Insurance Deductibles

Collecting deductibles is often a difficult task for any medical practice.  It is much easier to collect payment from a patient who is currently in the office to see the doctor, rather than a patient who receives a bill.  There are many patients who are unaware of what a deductible is, and refuse to pay the bill that they get in the mail, not matter what!  It helps to try to collect part of the deductible amount while the patient is in the office, and to have a notice placed in waiting room and front desk as to the practice's deductible policy.  Below is a notice that we gave to our practices to post in the waiting room/front desk area.

NOTICE



Welcome to the New Year.  As you know, with each New Year new insurance deductibles apply.  It is one of the more frustrating parts of medicine that with the arrival of each New Year, the application of deductibles replaces a significant amount of our insurance payments.  At this time of year, our cash flow is overly dependent on the collection of these deductibles.  As a practice, we utilize the best available online systems to determine our patient's individual obligations.  Unfortunately, this information is often incomplete.  It is the patient's responsibility to understand and honor this aspect of your insurance coverage.  Your deductible is due at the time of service.  If your insurance does not have a deductible, please be patient with our staff should they mistakenly ask you for a payment towards a deductible.

****Medicare Deductible for 2012 is $140.  Please be aware that many secondary insurance policies now have deductibles and/or do not pick up the Medicare deductible.

Surgical Global Periods

I am confident that all doctors have at least a basic understanding of the global package and what is expected of them during that time. However, what does and does not fall under the global period continues to be an issue for providers and medical billers alike.

Scenario #1: Provider performs pre-op visit and the subsequent surgery. Upon the follow -up visit, everything is found to be normal.

• Since the provider has already been reimbursed for the entire global period, there is no additional reimbursement. The provider should bill a 99024 to create a permanent record that the patient was seen for post-op evaluation.

Scenario #2: Provider performs pre-op visit and the subsequent surgery. Upon the follow-up visit, Provider finds a postoperative infection that needs additional care.

           

• The infection is unrelated to the diagnosis for which the surgical procedure was performed, therefore the provider should receive reimbursement for this encounter. The provider should code the encounter as they normally would for an office visit, but they must include a 24 modifier. Without the 24 modifier, the claim will be denied. 

A doctor can avoid a lot of denied claims by making sure that the biller includes the 24 modifier with claims such as in Scenario #2. If the modifier is not included, the claim will be denied and the biller will be left to try to figure out what caused the denial. The claim must then be appealed, where they will likely request chart notes. This requires an extensive amount of time and labor before the provider will receive reimbursement.

A good line of communication can avoid most of these denials on the front end.

Medical Billing Services & Solutions

2012 OIG WORK PLAN

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

Medical Billing Services & Solutions

PREPARE FOR HIPAA 5010 NOW TO PROTECT YOUR ORGANIZATION FROM FUTURE DENIALS

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

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.

Medical Billing Services & Solutions

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

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.

Example:

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