The professional Medical Coder/Billing Specialist of today faces many challenges and complexities when dealing with insurance contracts and carriers. The following tips will help pinpoint important concepts that we must continually manage in our fight for proper reimbursement for services rendered.
1. Review and copy patient's card at every visit. Verify eligibility, check demographics, and determine benefits and co-pay. One mistake in information can cost the practice precious time and money.
2. Embrace your coding manuals. Even with today's technology, we must review the basics to learn the coding guidelines and use them effectively. Make sure to link diagnosis code to the CPT code to show medical necessity for services performed. Continue to educate yourself and your staff and physicians to be more specific in the diagnosis codes.
3. Implement policies and procedures and train staff to process claims consistently and efficiently. Have short weekly correct claim and collection meetings with doctors and staff to motivate and stop problems before they escalate into thousands of uncollected dollars.
4. Master the proper use of modifiers and learn the ones accepted by each carrier. See billing guidelines on your carrier's Web site. Also review modifier rules; inappropriate use of modifiers is a common area for claim denials.
5. Understand the "NCCI" edits to prevent bundling denials. You can assess the carriers' acceptable diagnosis codes per service just as you can Medicare's LCDs and NCDs. On the web site, look under clinical or billing guidelines for this valuable information.
6. Read the managed care contracts and share the pertinent parts with the staff that is working with the information. Often, the front desk and/or billing specialists do not have access to the contract provisions. In many instances, you could be wasting time appealing an item that is non-covered by contract. Create an "insurance catalog" with a summary of the main provisions and contact information for easy reference. Make sure you include a copy of the fee schedule for each plan in which you participate. Enter the individual allowable for each in your computer system, if possible. Don't write off amounts that you could have collected had you known the contracted fees.
7. Set up a compliance programs as suggested by the federal government. Have an objective baseline audit to assess billing efficiency. A well developed and followed compliance plan could prevent penalties and interest should a governmental audit uncover billing errors. Recovery Audit Contractors (RACS) are companies contracted by CMS to audit physician charts and recoup funds for the Medicare system when they find they have paid claims in the past incorrectly. The contractors are paid a percentage of all funds recaptured for the Medicare trust fund. RACs are typically going back four years in their audits. PMI will cover RACs and PCS contractors in more detail during its Regional Conferences for Medical Office Professionals, presented across the country this fall.
8. Expedite claims processing by using the online services now available. Some systems allow practices to upload information on scheduled patients directly into the carrier's database to provide eligibility, coverage, etc. You may even find that you could get paid faster by filing claims directly to the carrier. Spending needless time on the phone is costly.
9. Develop a "denial tracking system" that categorizes each denial. This will pinpoint areas in the office that may need to be improved. You can project the amount of money uncollected because of incorrect patient demographics, posting errors, etc. Set up a system for timely review of aging reports. Unpaid claims and unapplied credits can get out of hand quickly. Setting up a timeline to monitor and review all accounts over 60 days will help keep your A/R under control.
10. Begin each day with a brief meeting to review problems detected the day before. Don't permit problems to escalate. Become passionate about coding and collections. Make sure the practice is receiving the proper reimbursement of claims. This will benefit the patient, the physician and you and your staff.
Maxine Inman Collins is a Coding and Billing Instructor with Practice Management Institute. For more information about PMI, visit www.pmiMD.com.