Being Smart Billers

Times are getting tougher.  CMS is getting tougher.  Abused procedures are not being paid anymore. 

Fraud is being fought at all levels.  Identities are to be safeguarded against theft.  Medical billers have to be smart and work smart. 

Working smart means you don't code it, bill it, and forget it.  Working smart means you VERIFY, VERIFY, VERIFY everything in the beginning.  You don't waste administrative time and money by working as a robot thinking you'll catch what you missed when you don't get paid or you get a denial.  To say, we do this on the backend is foolish and costly. 

How can it save you money when you have an employee making hours worth of phone calls trying to get info out of the insurance company or a patient that has moved and left no forwarding address, months after the patient was seen?  The window to fix things becomes smaller as time passes. 

James McCuen of The Coding Edge, Inc. an emergency medicine coding and billing company located in Sanford, Florida, told me many times in my training. VERIFY, VERIFY, VERIFY! What he taught me about verifying has been very beneficial and extremely fruitful over my career. 

One company I once worked for had everyone stop work to verify insurance, coverage with a previous visit and call patients listed as uninsured or self-pay.  It would take no more than an hour to do this and it paid in spades.  Mail returns were decreased, claim denials decreased, and appeals had stronger foundation.  The huge impact was an increase in revenue.  I consider James the Godfather of Medical Billing.  He is the "Merke Manual" of Billing. 

Last week, I received a phone call about an angry patient sent to debt collections.  He provided NO insurance information at the time of service.  Now, 5 years, he admits his visit to be work related.  When verifying this, there is NO record of injury on file at the Division of Workers Compensation as the employer never filed a first notice of injury.  If a claim is sent, it will no doubt be denied for timely filing and for not being a work related injury, so we'll be back to square 1.  What could we have done 5 years ago? 

Firstly, we could have looked at the chart to see what was documented.  When I looked at the CPT and diagnosis code I saw it was an open wound repair.  Did the doctor document how the wound happened?  Nope and the visit shows NO E-code used.  Some coders hate and refuse to use E-Codes but the E-Code could have given me a direction to follow.  For example E849.3 tells me this was an industrial place accident and E920.3 then completes the picture. 

Therefore the patient was cut at work using a knife.  Using the skills of Indiana Jones, you find out the patient worked at a local restaurant.  You call the employer to inform them that their employee has an unpaid work related injury and there is no record of injury on file. I find that informing the employer that you will report this to the Division of Workers Compensation will get the employer to file the report.  I then ask the employer for their worker comp insurance company. 

To verify, I call the insurance company and ask for the caseworker.  The caseworker has the report.  I need the case number and verification they won't deny the claim for timely filing because the employee withheld vital information.  I verify the claim address given by the caseworker.  So, in no time, a 5-year old mystery has been solved and verified.  Had this been done 5 years earlier, the claim would have been paid quicker.  The downside to this is that the employer would tell me about the road to take to get to Hades and the insurance company could deny the claim.  The account would be uncollectible.  The work to do this 5 years later took twice as much as it would have in the beginning.

Coders should NOT be afraid of using E-Codes.  They may not be a revenue generating code, but when used properly, they can generate revenue because they answer questions. For example, let's say a patient was in an auto accident.  Was the patient the passenger or driver?  When an insurance company gets an 800 or 900 series diagnosis code, they usually put the claim on hold pending information from the patient regarding the accident itself. If the patient doesn't respond, the claim could be denied.  Having the information through E-Codes could provide the answers the insurance company needs to keep the claim from being pended or denied. 

Last, being smart billers means we work unpaid or incorrectly paid claims rather than letting them rot and die.  Instead of trying to come up with ideas on how to increase revenue, we have to work what we have been given.  As was said by the California miners of 1849, "there's gold in them thar hills". Our gold is the accounts entrusted into our care and we need to work on those accounts in the earliest timeframe. 

For example, accounts that have not been paid or denied in 60 days should be investigated to find out why there has been no payment or an incorrect payment has been made.  Appeals always need to be followed up.  You must never give up and never surrender!  The moment you do, you and everyone else around you loses.   

The motto "Verify, Verify, Verify" really works and should be incorporated into every office every day. When you properly verify the information that you are given and bill correctly the first time, there should be no reason to not get paid. Your revenue is increased and denials will be decreased and you will have validity behind your work and especially your reputation. 

Steven M. Verno, CMBS, CEMCS, CMSCS , Professor, Medical Coding and Billing Instruction
Florida Metropolitan University. Director of Reimbursement, Coding and Billing Training and Consultant, Emergency Medicine Specialists.