Improper form

Defensive providers will often look at the form you submit to submit a claim. Most claims are legitimate, but there are a small number of claims that are fraudulent. If the claim form is filled out incorrectly, or if the documentation is incomplete, the provider may reject the claim. If you are submitting a claim for a medical procedure, make sure that you follow the correct form. Some providers will reject a claim if they see notes in the “medical comments” section. If you have any questions about the proper form, call the provider and discuss it with them. Sometimes, providers may be unaware that a particular form is required by the state. If you are having trouble with a particular form, try to call the provider and ask them about it – you may be able to get them to help you with the form.

Wrong diagnosis

Some providers will reject a claim if the provider does not agree with the condition that is listed on the claim. As a provider, you are expected to have a high level of expertise. However, as a healthcare system, you are allowed to have a percentage of claims rejected. If there is a claim that you are unsure of, call the patient’s provider and ask them if they agree with the diagnosis. You may be able to get the claim approved if the patient’s provider agrees with the diagnosis. Some providers will be stricter about accepting a non-standard diagnosis. If your patient’s provider is unsure of the diagnosis, you can try to get them to accept a different diagnosis. You can try to get them to agree to a different diagnosis that you think may be correct.

There is no evidence of coverage.

Some insurance providers will reject a claim if they find that there is no evidence of coverage. This is often related to a doctor’s visit, but it can apply to any type of visit. It is important to have a paper trail for all of your visits – keep notes about what happened, what the visit was for, and who the visit was for. Some providers will reject a claim if they find that there is no evidence of that the visit took place. It is important to have evidence that a visit took place. It is not an automatic rejection if the provider does not explicitly say that there needs to be evidence of coverage, but you should expect a rejection if there is no record of coverage.

The provider isn’t a contracted provider.

Medical insurance is regulated by the government – and each state has a specific set of laws that govern how claims are processed. Some providers will reject a claim because they are not a contracted provider. There are a large number of contracted providers, and it is possible to have a claim rejected because the provider is not a contracted provider. If you are submitting a claim to a non-contracted provider, you should expect that the claim will be rejected. Most states have some kind of database that lists all of the contracted providers. If you are submitting a claim to a non-listed provider, the claim will be rejected. You may be able to get the claim approved if you can get the provider added to the state’s database of contracted providers.

Incorrect Timing of Services

Some providers will reject a claim due to timing issues. Providers have a certain number of days that they are allowed to submit claims. If a provider submits a claim after the allowed number of days, the provider may be rejected. If you are having trouble with this, you can call the provider and ask them if they are late with a particular claim. If they are late, you can try to get them to redeem the claim. Some providers will be strict about redeeming a late claim, but you can try to get them to accept it.

Other common reasons claims are rejected

Some providers will reject a claim because it was not submitted by an experienced provider. There are some claims that are difficult to submit, and it may be easier to try to get a friend to submit a claim for you. There are some claims that are difficult to submit from an insurance perspective. These claims can often be difficult to submit from an experience perspective as well. If you are submitting a claim for a difficult to explain condition, you can expect that claim to be rejected. Some policies require a certain level of documentation with each claim. Some policies require that you submit a doctor’s note with each claim. Some policies require that you submit a note from a specialist with each claim. Some policies require that you submit a note from a patient with each claim. If a particular requirement is listed on the policy, you can expect that requirement to be part of the reason that the claim gets rejected.

Summary

Medical insurance claims are challenging. There are many reasons that a claim can be rejected, and there is little that providers can do to avoid this. It is important to understand what the most common reasons are for a claim to be rejected, so that you can try to avoid them in the future.

PRIMARY VS. SECONDARY PAYER RESPONSIBILITY

Following is a list of some common scenarios in which Medicare and other health insurance or coverage may be utilized, as well as which entity will be the primary or secondary payer in these instances.

Working Age (Medicare beneficiaries 65 and up) and Employer Group Health Plan (GHP)

An individual is 65 or older, has a GHP through current or spouse’s current employment, and the employer has fewer than 20 employees: Medicare pays first, and GHP pays second.

An individual is 65 or older, has a GHP through current employment or a spouse’s current employment, and the employer has 20 or more employees (or at least one employer is a multi-employer group that employs 20 or more individuals): GHP covers primary care, while Medicare covers secondary care.

An individual is 65 or older, self-employed, and covered by a GHP through current employment or a spouse’s current employment, AND the employer employs 20 or more people (or at least one employer is a multi-employer group that employs 20 or more people): GHP covers primary care, while Medicare covers secondary care.

As a “secondary payer,” Medicare is the next in line to pay your medical bills. If you are covered by another insurance plan in addition to Medicare, that insurer is likely to be the primary payer of your medical bills. The primary payer will cover the claim up to his/her limits, and then the secondary payer will attempt to cover any remaining costs (if any). However, this does not mean that Medicare will cover all of the remaining costs, nor will it cover the same services that the primary payer has provided. It is the primary payer who is solely responsible for settling a claim. Medicare continues to be the primary payer for those without other health insurance or coverage. Depending on the circumstances, Medicare may also serve as the primary payer.

PRIMARY VS. SECONDARY PAYER RESPONSIBILITY

Some common scenarios in which Medicare and other health insurance or coverage may be utilized, as well as which entity will be the primary or secondary payer in these instances.

Working Age (Medicare beneficiaries 65 and up) and Employer Group Health Plan (GHP)

When an individual is 65 or older, has a GHP through their current employment or a spouse’s current employment, and the employer has fewer than 20 employees, Medicare will pay first, followed by the GHP.

An individual who is 65 years of age or older and has a GHP through either their employment or that of their spouse, and that employer has 20 or more employees (or a multi-employer group with at least 20 employees): GHP covers primary care, while Medicare covers secondary care.

An individual is disabled, is covered by a GHP through his or her current employment (or through the employment of a family member), AND the employer has 100 or more employees (or at least one employer is a multi-employer group that employs 100 or more individuals): GHP covers primary care, while Medicare covers secondary care.

End-Stage Renal Disease (ESRD) (ESRD)

An individual has ESRD, is covered by a GHP, and is within the first 30 months of Medicare eligibility or entitlement. During a 30-month coordination period for ESRD, GHP pays primary and Medicare pays secondary.

An individual has ESRD, is enrolled in a Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) plan, and is in the first 30 months of Medicare eligibility or entitlement. During the 30-month coordination period for ESRD, COBRA pays first and Medicare pays second.

The 1985 Consolidated Omnibus Budget Reconciliation Act (COBRA)

An individual has ESRD, is covered by COBRA, and is within the first 30 months of Medicare eligibility or entitlement. During the 30-month coordination period for ESRD, COBRA pays first and Medicare pays second.

An individual is 65 years of age or older and is covered by Medicare and COBRA. Medicare pays first, and COBRA pays second.

A person is disabled and is covered by Medicare and COBRA. Medicare pays first, and COBRA pays second.

Health Insurance for Retirees

A person who is 65 or older and has an employer-sponsored retirement plan. Medicare pays first, and retiree coverage pays second.

Liability insurance and no-fault insurance

An individual is eligible for Medicare if he or she was involved in an accident or other situation involving no-fault or liability insurance. Liability insurance or no-fault insurance pays. Medicare pays first for accident or other situation-related health-care services claimed or released, and Medicaid pays second.

 Insurance for Workers’ Compensation

Because of a job-related illness or injury, an individual is eligible for Medicare and is covered by Workers’ Compensation. Workers’ Compensation pays first and foremost for health-care items or services related to work-related illness or injury claims. In most cases, Medicare will not pay for an injury or illness/disease that is covered by workers’ compensation. If workers’ compensation denies all or part of a claim on the grounds that it is not covered by workers’ compensation, a claim may be filed with Medicare.

If a claim is not covered by workers’ compensation, Medicare may pay it if it relates to a medical service or product covered by Medicare. Prior to settling a workers’ compensation case, the parties should consider Medicare’s interest in future medical services, as well as whether the settlement will include a Workers’ Compensation Medicare Set-aside Arrangement (WCMSA).

PROVIDERS’ RESPONSIBILITIES UNDER MSP

As a Part A institutional provider (such as a hospital), you must:

Prior to providing hospital services, obtain billing information. It is recommended that you use the CMS questionnaire or a similar type of questionnaire; and

Use the condition and occurrence codes on the claim to send any MSP information to the intermediary.

As a Part B provider (physician or supplier), you must:

To obtain MSP information, follow the proper claim rules, such as group health coverage through employment or non-group health coverage due to an injury or illness.

Inquire with the beneficiary during the visit if he or she is pursuing legal action in connection with the services provided; and

Submit an Explanation of Benefits (EOB) form to the designated carrier, including all relevant MSP information. In addition, when submitting an electronic claim, include all of the fields, loops, and segments required to process an MSP claim.

Managing your practice while keeping an eye on accurate insurance reimbursement can be challenging. WWS can help you manage your entire medical billing process. To learn more about our medical billing services, don’t hesitate to

contact us at +1(302)613-1356 or support@wonderws.com.

Fixing claim rejections is easy once you know what’s going on. Multiple rejection messages may appear for one entry because each payer/clearinghouse worded their rejection message differently.

MISSING OR INVALID PAYER ID

According to this rejection, the payer ID used on the claim isn’t eligible for electronic submission. An electronic connection must be established between a payer and a clearinghouse to send claims. Every payer has a unique payer ID, but sometimes the clearinghouse has a payer ID that’s different from the payer’s. Those claims should be submitted with the clearinghouse payer ID. With the clearinghouse’s outbound payer ID, claims go to the payer.

THE ZIP CODE OF THE SUBSCRIBER IS MISSING OR INVALID.

This rejection indicates that the claim has an invalid ZIP code. Payers typically require the full 9-digit ZIP code on electronic claims. The rejection usually indicates that the claim does not include the 4-digit extension. You can verify your zip code by using Zip Code Lookup provided by the US Postal Service. If all corrective actions have been completed, rebill and resubmit all affected claims.

SUBSCRIBER PRIMARY IDENTIFIER IS INVALID

There are three possible explanations for this rejection:

• The claim was sent to the incorrect payer ID. If this rejection was received on claims for multiple patients, this is the most likely cause.
• The patient’s demographics or insurance policy were ineligible for the date of service billed.
• The patient is either a newborn or has recently been added to the guarantor’s insurance policy.

Depending on the cause, the following steps will be taken to resolve the issue:

• Verify and edit the payer ID if the claim was submitted to the incorrect payer ID.
• Verify the patient’s eligibility if the patient’s demographics or policy are incorrect.

 NPI OF BILLING PROVIDER IS MISSING OR INVALID

Most likely, this error is caused by an incorrect billing NPI. Your NPI is likely on file with payers. Upon receiving a claim, they look in their system if they have the billing NPI on file. In the absence of it on file, they’ll deny the claim. Quoting not having your NPI and Tax ID on file. 

As a result, this error could also refer to a claim that was submitted with the incorrect Tax ID reported in (the equivalent of) Box 25 on the claim. Be sure to submit claims using the same NPI & Tax ID.

INVALID DIAGNOSIS CODEDiagnostic codes are updated, changed, and deleted every year on October 1. To avoid this rejection, ensure that the diagnosis is current as of the date of service. Also, double-check that the diagnosis matches the procedure being performed. Make certain that the diagnosis code is coded accurately.

Fixing claim rejections is a critical process, but it’s time-consuming. WWS can help you avoid claim rejections and submit clean claims. For more info about our medical billing services, call +1(302)613-1356 or email us at support@wonderws.com

Are you on top of the CMS documentation guidelines?

The following points identify CMS guidelines for correct documentation that supports and validates the claim submitted for services/procedures:

• The record of the encounter/episode of care should be complete and legible
• Documentation should include:
  1. Reason for the encounter
  2. Assessment, diagnosis, and clinical impression
  3. Medical plan of care
  4. Date and legible identity of the observer
• The rationale is documented for ordering diagnostic and ancillary services
• Past and present diagnoses are documented
• Diagnosis and treatments are supported in the medical record and match the codes reported on the CMS-1500 for the patient’s services

Lack of a valid reason for an encounter is one of the most frequent pitfalls that leads to a denied claim, which could be because a patient may not present with a chief complaint (CC), or it’s difficult to determine the reason for the encounter, or when the CC does not correlate to the components of the assessment.

The data indicates all health care organizations should have regular documentation, coding and billing audits performed as part of their annual compliance plan. Communication and educational tools for providers and coding staff can be implemented to related documentation and coding-related issues from routine audits.

The Medicare Fee for Service (FFS) Recovery Audit Program’s (RACs) mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.

CERT and RACs shortlisted the top errors in CDI:

• Incomplete progress notes: They are either unsigned, updated or have insufficient details.
• Unauthenticated medical record: The medical record bears no provider signature, initials, supervising signature, or a legible signature.
• No documentation to support the service or procedure: Incomplete or missing signed order or progress note describing intent for service/procedure/test.

CERT Identifies Common E/M Services

Here are the top three services CERT targets:

• E&M services for established office visits
• Initial hospital visits
• Subsequent hospital visits

High error rates were reported by CERT for:

• Insufficient documentation
• Lack of support for the medical necessity
• Inaccurate E/M codes

CERT also targets:

1. Incomplete documentation

Including misspelled words or incomplete sentences that lack meaning led the auditor to believe the information was copied or the provider didn’t read it.

2. Holes in the record

These appear often in records, at times with drug names missing. It is especially notable when the physician has signed off on the record, proving that he didn’t bother to read it thoroughly.

3. Noncompliance with organizational policies

Practices should have a compliance plan in place that focuses on the CPT® codes your providers use most often for ensuring accurate and thorough documentation. The practice should train providers on compliance plan processes, require that they verify that they received and understand the training, and ensure that they follow the plan by defining disciplinary actions if they fail to do so.

Services must be reasonable and necessary

The provider must be clearly able to documents that the patient’s diagnosis justifies the treatment rendered to avoid the slightest indication that the treatment is for the convenience or comfort of the patient, provider, or supplier.

Drawbacks of auto-populate in an EMR

Providers should double check when the EMR auto-populates documentation. Ensure that the records do not demonstrate auto-population of the word ‘routine,’ as this might lead to diluting the provider’s case for the unique medical necessity of care for the specific medical condition.

Providers also shouldn’t quickly check off boxes in the EMR or in the record without carefully reviewing the accuracy of the documentation. Checkboxes lend themselves to quick completion of documentation that may be inaccurate.

Note:

Physicians who get paid for an over-documented service do not necessarily get to keep the money. Auditors on the payers’ side look for evidence-based documentation to prove medical necessity, and if they don’t find it, the payers ask for their money back. Physicians must be able to substantiate their claims of medical necessity with accurate documentation.

Learn More on timely documentation that reflects the scope of services provided. Contact us or Schedule a free live demo to overcome from Documentations Errors.

You have more control over the terms of your payer contracts than you realise (including how much you’re paid).  Knowing how you can get the highest return from payer contracts is essential to your practice’s success especially when you consider that about half of your revenue is most likely tied to your commercial payer contracts’ fee schedules.

When researching a Payer, particularly if your practice has not previously contracted with that Payer, you should consider the following questions:

⇒Which products does the Payer/medical group/IPA offer (i.e., HMO, PPO, ACO, POS, Medicare, Medi-Cal, ERISA/self-funded, Workers Comp, etc.

⇒What is the Payer’s market share in your area

⇒What is the total number of enrollees by product

⇒Is the Payer financially solvent?

⇒Are your referral sources participating?

⇒How many and what is the nature of patient complaints that have been filed against the Payer?

⇒Does the Payer have any plans for increasing the number of enrollees in your service area or for adding new products? (read their press releases)

⇒What is the average turnaround time on payment of claims?

Best Practices for Payer Contracting

Negotiating a new or preexisting contract with a Payer can be tough, but it doesn’t mean that your practice has zero chance of getting what it wants. 

The key is to go in prepared. With a few proven strategies, called 10 Best Payer Contracting Practices you can increase your reimbursement and receive more patient referrals with a little help and it doesn’t matter whether you’re a novice or an expert negotiator.

1. PREPARE:

Practice 1

• Know your insurer. Know your history with the insurer. Volume of your clients;
• Why the insurer should include birth centres in their network

Practice 2

Benchmark against Medicare and other payers with which you have contracts to identify areas where you may be under reimbursed compared to the market. Use the “20/80” rule.

Practice 3

S – Strength

W – Weakness

O – Opportunities

T – Threats

SWOT Analysis for your payer fee schedules: Look for opportunities to increase reimbursement for services that are not reimbursed at market competitive rates, and assess your charge master.

Practice 4

Who will contract on your behalf and who at the Insurer “Reach out to the person responsible in your region for facility contracting at a Payer. Who is that person?

Practice 5

Proposal “After the Initial email or contact, prepare a Proposal Letter and Rate Sheet.

 2. NEGOTIATE

Practice 6

Deliver highly impact proposal letter to a facility contracts manager at the payer. Have available data regarding your outcomes, birth centre outcomes, licensing, accreditation, etc.

 Practice 7:

More follow up, follow up again and again, and keep the payer in constant communication.

 Practice 8

Evaluate payer proposals and look for ways to optimise counter offers. If payer does not provide a proposal or counter proposal, don’t take first “No” as an answer.

Practice 9

Review contract for language that affects operations, including reimbursement.

 3. MONITOR

Practice 10

Monitor payments, identify reimbursement issues quickly and work closely with your payer representatives to resolve any payment issues as quickly as possible.

What is a Closed and Narrow Network?

A closed network is a payer network which currently has participating providers similar to you and, therefore, is not adding more similar providers, including you, to their network.

A narrow network means it has just a few participating providers of a certain type and are not looking to expand further.

How to differentiate your value

• Clinical Benefits leading to cost savings
• Product Advantages
• Service Advantages
• Geographic Coverage
• Referrals
• Out of Network Business, Book of business potential

Review contract for language that affects reimbursements

• Term and termination (90 days without cause)
• Use of non-par providers, e.g., ancillary services, anaesthesia
• Timely submission of claims
• Timely claims payments (30-45 days from receipt of claims)
• Claims Payment Adjustments: You are responsible vs. a withhold from future payments
• Retrospective review of over payments, 90 days maximum, 180 is usual, pay them vs. payer deducts automatically
• “Favoured Nation”‐ Never!

 Payer Market Fee Schedule or your billed charges

• Identify the top revenue producing codes which drive 80%+ of your revenue and compare payer’s fee schedule to your billed charges
• Compare the payer’s market fee schedule to local Medicare rates and to the weighted average rates of your commercial payer fee schedule for top codes
• Always make sure your billed charges exceed the highest rate of any payer contracted
• Rate for the same HCPCS or CPT code and it is best to set them at UCR thresholds
• Often these payer fee schedules are very low

Percent of Billed Charges

• This seems like it has no downside
• However, be aware of limitations such as “not >X% of Medicare”,
• Also, with complementary payers, if it is set too high this may prevent claims adjudication by the primary payer

Footnotes

If you’re tired of having to work harder and see more patients just to maintain your practice, then look at your payer contract could reveal ways to increase your income without increasing your workload. Follow the 10 Best Practices, in order (Prepare, Negotiate and Monitor), know your value proposition. Before you sign a contract, audit the contracts’ language even if you have not had operational problems and be aware of the types of fee schedule amendments and optimise them.

Speak to one of our experts today for Payer Contracting Questions, please phone us at +1(302) 613-1356 or write us to  support@wonderws.com

We look forward to hearing from you and are glad to provide information that helps you to run a more profitable practice.

If your practice received an electronic health record (EHR) incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program, you may be subject to an audit. The best way to get ready for a meaningful use (MU) audit of your practice is to assume you will be audited and prepare accordingly.

Preparing your medical practice for a Meaningful Use compliance audit is much easier with some preparation and planning throughout the year. Here are some strategies that your practice can use to make sure you meet all the requirements of the MU program should the auditors come calling, and ensure you can keep the incentive money you earned.

1. Assume you’ll be audited

The best thing a physician can do to ensure an audit goes well is assume they will be audited before they attest and prepare for it. Because some physicians are chosen for audits at random, there is no way to completely eliminate the possibility of being audited.

2. Take charge

Many small practices leave the legwork of meaningful use to practice managers. While it is good to have some level of trust in the practice manager or whomever is in charge of the legwork, it’s always smart for physicians to verify for themselves that the work is being done and not simply assume.

3. Avoid discrepancies

The auditors are looking for discrepancies between what was submitted during the attestation process and what was actually done. Smaller practices might not have a dedicated administrative team to shoulder the needs of a Meaningful Use audit. The practice manager might not have the necessary skills to properly prepare for an audit. In this instance, physicians should step in to supervise or take charge of the audit preparation to ensure they are able to pass the audit successfully.

4. Ensure EHR certification

Your practice must have certified use of EHR technology on or before the date of any attestation period, approved by an authorized certification body. Simply being on the certified system prior to running meaningful use reports is not sufficient. To satisfy the certification requirements, you will need to have documentation from your vendor confirming the version you are using.

5. Respond promptly

Complying with the demands of an audit means accomplishing a long list of tasks. But there are also things physicians should avoid doing. It’s also important to respond right away after receiving an audit letter. Getting the necessary documents in order can be a time consuming process. Auditors generally allow 14 days to respond to an audit notice. Physicians should not to engage the auditors on their own, outside of the document exchange.

Schedule a free demo to know more about on Meaningful use Audit http://localhost/main-site-update/live-demo/