We are now deep into the Christmas Season and it is time for many practices and billing companies to close down for a short period so that the staff can take a few days off for holiday vacations.  This is an excellent time to sit down and write out your medical billing resolutions for 2007. 

Pull out those pesky health insurance contracts and go over them.  Look to see if they need updating due to changes in State or Federal laws.  If your State law has a 6 month timeframe to submit claims, and your contract allows 90 days, then have this changed.  If you are getting an increase in retroactive reviews, then see about adding a clause that protects you on this so if you have to send a claim, it won't be denied for timely filing.  Look at your reimbursement.  Maybe it is tied to an old Medicare allowable that has now increased.  Run a posting and aging report.  Look to see if you have been paid exactly how you are supposed to be paid.  Look to see how many claims are unpaid after 90 days from the claim submission.  You want to go after this money and talk to the insurance company about this.  Look at how many claims are applied to the deductible with the patient refusing to pay.  You may have agreed to give the insurance company a 60% discount to be contracted.  If the 40% is applied to the deductible and the patient doesn't pay, you just gave a 100% discount to the insurance company.  If you send the 40% to your debt collection agency and they collect 40%, you gave the insurance company and patient a 76% discount.  You might want to change your contract to increase your payment by 20% or have any discounts allowed be null and void if the patient does not pay you in 30 days of being billed and the patient pays the debt collection fees.  After all, why should you lose because the patient wants to be a pest and not pay?  Look for things that are missing in your contract such as exact timeframes for the insurance company to pay a claim.  One contract I just looked at said the insurance company can pay the doctors claims as promptly as possible.  Make sure you have exact timeframe for the insurance company to pay and have them define payment.  It could be when they send the check, it should be when you receive the check.  Make sure it outlines what happens when the claim is not paid on time.  This way you don't have claims sitting at the insurance company for years.  There are many other things to look for in a health insurance contract.  If you aren't experienced with health insurance contracts, hire someone that has the knowledge and experience, and above all, always have your contracts reviewed by a health insurance contract attorney.

Take a look at the practice A/R.  Why is there money still due after 90 days?  The older the account, the harder it will be to collect on the account.  If the doctor is not contracted and there has been no response from the insurance company in 60 days, maybe it is time to have the patient get involved.  After all, this is their debt we're talking about.  There are some Federal laws that specify if the claim has not been paid or denied in 60 days, it is deemed to be denied and THE PATIENT, has a limited amount of time to appeal their claim denial.

 If it is an auto accident or workers comp claim, maybe the accident was never reported.  Maybe the auto accident has a high deductible and the payment was applied to that.  Some auto carriers state they do not respond to providers that are not contracted with them, so they send the EOB to the patient.  If you are able to, check with the workers comp carrier.  They may give the excuse they never received the claim, so resend them via delivery confirmation.  I check with my Division of Workers' Comp web site and I can tell if the injury was never reported, which then allows me to bill the patient.  You see, the State cannot help me or the patient is there is no record of injury on file.  Also, Just because a patient says they were injured on the job, doesn't mean it is so.  I just worked a patient complaint to the State where he complained we are billing him and the patient complained he was injured on the job.  There was no record of the injury on file and both the patient's health insurance and workers' comp insurance are stating the other is responsible for payment of the claim.  The happy ending is, the patient lied and this was not a work related injury.  The patient's health insurance CEO responded with a nice check. 

Take a look at your appeals you are using.  They may need updating if they are not working for you.  Just like the drugs that are no longer working because the bacteria and viruses have become immune, so do our appeals.  Appealing a claim is like playing chess.  You have to stay several moves ahead of your opponent. 

I would like to suggest that in 2007, the insurance companies meet with us to discuss coming up with a way to help eliminate the problems we are all having with claims issues.  Not only does it cost us, it costs them to fight us when we fight back with a denial.  With over 600,000 doctors in the U.S., this is very costly to have a claim sent to the wrong insurance company because the patient is using an outdated card or the service was not a benefit.  Having the insurance company provide the practice with copies of all of it's benefit manuals, and to have access to the policies and procedures, as well as allowing us all to see if the patient still has coverage, regardless if the doctor is contracted or not, would go along way to keep the cost of healthcare down. 

Go over your Practice Financial Plan to see if it too needs updating.  Every practice should have one and it should be discussed with the patient at the time of service.  The Practice Financial Plan should discuss collecting of co-pays, deductibles, and uninsured patient payments. Whether there is a charge to send statements and if an account is sent to a debt collection agency, whether the patient pays the collection agencies fees.   It should address the claims processing system for par and non-par carriers, time payment plans, children of divorces, coordination of benefits, and allowing a reduction of an amount due when negotiating a contract with an uninsured patient.  The more you educate your patient, the less angry the patient should be when you have to end up sending them a bill, if your practice does this. 

Take a look at your expenses.  See where you can decrease them this next year.  Maybe by verifying information before you send a claim will cut back on your expenses.  It could cost you 17 cents to find out the patient's coverage terminated, versus treating the patient, sending a claim, then getting a denial 60 days later, then end up billing the patient.  Which is better to spend? 17 cents up front or $500 or more per patient on the back end?

Are you ready for the NPI and the new CMS 1500 form?  That will come so quickly once the new year is here. 

Have you reviewed your superbills and your billing software with the 2007 CPT and ICD-9 manuals to ensure you are now using current codes?  I just went to a local practice for an ear ache and they have codes on them that were deleted 2 years ago.  I listened to them wonder why their claims go unpaid. 

There are many things we can do now, before the new year arrives so that 2007 is a much better year than 2006.

Steven M. Verno, CMBSI, CMMB, CMMC, NREMT-P
Director of Reimbursement, Compliance Director
Medical Association of Billers