Tuesday, December 27, 2011


The Office of Inspector General (OlG) has released its Work Plan for 2012.  The OIG sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities including CMS.

The OIG plans to initiate the following NEW activities related to physician services:
1)     High Cumulative Part B Payments – The OIG will review high cumulative Part B payments to determine if they are reasonable and necessary, adequately documented, and provided consistent with Federal Regulations.
2)     Incident-to-Services – The OIG will review whether “incident to” billing has a higher error rate than that for non-incident-to-services.
3)     E/M Services: Use of Modifiers during Global Surgery Period – The OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period to determine if Medicare payments were in accordance with Medicare requirements.

To avoid potential penalties in 2012, be sure that all providers in your practice are documenting exactly what they are billing out to Medicare.  Remember, if it isn't documented, it didnt happen!!!

For more information on this topic, visit http://oig.hhs.gov/reports-and-publications/workplan/index.asp

Thursday, December 8, 2011


Beginning on January 1, 2012, a federal mandate requires providers, health plans, and clearinghouses to use new standards when electronically conducting certain health care transactions.  Included are claims, remittances, eligibility, and claim status requests and responses.  As of March 31, 2011, claims submitted using the current HIPAA 4010 standards will start being denied by CMS.  Commercial insurance carriers may deny claims as soon as January 1, 2012.
As the deadline approaches, providers and health care organizations need to upgrade and test their claims management systems to ensure that they are prepared to accommodate 5010.  The required upgrade to 5010 was prompted by the need for a comprehensive electronic data exchange for the expanded ICD-10 code set mandated for compliance by October 1, 2013.

For more information on this topic, visit www.cms.gov/Versions5010andD0/

Medical Billing Services & Solutions

Monday, November 28, 2011

OB/GYN Billing

As you know, obstetrics and gynecology are technically two separate medical specialties dealing with the female reproductive organs, differentiated by whether the woman is in a pregnant or non-pregnant state.  However, the two specialties are usually combined to form a single surgical-medical specialty which enables the physician to care for his or her patients prior to, during, and after pregnancies.  This creates a broad range of conditions that the practicing OB/GYN will treat and many different procedures that the physician will perform.
As an OB/GYN medical billing specialist, knowledge of the specialty is vital to ensuring that the billing is being handled correctly.  The medical biller must play close attention to detail.  They must understand what is included in a global obstetrical package, and what can be billed separately…for all insurance carriers.  They need to be knowledgeable on how to receive full reimbursement for all medications, injectibles, and devices the physician may use.
The medical biller must also have a complete understanding of Well Woman Exam coding.  The biller must know which insurance plans will pay when a G0101 (Cervical or Vaginal cancer screening), Q0091 (Screening papanicolaou smear), S0610 (New patient-annual gynecological exam), or S0612 (Established patient – annual gynecological exam) is submitted.  Some pay for a specific code, and some with a combination of the codes.  Other payers will pay when submitted with a Preventive Visit (9938*-9939* codes), and others when included with an Office Visit (9920*-9921* codes).  The biller must also know what diagnosis codes are required to be submitted with the above Procedure codes.
The OB/GYN specialty requires knowledgeable billers that have both education and experience handling all aspects of the specialty.  If the medical biller doesn’t understand exactly what the insurance carriers require so that the physician can receive full reimbursement, then the denied claims can accumulate rapidly.  No physician can afford an interruption in cash flow, especially if it is due to inexperience.  Every OB/GYN desires full reimbursement for his or her services, and it is vital to have a qualified biller that is up for the task.

Thursday, November 17, 2011

Internal Medicine Billing

The billing process for Internal Medicine practitioners is different than many specialties.  The American College of Physicians defines internists as “physicians who specialize in the prevention, detection, and treatment of illnesses in adults."  Internists must be skilled at managing patients who have undifferentiated or multi-system disease processes.  Internists will see patients in the office, at the hospital, in nursing homes, and also in skilled nursing facilities.  In summary, Internal Medicine is a broad specialty with many different aspects, all of which bring something unique to the medical billing process.
As a medical biller, it is important to make sure that you understand all aspects of Internal Medicine to ensure that the job is done correctly.  Since many internists see up to 40 or more patients per day, one simple mistake can result in 200 “simple” mistakes over the course of a week.  Just as the doctor has a background in coding, medical billers must also have a background in coding to make sure that what they are submitting to insurance companies is correct.
Someone handling the medical billing for an internal medicine practice should have a comprehensive education on what constitutes a Level 1, 2, 3, 4, and 5 office visit.  They should also be knowledgeable on ICD-10 changes that will eventually occur.  An Internal Medicine Biller should understand how to handle the billing of hospital charges, nursing home visits, and SNF encounters.  Collecting full reimbursement for immunizations and injectable drugs poses its own challenges.  Properly submitting charges for in house/CLIA waived labs is another aspect of the specialty that is unique.  To top it all off, we haven’t even discussed A SINGLE PROCEDURE yet!
Due to the volume of charges that Internal Medicine Practices produce, if an inexperienced biller is in charge, it can get costly, very quickly.  It is easy to submit claims to the different insurance carriers.  It is not easy to make sure that what was submitted is correctly submitted. 
The key to receiving full reimbursement is having the knowledge of how to submit the charges correctly the first time.  Then the biller must rigorously appeal all denials to make sure that the practice receives full reimbursement.

Medical Billing Services & Solutions

Tuesday, November 8, 2011

Avoid CO-16 Denials for Missing Information (Immunizations/Injectible Drugs)

As you know, the fall is flu shot season.  When billing for an immunization, such as a flu shot, CMS requires the NDC code to be submitted along with the claim.  We recently submitted a Medical Billing Tip to our software vendor, and won the contest for the month of November.  Granted, this is specific to Kareo, but it may apply to many other medical billing software platforms as well.

Avoiding CO-16 Denials for Missing Information

CMS requires that immunizations and injectible drugs include the 11 digit NDC code be submitted on the claim.  The FDA website and the packaging label generally only list 10 digits.  The NDC code is a unique 10 digit, 3-segment number.  The first segment is the labeler code, the second segment is the product code and the third is the package code.  The configuration will be in one of the following formats:

4-4-2 or 5-3-2 or 5-4-1

The code submitted must use the following format:  5-4-2

Therefore, when you enter the NDC code in the Kareo procedure file, follow the format rule of 5-4-2.

On a code on the packaging label is 4-4-2, you enter a leading zero in the first segment.
On a code that is 5-3-2, enter a leading zero on the second segment.
On a code that is a 5-4-1, enter a leading zero on the third segment.

This will stop any CO-16 denials for missing information.

Bob Nichols
Medical Billing Services & Solutions
Chesapeake, VA

Wednesday, October 26, 2011

Medicare Payment Advisory Commission to Impose Pay Cut For Medicare Providers

The Medicare Payment Advisory Commission is charged with supervising $500 billion in Medicare cuts as a part of the Patient Protection and Affordable Care Act.  In September of 2011, MedPAC proposed that specialists will receive a 6% cut in their fees per year for three years followed by a 7 year freeze without any adjustment for inflation; general practitioners will face a 10 year freeze on their reimbursement fees, with no adjustment for inflation.  Despite overwhelming opposition from Medicare patients, Medicare providers, and many Health Organizations, they have recently gone ahead and voted to impose these drastic pay cuts on all doctors that accept Medicare as of January 1, 2012.

These cuts and pay freezes will equate to a 50% real pay cut for specialists and a 30% real pay cut for general practitioners over the next 10 years.  This assumes that inflation stays at a very low 3%.  Obviously, higher inflation would make the cuts in real pay even more drastic.

Consequences of this decision:

1)  Many physicians, and most specialists, will refuse to treat patients with Medicare as their primary insurance.  There are certain costs that physicians assume by practicing medicine and treating patients.  These include the obvious business overhead expenses, such as: rent, utilities, malpractice insurance, medical supplies, salaries of employees/nurses, etc.  Why would a physician want to treat a Medicare patient when they know that the reimbursement for treating that patient may not cover their expenses?

2)  More medical care will be turned over to nurses, nurse practitioners, and physician assistants.  Few people will ever get to see a doctor under the Medicare program.

3)  Medicaid will follow suit and cut their reimbursement fees as well.

4)  Many commercial insurance companies will also follow suit and cut reimbursement fees.

5)  The quality of health care in America will be drastically impacted because many students will choose to pursue careers in other fields.  The cost of medical school plus interest on student loans is always increasing.  Decreased future earnings to pay back these loans will prevent attending medical school from being a viable option.

If we do not take a stand, these cuts will drastically impact the health care industry in the United States.  I encourage you to write your Congressional Representatives and U.S. Senate Representatives to make your voice heard.

Thursday, October 13, 2011

Maximizing Collection of Patient Debt

As a billing company, we are obligated to honor the patient collection policy of the practice and its physician owner/s.  Unfortunately, too often we encounter practices without written policy on this critical component of the practice income.  Front desk and billing staff need guidelines to follow.  It is imperative that the practice owner(s) be the one who establishes policy regarding patient responsible debts and then be consistent in support of the policy.  It is inevitable that patients are going to “forget their checkbook” or fail to inform the practice of a lapse or change in coverage.  However, at what point should the patient not be able to receive services if they have not paid their copay or deductible?  How many patient statements should be sent when the patient is not making any attempt to pay before the practice refuses to see the patient?  Unfortunately, most practices simply cannot afford to allow those patients to receive services without honoring the cost share associated with their health insurance contract.  Be sure to make every way to pay available to the patient.  Be sure to offer credit cards as a payment option.
To the best of your ability, the practice policy should be clear and give the staff the authority to enforce the policy.  Many staff members are uncomfortable asking for money and empathize with patients who perhaps are struggling financially.  The employees assigned to the front desk staff need to be willing to ask for the patient’s copay and should have accurate patient debt information readily available.  Staff can pull the patient aside and explain that as a participating provider, the practice has agreed to require patients to pay their cost share as defined in the insurance contract.  Failure to do so could result in being terminated as a participating provider.   Everyone empathizes with our patients who truly are struggling, but it should be the decision of the physician/owner to give away their money, not someone at the front desk who feels bad for the patient.
Consistency in the enforcement of cost share literally trains the patient population.  If your patients repeatedly come to appointments without bringing their check book or credit card and still receive treatment, they have the right to protest when all of the sudden payment is demanded.  Patients need to be gently trained by the front desk staff/practice manager that they are required pay whatever monies are due based on the insurance contract that “THEY” selected.  After all, the patient chose the insurance plan that they wanted, not the other way around.  Rules and procedures need to be put in place by the doctor and followed by the staff 100% of the time to prevent patients from finding a reason not to pay.  If there is confusion amongst staff members as to whether or not a copay is due, or whether or not the patient has had “Bad Debt Written Off” in the past, the patient isn’t likely to volunteer that information or offer payment while at the front desk today.

Procedures to increase patient collections:
1.       An eligibility report on each patient’s insurance should be run at the end of each day for the next day.  This will enable the staff to know exactly what copay is owed, before the first patient shows up at 8:00AM.
2.       Outstanding patient debt should be printed on the superbill or be readily available to the front desk staff.  If it does not appear on the superbill, at the end of each day, staff should look in the billing system to determine if there is a balance on the patient’s account.  If there have been more than two statements without payment, then the practice should designate an individual to meet with the patient prior to the physician encounter and review the unpaid balance.  If the patient cannot afford to pay the entire balance, then a payment plan can be set up.  The first installment needs to be due before the staff takes them back to see the doctor.
3.       Patients with a qualifying balance should receive a statement every month.  Patient statements should be sent out, from the billing office, at least 3 times per week. (We send patient statements EVERY DAY.)  This reduces the time between the patient receiving the EOB from their insurance company and receiving a patient statement from the practice.  It also evens out the number of phone calls from patients about their statement.  In order for this to be effective, the billing office must stay current with submitting charges and posting payments every day.
4.       Send patient a 2nd statement 30 days later.  We most often see practices send 3 statements prior to sending the 10-day collections notice.
5.       If there is no payment after the third statement, a 10 day collections notice should be sent to the patient.  The patient should also be called by the front desk staff to alert them of the forthcoming “10 day collections letter”.  Patients that have not made a payment or addressed the balance after the 3rd notice are unlikely to do so without something that catches his or her attention.  Some patients will respond before they are sent to collections.
6.       After the 3rd statement/ 10-day collections notice letter, account balances above a certain amount should be sent to a collection agency.  A note should be made in the patient’s chart that a balance was sent to collections.  The smaller balances, perhaps $50 and below, should be written off, and put in the patient’s chart.  The small balances can’t be forgotten about, even if the patient isn’t seen for an extended period of time.  Balances above $50 can be sent to collections.
It is vital to collecting patient debt that guidelines, like the ones listed above, are implemented and followed 100% of the time.  A practice teaches its patients that they do or do not have to pay cost shares.  Once a patient realizes that debt will eventually be written off, never to be heard of again, the likelihood of them honoring their cost shares diminishes demonstrably.  Unfortunately, being sent to collections may sever the relationship with that patient.  If we are consistent in asking for payment and respectful of those who are truly struggling, we have to ask ourselves how many non-paying patients can the practice afford to carry.  When we reach that point, having a patient leave is not always a bad thing.

Medical Billing Services & Solutions

Send us an email if you have any questions.

Thursday, September 15, 2011

Denial Management 101

Every medical practice experiences denied claims, however some experience a far greater number of denials than others.  The best performing practices can have denial percentages as low as 5%.  Other practices are seeing claims denied 25-30% of the time.  It is key to understand that once a Medicare claim is denied and appealed correctly, it will take at least 1-3 months before the provider receives payment.  In tough economic times, this cash flow delay is unacceptable for most every practice.  Healthcare professionals are always looking for ways to improve their billing performance.  The best way to improve billing performance is to prevent many of these denied claims before they happen.

For those that have been involved in physician billing for over 20 years, we know that there was once a time when claims were submitted to the payers and we subsequently received payments.  It used to be much less sophisticated than it is today.  An individual claim processor manually reviewed, processed, and paid every single claim.  Over the last two decades, much of that work is now being done by a computer.  Programs are written to make sure that the medical practice/medical billing service is "dotting their i's and crossing their t's".  If there is any doubt, they deny it.  They assume that most medical practices will not go through the trouble of following up on denied claims.  This saves the payers money.

To ensure that you, as a provider, are not leaving money on the table, it is vital to be proactive as to what the root of the denials is.  Keep track of how many claims are denied every month, identify the reasons for denials, and track your denial performance over time.

1:  Determine your Denial Percentage at the end of every month.
  1. Total # (and charge amount) of claims filed to a payer.
  2. Number (and dollar value) of denied line items.
  3. Calculate Percentage by dividing "number of denied line items" by the "total claims filed to payer"
This will enable you to track from month to month whether or not your practice is improving.  This should be tracked as a complete practice, as well as by individual provider, location, and by payer.  This will give you insight as to where and why problems may be occuring.

2:  Determine the main reasons for the claim denials.
  • Registration error
  • Charge entry error
  • Lack of referrals & Pre-authorizations
  • Insurance Company needs info from patient
  • Duplicates
  • Medical Necessity/CPT Code does not match ICD-9 Code
  • Documentation
  • Bundled/Non-covered  {ex)modifiers}
  • Credentialing
This information will enable your practice to understand why claims are being denied, and where on the job training needs to take place.

3.  Track your denial performance over time.

The details about your claims denials will allow you to focus your energy on the most frequent reasons that claims are being denied.  The provider/practice management staff will know the most efficient ways to address the problem if they know the root cause of the why claims are being denied.  Every time you reduce your denial rate you bring more money to the bottom line of your practice.  Not only do you get paid correctly and timely, you have eliminated all the labor hours involved in reworking denied claims.

Medical Billing Services & Solutions