post. One of my doctors has lost an insane amount of money, and I would like you all to learn from his mistake.
I have a small Internal Med with an emphasis in Cardiology in Montclair. I go to their office once a week, after hours, and do all the charges and claims in about an hour. This isn’t bragging, they are small, and I am fast, and they only have me enter charges and send electronic claims. I have been doing their billing for four years and, until recently, I had never even seen one of their EOBs. They don’t want to pay me to post the payments, because they think it will cost them too much money.
I finally signed them up for a user name and password on the Online Provider Services Medicare website, against the office manager’s strenuous objections. On the first EOB I pull up, I immediately notice that ALL the EKGs I billed had been translating as 93005 instead if 93000. The reimbursement for a 93005 is $8.93 (allowed $11.16 minus the 20% coinsurance) and the reimbursement for the 93000 is $15.14 (allowed $18.93 less $3.79 for the coinsurance). That means my Internal Med has been losing $6.21 on every EKG for at least the last four years. He probably does 20 EKGs per week. So, ($6.21) x (20 EKGs per week) x (52 weeks) x (4 years) = $25,833.60. This does not account for the fact that over the last four years Medicare reimbursements have been decreasing.
Even after this, I have not been able to convince them that it would be more cost efficient in the long run to have me post the payments as well as the charges. Please, please, please use this as a warning and properly reconcile your EOBs with your payments. Every EOB for every charge.
Also, do it by line item and not by charge, because it is too easy to miss something important. Something like this.
P.S. If you have any questions about what you should be getting paid for things, use the Medicare Fee Schedule Look-Up. Most companies will pay a similar amount, so you are mostly safe using that as a standard.
Today we are going to play Unpleasant Truth Time. All those rules that you painstakingly memorized to get your claims out of the door are just the beginning. Insurance companies have more reasons to deny your claims then I could even begin to list here, and the biggest and most time consuming part of your job will be to unravel those reasons and get your doctor her money. This post will help you to do that. Email me at newgenerationbilling.com for the Cliff Notes version of this post.
There are two kinds of follow up–loose paper follow up and insurance aging follow up. Your loose papers are denials, partial payments, and requests for information from the insurance companies. Even with a healthy account you are going to have your share of these.
When you have denied and partially paid charges, here are your options to get them paid:
3. Appealing to the insurance company
4. Appealing to the insurance commissioner
When you resubmit a claim it is usually to correct an error. When I get a denial from an insurance company, the first thing I do is to make sure that I billed everything correctly, even though I have been doing this for over a decade now. And I make sure to check EVERYTHING. I review the diagnosis, service, date, doctor, facility, insurance, and id#, because these are all thingsI have messed up on in the past. Just a quick aside for those of you who are planning on calling us for billing or consulting services, please be assured, those mistakes are very rare. If I was the kind of person to use a smiley face in my professional blog, I would put one here.
When you do make a mistake all you have to do is correct the claim and mark in box 19 that this is a corrected claim and indicate what you fixed. Here is an example. Say you billed a DX of 627.9 (postmenopausal syndrome) to a Mr. Henry Winkler. Now, Mister Henry Winkler is not going to have postmenopausal syndrome because he is a man. You pull up the superbill and realize that you meant to bill 682.9 (cellulitis). Change your ICD9 code, in box 19 write “Corrected claim, Corrected ICD9 code”, and resubmit your claim.
Most of the denials you receive, however, will not be your fault. This is where you would call the insurance and have them reprocess the claim. Insurance companies process claims wrong all the time. Several times I have even had my claims denied as duplicates to themselves! If the claim was denied due to an error on the part of the insurance, usually all we have to do is call them and get them to send the claim back for reprocessing. Make sure you have the following information available when you call because it will save you a great deal of stress:
1. Your provider’s NPI and Tax ID. They don’t always ask for both of these, but having them in front of you when you do your follow up will save you time with those representatives that do want both numbers.
2. The patient’s ID number, name, and date of birth. They always ask for all three of these things. When you’re on the phone with an insurance company, the rep won’t hurry you, or tell you that you’re wasting her time, or ask you to hang up and call back once you have the information. But if you are scrambling around for it, you are wasting your own time.
3. The date of the charge you are calling in regards to, and total billed amount of the charge. The insurance is going to have a lot of claims on file, so they are going to need the amount of your claim to make sure the two of you are talking about the same thing.
When you request that a claim be reprocessed, please don’t take no for an answer. If the claims representative won’t help you, go up to a supervisor. Hang up and call again. Since you’ve already checked your claim top to bottom, you know that the error was not on your side and you should not have to take any more of your time to resolve this issue.
You will run across things that a phone call cannot resolve. In those cases, we send in written appeals. With my appeals I send a copy of the claim, any documentation I have to support my position, and a letter. In my letter I explain exactly what my objection is, what documentation I am attaching, and what result I expect to see. Here is a sample Appeal letter for something like a timely filing. I keep templates of my letters on file for the most common denials: timeliness, medical necessity, incorrect duplicate denials. If you want, I can post samples of those as well, just email or comment and I’ll put them up.
Now, no matter how exactly worded your letter, and no matter how thorough your documentation, sometimes your appeals will be denied. Your last resort is to go to the insurance commissioner. You can see your options on the state website http://www.insurance.ca.gov/ and there are step by step instructions on how to file your complaint.
Once all the loose papers on your desk have been taken care of, it is vital that you pull an aging report. The claims that get denied and partially paid are the claims the insurance receives. If you read the appeal letter, you probably realize that many of the outstanding claims you have on your accounts receivable right now are claims that the insurance has “never received.” The insurance will never send you a zero dollar EOB or a request for information, and your time limit to file and to appeal will run out before you realize.
Doctors, office managers, billers, please remember to pull your aging on a monthly basis. Not only will you catch the follow up that you would not otherwise find, you can make sure that your aging is healthy. A healthy aging will have at least 80% of your outstanding balances within 60 days. We have customers with 90% of the charges outstanding within 60 days.
If you pull your aging and you don’t like what you see, that is where New Generation comes in. Call us at (909) 374-5439 or email us at newgenerationbilling.com. You have plenty of options, call us and find out what the are.