Anecdotal evidence shows that up to 70% of claims submitted by a medical provider have either missing or incomplete information. These errors could be minor (think name mismatch) or more troublesome like missing Social Security or Medicare numbers that make adjudication impossible.

Surprisingly, under 30% of claims are returned for zero payment, according to the National Health Insurer Report Card. Most of the time, it’s because the patient is responsible for the balance against a deductible. Seven percent of claims are returned because of edits, and another 5% for some other type of denial. Even with a combined denial rate of 12%, billions are being left on the table.

The Medical Group Management Association pegs the cost to rework a claim at $25.00, but that more than half of denied claims are NEVER re-worked. For even the smallest medical practice, that’s serious money and money that the practice rightfully earned.

Knowing what each staff member roles are all critical to better claims performance. Improving any one of the roles or workflow processes within your office will truly pay dividends to your practice.

Everyone is part of the claims staff

You likely don’t consider providers, those who work directly with the patients/doctors, or your fitters to be part of your billing staff, but EVERY SINGLE member of your staff must do their part. The following shows the importance of each person in a DME/Orthotics Suppliers office as well as the responsibilities (but not limited to) of each.

1. Office Staff: provide a critical first step to claims. They need to be responsible for the following:

• Having a CORRECT physician order
• Obtaining correct patient insurance information to include: ID number (for primary & secondary insurance), Subscriber information -> name and DOB; Claims mailing address; Insurance telephone number
• If a patient is coming into the office to obtain the item then the Office Staff is responsible for ALL that the fitter is responsible for
• Ensuring that your Billing Staff/Company has the ALL necessary and correct information for keying and billing of the claim (ie: Correct paperwork, Correct Patient Demographics, Correct Item for billing, and Medical Records)

2. Fitters:  they also provide a critical role to ensure clean claims go out. Responsibilities include (but not limited to)

• Obtaining a correct ABN if necessary (Medicare patients)
• Ensuring the Product sticker is on the POD, or Manufacture Name and item number, along with the HCPCS code used for billing.
• Ensuring the POD is properly FILLED out (can provide the requirements for this upon request)
• Ensuring the Patients address (physical address, not PO box) is on the POD
• Obtaining MR specifically for BACK BRACES, KNEE BRACES, HIP Orthotics from the physician if working out of the clinic at the TIME of pick up.

3. Physicians: they are the bread to your butter when it comes to the items that typically get a pre-payment review and/or have certain medical necessity guidelines that MUST be met (ie- specifics on what needs to be in the medical records -> IE: for BACK BRACES & KNEE BRACES, to name a few)

• Responsible for making sure the item being prescribed is notated in the patients’ Medical Records from that visit and a notation as to WHY this item is being prescribed
• Responsible for making sure it is medically necessary for prescribing the item to the patient.
• Responsible for (Physician and/or Physician’s office) providing Medical Records to the Supplier at the time of the order and/or request.

4. Billing Staff: Once all the above occurs it’s now time to get that claim out the door! Responsibilities include (but certainly are NOT limited to)

• Ensuring that all proper paperwork is in order for the patients’ file (per the Supplier Handbook, Medicare)
• Ensuring that the item meets medical necessity requirements for the payer
• Scrubbing and auditing the claim prior to submission: proper HCPC’s being used, Diagnosis codes, modifiers, coding & Billing rules
• Submitting claims to insurance in a timely manner
• Following up on outstanding claims, working denials as they come in, making any necessary corrections to claims for resubmission

If each player in the game knows exactly what they are responsible for you will see a very effective and quick turn around on your claims; which lead to your cash flow being quicker and increased revenue.

Never underestimate the amount of resistance you may get to any change effort. Change is difficult, and people default into whatever they’ve done in the past. Driving meaningful change requires careful planning and implementation to help people understand why the change is occurring and why it’s important.

A  fitter and a Physician may think that the above really isn’t their job or necessary. As a consequence, charges may be underreported, items dispensed when not medically necessary (leaving the provider out of money for the item) , Items dispensed together, when it goes against billing rules (leaving the provider at a lost for that item), prolonging the claims process (delaying the provider’s money). Every staff member should understand his/her role in the billing practice. And every staff member does have a role.

Otherwise, you’re just leaving money on the table.

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