Category Archives: Follow up

Every practice does it…

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.

  1. 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. 
  2. 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. 
  3. 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 letter that 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.

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Filed under Accounts receivable, Authorizations, Billing, Denials, Doctor's Office, Follow up, Health Care, HMO, Medical Billing

Modifiers 24 and 79

A few months ago we had to do some training on our ophthalmologist account regarding when to bill the 24 modifier versus the 79 modifier in the global period to a surgery or in-office procedure. I figure, if our employees are having questions, some of you might be too, and I want you to get the maximum reimbursement for your services. First, the exact descriptions of the modifiers from the CPT book:

24 – Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Post-operative Period:
The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:
The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)

Many of our doctors do both minor and major surgeries, and we all know that patients need to come back in for follow up care on their various incisions, wounds, and ulcers to make sure everything is healing properly. The insurance companies will not pay for these follow up visits, or any visit done in a certain amount of time after the procedure without the proper modifiers as they consider the follow up visit to be an integral part of the original procedure. This time period is called the global period and the length of time varies depending on the procedure performed.  The issue with this no-payment rule comes in when the doctor diagnosis the patient with something additional during the follow up visit, or the patient needs another procedure. At that point, the doctor needs to do a complete visit including review of systems and exam and make a medical decision, and we can all agree that she should be paid for that. Here is how you get her paid. Modifier 24 goes on the office visit and you make sure you have a primary diagnosis that is different than the diagnosis on the original procedure. If the patient needs any in-office procedures, put a 79 on the procedure and make sure the diagnosis is different than the one on the original procedure. If the patient needs another major surgery in that time period, unrelated to the original, use modifier 79 as the first modifier on the surgery.  Just to avoid confusion, whether you use the modifier 24 or the modifier 79, the modifier would go on the visit subsequent to the surgery or in-office procedure.

To answer a popular question, yes, you can use modifier 79 when you are billing for the same surgery on a different body part. For example, if the patient had a cataract surgery on the left eye in January and he is getting cataract surgery on his right eye in February, you can use the same diagnosis of cataracts, the same CPT code for the surgery, and add the 79 modifier. Here is how that would look:

Date                          ICD9 code            CPT Code    Modifiers

01/13/14                 366.17                    66984             LT

02/18/14                366.17                    66984              79    RT

As for using the 24 modifier, there are all kinds of good, justifiable reasons to bill with that modifier and get your office visit paid separately. Here are just a few:

1) Patient is requesting a refill on medication for her chronic condition (hypertension, diabetes, hypothyroidism, migraines, neuralgia)

2) The patient came in with an unrelated chief complaint on his follow up visit

3) Patient came in for the follow up and the doctor identified symptoms of something else during the exam

This is by no means a comprehensive list, so if you are not sure whether or not your particular patient meets the requirements for using a 24 on the office visit, send me a quick email and I’ll let you know how I would bill it. Here is an example of how a charge like that would look.

Date                          ICD9 code                             CPT Code    Modifiers

01/13/14                  366.17                                    66984             LT

02/18/14                 250.60    362.01                  99214             24

I also have another chart for you (I love charts!) detailing the global period for each procedure. It is LONG. I do not suggest you print this one out, but save it on your own computer for reference. Oh, and, the global period for any given code is either going to be 10 days or 90 days, if it has one at all. FYI. As always, I saved the chart to my Links and Tools page for you.

EDIT: Just a quick FYI, global surgery rules do not apply to assistant surgeons. So, anyone who is billing a code for a provider assisting with a surgery, these rules don’t actually apply to you. Just go ahead and use modifiers 80-82 the way you’ve been doing. In fact, if we do send in a claim with modifier 79 (or 78 for that matter), the claim will actually be returned as unprocessable. Thank you, Adam, for helping to clear up the confusion.

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Filed under Billing, Claims, CPT, Doctor's Office, Follow up, Health Care, ICD9, Medical Billing, Modifiers, Office Visit

Quick Workers Comp Tools

Have you ever wished that you could have a list of all the lists and tools and links you need for Workers Comp in one place? Well now you can! You’re welcome.

Doctor’s First Report

PR-2 Report

OMFS Schedule

OMFS DME Prices

NDC Numbers for substances

OMFS Fee schedule for pharmeceuticals

EAMS

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Filed under Claims, CPT, Doctor's Office, Follow up, Health Care, Medical Billing, OMFS, Workers Compensation

Please post your payments

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.

$25k. Gah.

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.

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Filed under Accounts receivable, Billing, Claims, CPT, Denials, Doctor's Office, Follow up, Health Care, Medical Billing, Medicare, Office policy, Uncategorized

The insurance denied your claim, now what?

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:

1. Resubmission

2. Reprocessing

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 things  I 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.

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Filed under Accounts receivable, Billing, Claims, Denials, Doctor's Office, Follow up, Health Care, Medical Billing, Office policy