Medical Bill dispute - How to avoid and how to resolve

The crucial Guide of Disputing Medical Bills or Insurance Policy (Complete Guide)

Over the years, the majority of the folks are encountering complicated issues with medical billing.  Therefore, it is highly recommended that you have to know how to dispute a medical bill or denied insurance. Fixing errors in medical bills can be challenging as one need to follow the complete procedure.  These days, lots of people are frustrated with expensive hospital bills.  Thus, it is your responsibility to invest proper time in the proper analyzation and find out the errors in the bills.


For dispute, a person should make contact with a hospital and Fix the errors.  If you want to dispute a medical bill effectively then firstly you should find out the errors.  In order to know more regarding Disputing medical bills or denied insurance policy, then you should read forthcoming paragraphs properly.

Steps to be taken to resolve

How to review your Medical bills.

* All you need to review your bills. Make sure that you are analyzing all the parts in the statement invoice or medical bills. Most of the hospitals are charging a lot of additional costs like full-day rate of the room and other charges. 

* Check all the procedure code which they mentioned in invoice . Most of them cost based on the time and hence double verify the time you spend with provider and what is mentioned in the invoice.

* Check how much insurance are paid and what the left over from the insurance . Compare with insurance EOB.

* If any non covered service from insurance then you need to make contact with an insurer and get to know regarding the coverage.  Make sure that it is covering all the legitimate charges with ease.  A professional call will able to resolve the claim dispute with ease. 

* After that, you have to invest a significant amount of time in the research and check the fair price of medicines or injections.  If you want to raise any dispute, then it is your responsibility to show any proof.  All you need to make a relevant comparison and find out the Fair price of each medicine or other materials.

* You should have paid copay , coins, insurance Deductible and other patient responsibilities  at the time of visit but they charged again.

If you find any mismatch, follow the below procedures.

Make contact with a hospital

In order to raise the dispute, then it is your responsibility to call the hospital. All you need to share the biggest errors and what you find in he bills.  You need to keep essential notes like Name of the Person, and other crucial details like receipt which you paid or EOB reference regarding the bill. 

Most of the time the problem and dispute would be solved just by calling them directly.


Finance help - Make a call with Doctor office Manager or Billing office.

If possible, then the user should make contact with a doctor office manager and discuss problems with him.  Lots of medical office are offering financial assistance programs which are helpful for those who are raising the disputes.  According to professionals, almost 90% of the medical bills are associated with some sort of mistakes.  It is really dangerous that is creating a big hole in the pocket.


Sample Medical Dispute letter
   
Disputing complicated mistakes on the medical bill isn't the task of the kids as you need to invest proper time and efforts in the correction.  Make sure that you are following the proper terms and conditions. If you don't have proof, then you will not be able to get the claim.  It would be better to find out the sample medical dispute letter and raise a particular dispute. Make sure that you are sending a particular dispute letter to the billing department.  Lots of disputes are always associated with honest mistakes. According to professionals, you will able to dispute solved if you a claim within 90 days. 

Self Pay – No insurance cases

Before raising any dispute, the patient should pay close attention to the law of the state. Most of the hospitals are overcharging from the self-pay patient. Therefore, it would be better to obtain a particular sample of allowed amount for that procedure mainly Medicare. After that, you have to attach essential copies along with a letter. If you are providing proof such receipts, fee schedule document, then one will able to get the dispute very easily.

Currently, if you don't have any Insurance policy, then it would be better to pay the bill via Cash. Lots of healthcare providers are giving a discount to every customer.  If you are negotiating, then it would be better to initiate with a lower offer.


Raise a particular complaint

It is highly recommended that you should take the dispute to another level.  If a claim is expensive, then you must find out the insurance codes from the bills and allowed amount from the common insurance.


Going to attorney

Its not advisable to attorney for small amount, If you want to avoid the hassle, then you should hire a personal attorney who would be helpful for you.  Before hiring any advocate, one should discuss the fee with him/her. Majority of the lawyers are charging a fee on an hourly basis. User will able to find a personal lawyer from the Internet


How do I dispute an old medical bill?

Want to dispute Old medical bills? You will able to rise for the dispute, but chances of success are relatively lower.  Make sure that you are following the proper rules & regulations of the hospital. For effective outcomes, one should make contact with a debt attorney who will assist you in raising the dispute against old medical bills.  If you have evidence, then you will able to get the dispute solved.  According to professionals, it is a little bit complicated or lengthy process to obtain the claim. You have to fight with the hospitals.  It is your responsibility to make contact with the hospital related to the dispute. It would be better to grab a complete copy of incorrect bills with them.

Proper research is mandatory

Before initiating any dispute, it is your responsibility to invest proper time in the research.  You should check the current worth of medicines, injections, and other things. If you want to claim instantly, then the user must make contact with an anesthesiologist office.

Moving further, if you don't want to invest precious time in the research, then the user should find out a personal attorney who will able to raise the dispute.  An experienced lawyer would be helpful  in filing a particular appeal.  He will surely file the complaint according to the proper instructions.



Avoiding Dispute tips

Always keep the all the records related healthcare whether its from insurance, hospital or Doctor office receipt. That would solve most of the problem and most importantly your time.

Medical billing specialist salary - How much they can earn and requirements

Medical billing specialist salary

Becoming a proficient medical biller isn't easy as one should invest proper time in learning.  Specialists are relatively expert in verifying medical bills, claims and insurance and patient invoices.  Being a medical biller, it is your responsibility to invest proper time in the internship. This particular job requires a lot of important things, and basic degree and certificate in code or billing specialist.


 According to professionals, a proficient medical biller is getting anywhere between $3k to $6k (Big practice, big companies and hospitals) per month as salary.  No doubt, salary depends on a lot of important facts like certifications, additional skills, and education as well mainly with experience and your position.  Therefore, a person must grab certificate courses and increasing the knowledge in different domain that is proven to be mandatory. After becoming a proficient medical biller, one will able to work on not paid aged claims and which would be making him specialist.


So we could tabulate the Medical billing specialist salary as below, All are given per month.

1. Entry level - $2.5k - $3.5k ( Hourly basis too)
2. Mid level - 4.5k - $5k
3. Experience level - Specialist in one area - $6k and More

 How much does a medical billing specialist make an hour?

According to researchers, coders or medical billers are high in the demand.  They are making $16.42 per hour.  Federal Government is offering a lot of incentives to the potential users to attract more people in the company. In order to become a proficient medical biller, then you must be pass out from the college.   Medical billers are growing with at least 20%.  It is a little bit tough job where the user needs to maintain the patient records and handling the medical records, scheduling patients and entry job as well. If you are Medical coder need to be proficiency with CPT and ICD 10 code and insurance coverage policy according to thier edit.   They have to analyses super billing and visit note and covert into codes according to the history of treatment and diagnoses as well.

The pay scale of Medical Billers

No doubt, wages of the medical billers is growing continually.  A professional or experienced medical biller is earning $34,160 yearly. All things depend on the location, level of experience, and skills.  Top medical billers are earning almost $56000 each year. If you are one who wants to become a proficient college degree, then a college degree is required to enroll in the job. After that, it is your responsibility to invest a significant amount of time in learning through certification and get the required knowledge.



• How much do billers get paid?

You will find a lot of certified Hospitals, which is employing the proficient Medical billers to calculate the overall worth of the services.  They are preparing essential bills and sending them to the insurance and patients.  Proficient billers are already familiar with a lot of important things like fee structure and other CPT , ICD codes.  They have an answer to every question related to the denial management.  Most of the professional medical billers are working in surgical or general hospitals.

It is a great opportunity for those who want to complete their studies, along with work.  Medical billing system totally depends on the medical coders. Insurance coverage is making the use of essential codes for the coverage. Salary of a medical biller always depends on the certifications, level of experience, skills as well. If you want to maximize the salary, then it is your responsibility to complete an essential program. As we previously said salary is totally differ to person to person.


Requirement for Medical billing specialist

Following are some essential things that will assist you in becoming a proficient medical biller specialist.

* Level of Qualification

Majority of the small clinics are hiring the coders or billers without prior experience and high level of education.  They are just asking for the certificate training program only. You will able to complete specific training using online websites. Lots of colleges or technical schools are out there where one can learn regarding medical terminology.  This specific program is associated with basic information related to physiology and human anatomy.

** Requirements of career

A person must obtain medical coding and billing degree, which is proven to be essential for a newbie. All you need to find out a perfect institution from where you can learn more regarding codes and another medical billing process. I dont say its must but it helps to get the job easily.

** Education qualification

A medical biller must have essential things like a post secondary certificate and an essential degree as well.  These crucial things will assist you in earning more salary.

** Certifications

If you are obtaining at least one or two coding and billing certification, then you will be surely able to earn a lot of money.  Experienced and skilled persons are also earning huge amount of money. Certification course usually take  6- 12  months.

AR specialists specialize in one or more of the following areas:

• Claims reviewer. Provides expert advice to healthcare providers.

• Coding reviewer. Prepares claims for doctors to submit to the claims. Checking ICD and CPT combination and document verification.


** Experience is must

After getting the degree, it is your responsibility to invest proper time in the internship and get the experience in all domain charge entry, payment posting, denial management with medical code knowledge. Additional training has become mandatory for those who want to become a proficient medical biller.

Is it easy to get into Healthcare industry ?

Absolutely No, These days, lots of organizations are making the use of Paper-based system that is a little bit complicated and time-consuming. Some clinics or hospitals are packed with thousands of patients.  Neither Doctors nor their staff has time for such a tougher task. Therefore, lots of hospital and clinicians are opting for medical billing and coding process.  According to professionals, certified medical billing companies are investing a significant amount of time in the precious HER technology as it is quite better than others. 

Medical billing and coding both are different things.  To become a professional medical biller, then the user needs to invest proper time in the learning.  You need to consider various diagnosis and procedure as well.  Here I have recapitulated vital things related to medical billing and coding where you have a glance.



How is Job Growth ?

Medical billers are on its hype, and a potential biller is earning a significant amount of money. If a person has knowledge related to crucial codes, then he/she will able to become a perfect medical biller with ease.  It is considered a little bit tough task where you need to maintain the significant amount of information in the records. Hospitals are making the use of electronic health records.

Conclusive words

Lastly,   Medical billing has become one of the most important things in hospitals. For such a process, every hospital is looking for the proficient biller.  They are keeping the records and giving information to the insurance companies for the coverage.  Sometimes, hospitals are paying a little part of the insurance, which is known as co-paying.  Along with codes, you have to make the use of software where one can easily keep the records.

MSP Billing Procedures - Detailed reveiw

a. General Requirements

When Medicare is the secondary payer, the claim must first be submitted to the primary insurer. The primary insurer must process the claim in accordance with the coverage provisions of its contract. If, after processing the claim, the primary insurer does not pay in full for the services, the claim may be submitted to Medicare electronically or via a paper claim for consideration of secondary benefits.
Note: It is the provider's responsibility to obtain primary insurance information from the beneficiary and bill Medicare appropriately. Claim filing extensions will not be granted because of incorrect insurance information.

The Medicare paper claim must include a copy of the primary insurer's explanation of benefits (EOB). The EOB should include the following information:

name and address of the primary insurer
name of subscriber and policy number
name of the provider of services
itemized charges for all procedure codes reported
a detailed explanation of any denials or payment codes
date of service

NOTE: A detailed explanation of any primary insurer denial or payment codes MUST be submitted with the claim and EOB. If the denial/payment code descriptions or any of the above information is not included with the claim, it may result in a delay in processing or denial of the claim.

If the beneficiary is covered by more than one insurer primary to Medicare (e.g., a working aged beneficiary who was in an automobile accident), the explanation of benefits statement from BOTH plans must be submitted with the claim.

Are Your Medicare Secondary Payer (MSP) Claims Rejecting?

Medicare Secondary Payer (MSP) refers to instances in which Medicare does not have primary responsibility for paying the medical expenses of a Medicare beneficiary. This is because the Medicare beneficiary may be entitled to other coverage, which should pay the primary health benefits.

Medicare secondary claims can be submitted electronically. However, Palmetto GBA has rejected some claims because there was a mismatch between the MSP Type submitted on the claim and the specific patient's Medicare record. Below are some examples of situations that you may wish to verify when you receive these Medicare rejections:

Are we required to submit our Medicare Secondary Payer (MSP) claims electronically?

Answer:
Yes. Unless you have been approved to submit hard copy claims to Medicare, submit all Medicare claims electronically, including MSP claims. An exception to this requirement is when a patient has two or more payers who are primary to Medicare. In situations where Medicare is the tertiary payer, these claims may be submitted hard copy.

The ASC v5010 format allows for electronic submission of primary payer information for MSP claims. Palmetto GBA also offers the PC-ACE Pro32 EDI billing software, which supports electronic submission of MSP claims.



Do you routinely submit claims containing the same MSP Type (example: MSP type 47) when Medicare does not show this to be a valid MSP type for the specific patient?

If you submit your claims to a clearinghouse, does your clearinghouse understand that claims must be submitted with the correct MSP Type?

Is your patient covered by Medicare as an Aged Worker (Type 12), but claims for the patient are being submitted as Disability (Type 43)?

Was your patient's injury related to Workers' Compensation (Type 15), but you submitted the MSP claim as an Aged Worker (Type 12)?

If you submit claims through an electronic clearinghouse, make sure you provide the clearinghouse with the correct MSP Type for each claim. If you are still receiving rejections from Medicare, verify that your clearinghouse is submitting the MSP Type you provided for each patient.

If you answered 'Yes' to any of the above questions, your Medicare MSP claims are most likely rejecting because there is a mismatch of the type submitted and the Medicare MSP files. This situation can drastically impact the cash flow for your office. Below are the loops and segments where this information should be located in the electronic claims format:

b. Electronic Claim Submission

To submit Medicare Secondary Payer (MSP) claims electronically, please refer to the American National Standards Institute (ANSI) ASC X12N Implementation Guide. To learn how to report MSP claims in your software, contact your software vendor.

The following records are required in order to get a MSP claim to process. Other records may also be necessary depending on the information obtained by the primary insurer.  When sending a MSP claim electronically, the EOB from the primary insurance does not need to be sent separately.

Data Explanation	ANSI ASC X12	837 Version 5010
Payer Paid Amount	The amount paid by the primary insurer	2320 AMT02 and 2430 SVD02
Remaining Patient Liability Amount	The amount the patient is liable for	2320 AMT02 and 2430SVD02 (one or the other but not both)
Adjudication date	The date of payment or denial by the primary payer	2330B DTP03 or 2430 DTP03
Adjustment Group Code	The code identifying who is responsible	2320 CAS01 or 2430 CAS01
Claim Adjustment Reason Code	The code identifying the detailed reason the adjustment was made	2320 CAS02 or 2430 CAS02  (one or the other but not both)
Monetary Amount	The amount of the adjustment	2320 CAS03 or 2430 CAS03 (one or the other but not both)
Primary Insurer	The name of the primary insurer	2330B NM1
Value Codes (Part A)	The code indentifying the MSP Insurance type	2300 HI
Condition Codes (Part A)	The code indentifying accident and retirement information	2300 HI
Occurrence Codes (Part A)	The code indentifying other Insurance information	2300 HI

b.1 Paper Claim Submission

When submitting a paper claim to Medicare as the secondary payer:
The CMS-1500 (02-12) claim form must indicate the name and policy number of the beneficiary's primary insurance in items 11-11c. Please refer to Chapter 9 for additional instructions on completing the CMS 1500 (02-12) claim form.

Providers must submit a claim to Medicare if a beneficiary provides a copy of the primary explanation of benefits (EOB). The claim must be submitted to Medicare for secondary payment consideration with a copy of the EOB. If the beneficiary is not cooperative in supplying the EOB, the beneficiary may be billed for the amount Medicare would pay as the secondary payer.

Providers must bill both the primary insurer and Medicare the same charge for rendered services. If the primary insurer is billed $50.00 for an office visit and they pay $35.00, do not bill Medicare the remaining $15.00. Medicare must also be billed for the $50.00 charge, and a copy of the primary insurer's EOB must be attached to the completed claim form.

c. Determining Secondary Liability

Medicare may pay secondary when the primary insurer does not pay the entire charge. Medicare will not pay, however, if the provider accepts or is obligated to accept the primary insurer’s payment in full or if the primary insurer pays the charge in full.

If the primary insurer does not pay in full, Medicare’s secondary liability is calculated follows:

1. Compare the billed amount to the primary allowed amount and limiting charge amount (non-assigned claim only). Subtract the primary paid amount from the lowest number.

2. Determine what Medicare would pay if they were the primary payer.

3. Take the higher of the primary allowed amount or the Medicare allowed amount. Subtract the primary paid amount.

4. Compare the results of the first three steps. Medicare’s liability is the lowest of the three numbers.
If the primary insurer does not pay for certain services because the services are not covered by the plan, the benefits have been exhausted, or the primary insurer’s payment is applied to the beneficiary’s deductible, Medicare may pay primary benefits for covered services. The explanation of benefits from the primary insurer must state a valid reason for not paying certain services in order for Medicare to consider primary payment.

When the primary insurer’s reason for denial states that a service is not payable because it is considered an integral part of another service or part of a primary procedure (or similar message), Medicare has no liability. An exception may be made when the primary insurer holds the beneficiary responsible to pay for the service

c.1 Patient Liability when Medicare is Secondary

Agreements with all insurance companies must be reviewed prior to balance billing a patient for a Medicare secondary claim. Consider the following before attempting to bill the patient or try using our interactive form.

Non-Participating Providers

Non-participating with both the primary insurer and Medicare – You may bill the lower of the limiting charge amount (115% times the Medicare non-participating amount) or the billed amount.
Non-participating with Medicare only - You may bill an amount up to the primary insurer’s allowed amount.

Participating Providers

Participating with both the primary insurer and Medicare OR participating with Medicare only - You may bill the patient an amount up to the Medicare Fee Schedule allowance.

c.2 Determining Who Pays When Coverage Changes During Hospital Stay

When a patient’s coverage changes from one insurer to another during the course of a hospitalization, which insurance is financially responsible for the care? Part A and Part B handle this situation differently.

Example: Patient has Medicare on 10/31, the same day they were hospitalized for a two week stay. On 11/1, the patient’s insurance coverage changes to a HMO.

Part A: Whichever insurance the patient had on the day of admission is the insurer responsible for the entire hospital stay. Therefore, Medicare would be responsible for the entire Part A bill.
Part B: Responsibility shifts from one insurer to the other on the exact date of termination and enrollment. So in this example, Medicare would be responsible only for services rendered on 10/31, and the HMO would be responsible for physician services rendered 11/1 and after.

c.3 Medicare Deductible on MSP Claims

Medicare applies money to a beneficiary’s deductible regardless of primary insurer benefits. This means that even if the same charge is paid in full or in part by the primary insurer, Medicare’s fee schedule amount will be applied to the beneficiary’s deductible.

Medicare has certain rules that explain how much a patient is responsible for when Medicare deductible is applied on a Medicare Secondary Payer (MSP) claim. These rules differ from the standard guidelines in regard to the patient’s liability when Medicare deductible is applied.
Assigned claims – You may bill up to the Medicare fee schedule, minus payments made by the primary and secondary insurance.

Non-assigned claims

Non-participating with both the primary insurer and Medicare – You may bill the lower of the limiting charge amount (115% times the Medicare non-participating amount) or the billed amount.
Non-participating with Medicare only – You may bill an amount up to the primary insurer’s allowed amount.

d. Speed Payment of MSP Claims

Do your Medicare secondary payer (MSP) claims take longer than others to process?
Do you struggle completing electronic claims when Medicare is the secondary payer?
The number one error we see on electronic MSP claims involves the trailer type for the primary insurance. The trailer type is incorrectly keyed.

Take a moment to familiarize yourself with the trailer types listed below:
12 – Working Aged
13 – End Stage Renal Disease/ESRD
14 – Automobile/No Fault
15 – Worker’s Compensation
16 – Federal
41 – Black Lung
42 – Veteran’s Administration
43 – Disability
47 – Liability
Spending a moment double checking the trailer type is time well spent!

How is a Medicare secondary payment determined?

Q. How is a Medicare secondary payment determined?
 
A. The Medicare secondary payment is determined by a series of calculations and comparisons. The primary insurer’s claim processing details on their explanation of benefits (EOB) is needed to determine the secondary payment amount.
Three calculations are made per procedure. The lowest of the three is the secondary payment.
Calculation 1
If the Obligated to Accept payment in Full (OTAF) amount is present,
• Determine the lowest amount between the OTAF amounts vs. the billed amount of the service.
• Use the lowest amount listed above minus the primary paid amount.
If the OTAF amount is not present,
• Use the billed amount of the service minus the primary paid amount
Calculation 2
Determine Medicare's primary payment would be:
• Note the Medicare allowed amount for the procedure.
• If applicable, subtract Medicare's deductible indicated in the DEDCT column.
• Multiply the difference by the appropriate percentage: 62.5 percent, 80 percent, or 100 percent, depending on the procedure code.
Calculation 3
Compare the Medicare allowed amount to the primary insurer's allowed amount and select the higher allowed amount.
Using the higher allowed amount from listed above, subtract from the primary insurer's paid amount.
• The Medicare secondary payment is equal to the lowest payment amount resulting from calculation #1, #2 or #3 above.
Note: You may also utilize the Medicare secondary payer (MSP) calculator

Non practitioners billing - Incident service - Medicare guidelines

"Incident to" and the Initial Visit - Evaluation & Management (E/M) Service Guidelines

Novitas Solutions Medical Review (MR) Department has observed a continued trend of the utilization of non-physician practitioners to perform initial office visits as "incident to" services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:

"I have reviewed the Physician Assistant's note, examined the patient and agree with..."

“Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows……”

This is incorrect use of the non-physician practitioner and incorrect billing under the "incident to" guidelines. This article explains the Medicare definition of "incident to" services and the criteria that must be met to properly bill "incident to" services.

An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the "incident to" guidelines. As outlined below, the physician MUST perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.

Novitas Solutions MR will deny or down code claims for initial office visits billed as "incident to" when a non-physician practitioner performs the initial history and physical .

CMS defines "incident to" services as “services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”

In order to be covered as "incident to" the physician’s service, the following criteria must be met:

services must be an integral, although incidental, part of the physician’s professional service,commonly rendered without charge or included in the physician’s bill,of a type that are commonly furnished in physician’s offices or clinics, and furnished by the physician or by auxiliary personnel under the physician’s direct supervision "Incident to" services must be performed under the direct supervision of the physician. CMS directs that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

CMS further indicates, under direct supervision, “This does not mean, however, that to be considered "incident to", each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be "incident to" when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.” Hospital and skilled nursing facility services cannot be billed as "incident to" at any time.



Can ancillary staff that provides a service 'incident to' a physician or non-physician practitioner sign the documentation?

Answer:
No. The physician or non-physician practitioner, who is responsible for the patient's care, must sign the documentation. See our E/M Help Center article ‘Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices’ for more information.


Can incident to occur in place of service (POS) 19 or 22 (outpatient hospital)?

Answer:
No. Incident to services are limited to the office setting (place of service (POS) 11). However, if a provider establishes an office in a larger outpatient setting, the 'incident to' services and requirements are confined to this discrete part of the facility designated as his/her office.

Reminder:

Hospital Based Physician (employees of the hospital)
The hospital is billing and 'incident to' does not apply
Submit POS 19 or 22
Group of physicians (not employees of the hospital) and the office is confined to the discrete part of the facility
The physicians are incurring the expense and 'incident to' would apply
Submit POS 11 (not POS 19 or 22)




Can the modifier that indicates 'increased procedural services' be submitted with an E/M service when a physician spends an extended amount of time with a patient?

Answer:

No. CPT modifier 22 may only be submitted with services that have a zero, 10 or 90 day post-op period.  

Based on E/M documentation guidelines, time is not a controlling factor in determining the level of E/M service unless more than 50 percent of the visit was spent counseling and/or coordinating care.


‘INCIDENT TO’ BILLING CLARIFICATION

Louisiana Medicaid issues the following clarification for billing services as ‘incident to’ a physician’s professional service.

• ‘Incident to’ a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness. This means that the physician, under whose provider number a service is billed, must perform or be involved with a portion of the service billed. Physician involvement may take the form of personal participation in the service or may consist of direct personal supervision coupled with review and approval of the service notes at a future point in time.

• Please note that direct personal supervision by the physician must be provided when the billed service is performed by auxiliary personnel. Direct personal supervision in an office means the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the service is performed.

• In addition to services performed by non-physicians, such as nurses or aides, services performed by other non-physicians whose licenses allow them to perform physician-type services (Nurse Practitioners, Physician Assistants, and others) may qualify as ‘Incident to’ a physician’s service. However, it is important to remember that, even if the physician supervision requirements are met, the service does not qualify as ‘Incident to’ unless the physician performs or is involved with some portion of the service billed.

• In situations where non-physicians such as an NP or PA provides all parts of the service independent of a supervising physician’s involvement, the service does not meet the requirements of ‘Incident to’ billing. Instead, the service must be billed using the provider number of the non-physician practitioner and must meet the specific coverage requirements of the practitioner’s scope of practice.

When to file an appeal - Big question in Medical billing

Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.

Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.

Appeal level	Time limit for filing request	Where to file an appeal
First level: Redetermination	120 days from the initial claim determination	Medicare administrative contractor (MAC)
Second level: Reconsideration	180 days from the redetermination decision	Qualified independent contractor (QIC)
Third level: Administrative law judge hearing (ALJ)	60 days from the date of the reconsideration decision               Submit request by: Monetary threshold for requests filed before December 31, 2014: $140 Monetary threshold for requests filed on or after January 1, 2015: $150	Office of Medicare Hearings and Appeals
Fourth level: Medicare Appeals Council	60 days from the date of the ALJ decision	Departmental Appeals Board
Fifth level: Judicial review:	60 days from the date of the Medicare Appeals Council decision                                 Submit request by: Monetary threshold for requests made before December 31, 2014: $1,430. Monetary threshold for requests made on or after January 1, 2015: $1,460.	Federal District Court

Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

Part B clerical reopening

A clerical error could occur when one of the following happens to your claims:
• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Misapplication of a fee schedule
• Computer errors
• Denial of claims as duplicates which party believes incorrectly identified as duplicate
• Incorrect data items such as provider number, modifier, date of service

There are two options for conducting a clerical reopening of a claim:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.
• For the IVR reopening request help sheet, click here .
• For reopening requests in writing, use the clerical reopening .

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.

Second level of appeal: Reconsideration

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ)

If at least $140 remains in controversy following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.

Fourth level of appeal: Review by the Medicare Appeals Council

If a party to the an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested.
The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.

Fifth level of appeal: Judicial review

If $1,400 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.
• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.



Difference between appeal and Grievance

Appeal: A type of complaint a member (or an authorized representative) makes when the member disagrees with an action taken or wants Amerigroup to reconsider a decision. Complaint: Any expression of dissatisfaction to a Medicare health plan, provider, facility or Quality Improvement Organization (QIO) by an enrollee made orally or in writing. This can include concerns about the operations of providers or Medicare health plans such as: waiting times, the demeanor of health care personnel, the adequacy of facilities, the respect paid to enrollees, the claims regarding the right of the enrollee to receive services or receive payment for services previously rendered. It also includes a plan’s refusal to provide services to which the enrollee believes he or she is entitled. A complaint could be either a grievance or an appeal, or a single complaint could include elements of both. Every complaint must be handled under the appropriate grievance and/or appeal process.

Grievance: Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare  health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame.

An Appointment of Representative (AOR) Form is required if someone other than the member is filing a complaint or appeal on behalf of the member. There are some exceptions: Medical Doctors are not required to fill out an AOR when initiating an appeal for a Part C (Medical Appeal). However, The Centers for Medicare & Medicaid Services (CMS) require an AOR from Medical Doctors for Part D (Pharmacy) appeals, except for expedited Part D appeals. Personal Representative Forms will not be accepted in lieu of an AOR. The appeal timeframe will start once the AOR is signed by the member and representative and returned to the Medicare Complaints Appeals and Grievances (MCAG) department.



Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim
Q. Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim?
A. Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696 external link). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal.
Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal.
The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
• Congressional staff members,
• Family members of a beneficiary,
• Friends or neighbors of a beneficiary,
• Member of a beneficiary advocacy group,
• Member of a provider or supplier advocacy group,
• Attorneys, and
• Physicians or suppliers.


Additional records submission during appeals FAQ

Q: During the appeal process, at what point can additional records be submitted?
A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery auditor (RA) determination, the RA will forward the medical records they receive to the affiliated contractor, or First Coast Service Options Inc.

Departmental appeals board (DAB) FAQ
Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?
A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.

Amount in controversy (AIC) FAQ
Q: What does the term "amount in controversy" mean?
A: The amount in controversy (AIC) is the minimum threshold amount in dispute you must have in order to request the administrative law judge (ALJ) and judicial review levels in the appeal process. Click here external link for the current AIC for the ALJ level; click here external link for the current AIC for the Federal judicial review.

What is considered a relevant appeal FAQ
Q: Is there a resource for providers or beneficiaries that outlines what services or items can be appealed?
A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the resource listed below.

Resubmission of denied claim FAQ
Q: Can we resubmit a claim that was denied by the recovery auditor (RA) if we determine the incorrect code was submitted?
A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service.

Reason codes for denied claims FAQ
Q: What are the reason code ranges for claims when they have denied?
A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a "5". If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a "7", which is a non-medical denial.
Click here for the description of a Medicare Part A reason code. Enter the reason code into the box and click the submit button.


Appeals FAQs
Q: Can I resubmit or adjust a claim when an appeal is processing?

A: It is not recommended to submit a new or adjusted claim when the appeal is pending.
Resubmitting or adjusting the claim does not reduce the processing timeframe for the appeal. In fact, it may result in an appeal dismissal or delay the processing time for the outstanding appeal. This matter affects appeals at various levels.
Note: Adjustments to the initial claim or claim resubmission for the same service on the same date of service do not extend the appeal rights on the initial determination. Click here for information on when to file an appeal for each of the five levels.

How to fill/completing the PWK fax/mail coversheet

First Coast Service Options' (First Coast's) claims department is receiving a high volume of invalid or unnecessary PWK (5010 paperwork segment) fax/mail coversheets. If a coversheet is received containing inaccurate, incomplete, or invalid information, the coversheet will be either faxed or mailed back to the originating source, but without the documentation. Coversheets returned in this manner should not be resent; instead, the provider should await an additional documentation request (ADR) before submitting the documentation again to First Coast.

PWK issues

In other cases, the coversheets and additional documentation are not able to be appropriately attached to a claim due to several reasons. The following list has been developed to assist you in avoiding these situations.

1. PWK coversheet is received, completed accurately with documentation, but the claim was submitted without the indicators in the PWK loop.

• This will not allow us to assign the documentation in the system to the appropriate claim. If the claim requires documentation, an ADR letter will be sent and providers will need to respond to the letter.

2. PWK coversheet is received with the related documentation attached and a copy of our additional documentation request (ADR) letter. Again, the PWK loop indicators are not on the claim.

• There are two issues here: 1) without the PWK loop completed, the claim will not suspend to look for any anticipated documentation. Most importantly 2) the claim has already suspended for additional documentation; therefore, providers only need to respond to the ADR letter with appropriate documentation.

3. PWK coversheet is received with a request for an appeal/redetermination in the information box.

• The PWK process may only be used on initial claim submission. PWK cannot be used to bypass the standard appeals process. Please use the appropriate level of the appeals process if your claim has been denied or you need to make adjustments/corrections. Appeal requests submitted via the PWK fax/mail process will not be acknowledged.

4. In all of these instances, since the PWK fax/mail coversheet and/or claim is not being submitted correctly or with the correct information, the supporting documentation submitted to us is not being utilized to adjudicate the claim. Also, since in most cases this is outside of the standards for PWK, providers affected by these scenarios will not receive a response concerning the outcome or lack thereof.

5. Our internal claims area is being negatively impacted as well as our electronic storage capacity is being overwhelmed by unneeded, unusable documentation. Providers affected by this will more than likely never receive any indication of the negative impacts this is having on their claims.

Reminders

Here are some items to verify before faxing or mailing your form:

• Verify you have indicated the ACN (attachment control number [submitted in the PWK06 segment]), DCN (document control number [Part A]), ICN (internal control number [Part B]), the beneficiary's health insurance claim number (HICN)/Medicare number, billing provider's name and NPI (national provider identifier) on the fax/mail coversheet.

• Include an address to mail the coversheet to, in case we are unable to fax it back to the originating number.

• Fax users: ensure to send your PWK fax coversheet and documentation to the appropriate locality fax line. Example: claims for providers in Puerto Rico should be faxed to the Puerto Rico fax line; claims for Florida providers to the Florida fax line; etc. If a coversheet is received into the incorrect faxination account, we will be unable to locate the claim.

• Do not send in documentation without the completed fax/mail coversheet.

• Do not use the PWK coversheet for any reason other than the PWK process.

2015 Annual Update for the Health Professional Shortage Area (HPSA) Bonus - Update from Medicare

Provider Action Needed:

Change Request (CR) 8942 alerts you that the annual HPSA bonus payment file for 2015 will be made available by the Centers for Medicare & Medicaid Services (CMS) to your MAC and will be used for HPSA bonus payments on applicable claims with dates of service on or after January 1, 2015, through December 31, 2015. You should review Physican Bonuses below , whether you need to add modifer AQ to your claim in order to receive the bonus payment, or to see if the ZIP code in which you rendered services will automatically receive the HPSA bonus payment. Make sure that our billing staffs are aware of thes changes.

HPSA Designations

The Health Resources and Services Administration (HRSA) published an updated Federal Register Notice on June 27, 2013, that contains important information about new and withdrawn HPSA designations. For purposes of the Medicare Physician Bonus and the Medicare Surgical Bonus programs, changes in designation status are effective for dates of services on and after January 1 of the year following the designation date. Therefore, areas whose designation is shown as “Withdrawn” on the June 27, 2013 Federal Register list, remain eligible for the HPSA bonuses through December 31, 2013.

MMA Section 413(b) required CMS to revise some of the policies that address HPSA bonus payments. Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the HRSA as primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act. In addition, for claims with dates of service on or after July 1, 2004, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. If a zip code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.

MMA Changes

Effective January 1, 2005, a modifier no longer has to be included on claims to receive the HPSA bonus payment, which will be paid automatically, if services are provided in ZIP code areas that either:

• Fall entirely in a county designated as a full-county HPSA; or
• Fall entirely within the county, through a USPS determination of dominance; or
• Fall entirely within a partial county HPSA.

However, if services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.

The following are the specific instances in which a modifier must be entered:

• When services are provided in ZIP code areas that do not fall entirely within a designated full county HPSA bonus area;
• When services are provided in a ZIP code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision;
• When services are provided in a ZIP code area that falls partially within a non-full county HPSA;
• When services are provided in a ZIP code area that was not included in the automated file of HPSA areas based on the date of the data run used to create the file.

To determine if a service will automatically qualify to receive the bonus payment, review the information provided on the CMS Web site.  The HRSA website should be reviewed for the most recent designations.  Physicians may also use the HRSA website designations when making the decision on whether or not to include the HPSA modifier on their claims.

Some points to remember include the following:

• Medicare contractors will base the bonus on the amount actually paid (not the Medicare approved payment amount for each service) and the ten-percent bonus will be paid on a quarterly basis.
• The HPSA bonus pertains only to physician's professional services. Should a service be billed that has both a professional and technical component, only the professional component will receive the bonus payment.
• The key to eligibility is not that the beneficiary lives in a HPSA nor that the physician's office or primary location is in a HPSA, but rather that the services are actually rendered in a HPSA.
• To be considered for the bonus payment, the name, address, and ZIP code of the location where the service was rendered must be included on all electronic and paper claim submissions.
• Physicians should verify the eligibility of their area for a bonus before submitting services with a HPSA modifier for areas they think may still require the submission of a modifier to receive the bonus payment.
• Services submitted with the AQ modifier will be subject to validation by Medicare.

Affordable Care Act of 2010 Changes (New for January 2011 for the HSIP Bonus)

The Affordable Care Act of 2010, Section 5501 (b)(4) expands bonus payments for general surgeons in HPSAs.  Effective January 1, 2011 through December 31, 2015, physicians serving in designated HPSAs will receive an additional 10% bonus for major surgical procedures with a 10 or 90 day global period.  This additional payment, referred to as the HPSA Surgical Incentive Payment (HSIP) will be combined with the original HPSA payment and will be paid on a quarterly basis.  Modifier AQ should be appended for these major surgical procedures similar to claims for the Medicare original HPSA bonus when services are provided in ZIP code areas that do not fall entirely within a full or partial county HPSA.

Some points to remember:

•  The current HPSA physician bonus program requirements will remain intact.
• Medicare contractors will identify and pay the additional bonus on eligible services rendered in eligible ZIP code areas based on the HPSA ZIP code file as of December 31^st of the prior year.
• Medicare contractors will calculate the bonus amount based on the amount actually paid for the service, not the Medicare approved amount

Services submitted with modifier AQ will be subject to validation by Medicare.

Do we need to update the addition office address to insurance?

 
ADDRESS CHANGE or OTHER PRACTICE INFORMATION:

Yes. In order for CarePlus to maintain accurate participating provider  irectories and also for reimbursement  purposes, all changes to address or practice information should be submitted in writing to CarePlus as  soon  as  possible.  Notices  of  any  changes  must  adhere  to  time  frames  outlined  in  the  participation  agreement.

Changes that require notice to CarePlus may include, but are not limited to, the following:

* Provider Information
* Tax Identification Number
* National Provider Indicator (NPI)
* Address
* Phone Number
* Practice Name
* Adding a physician – physician joining practice/group. Please note that the new  physician must be credentialed first before rendering treatment to any CarePlus member.
* Provider deletions – provider no longer participating with the practice/group
* Medicare numbers


SITE VISITS – FACILITIES AND ENVIRONMENT:

CarePlus  conducts  site  visits  to  assess  the  office  environment  as  it  relates  to  physical  accessibility,  physical appearance, adequacy of patient care areas and medical equipment, medical record policies and  practice management. A site visit may be conducted upon initial credentialing and on other occasions as  determined by the Plan (e.g., quality review).



The standards reviewed during site visits include, but may not be limited to, the following:

 Accessibility/Physical Appearance

1.  Site is operated in a safe and secure manner.

2.  Provide reception areas, toilets, and telephones in accordance with patient/visitor volume.

3.  Adequately marked patient/visitor parking, when appropriate.

4.  Examination rooms, dressing rooms, and reception areas are constructed and maintained  in a manner that ensures patient privacy.

5.  Provisions are made to reasonably accommodate disabled individuals.

6.  Adequate lighting and ventilation are provided in all areas.

7.  Office/Facility is clean and properly maintained.

8.  Space allocated for a particular function or service is adequate for the activities performed  therein.

9.  Smoking is prohibited in the office/facility.

10. Office/Facility must be in compliance with applicable state and local building codes and  regulations; state and local fire prevention regulations; applicable federal regulation and  receive periodic inspection by local or state fire control agency, if this service is available  in the community.

superbill entering - Paper and Electronic Encounter Forms

Charge capture: Paper and Electronic Encounter Forms

Physicians and Non-Physician Practitioners (NPPs) may want to distance themselves from coding, but implementing an Electronic Health Record (EHR) moves them in the opposite direction. If using an EHR, after completing the note, the clinician selects the CPT® and ICD-9 codes (the procedure and diagnosis codes) that describe the service performed. These electronic charging systems have benefits and drawbacks, similar to and different from paper encounter forms.

Keep reading to learn about the benefits and pitfalls of both charging systems, and how to improve them. Why take the time out of your insanely busy week to do this?
Because physician code selection is as accurate as the tool used to select the code: no more, no less.

Let's start with electronic charging.

Beware of abbreviations and shortened descriptions

A cardiologist looked at this description in the drop down box of his EHR.  "EP Consult".  The cardiologist read: Electro Physiology Consult.  The programmer meant, "Established Patient Consult."  Do you see the problem with this?  The abbreviation was open to interpretation, and isn't a standard CPT® abbreviation.  And, consults are not defined as new or established visits, further confusing the matter.  It's true: there is only so much space in the drop down charge entry box.  But, shortened descriptions and abbreviations are an invitation to inaccurate code selection.

How about searching for CPT® or ICD-9 codes?

Searching an electronic data base is not always easy or productive.  One group using a diagnosis code look up integrated into their EHR made a major error.  The search term:  confusion.  An elderly patient presented to the hospital, and one of the patient's symptoms was confusion.  The search engine returned the ICD-9 code for psychosis.  A more accurate code would be altered mental status. This incorrect code--psychosis--was submitted on hundreds of claims.  A psychiatric diagnosis was reported in place of a medical symptom.  Hope it wasn't my mother's claim.

Can't find the procedure code?

What did a physician or NPP do the past when the code wasn't on the encounter form?  Write a brief description, and leave it for the coder.  What does a clinician using an EHR charging system do?  Too often the answer is bill for an E/M service only, and move on, leaving the service unbilled.  It is critical to have a process that allows the physician to send the record to the coder in this situation.

The case of the missing CPT® book

A huge pitfall of electronic charging is that the office doesn't buy enough (or any!) CPT® books.  Recently, I was at an office and asked for a CPT® book.  They brought me a 2007 CPT® book and a 2005 ICD-9 book.  Really, those were the most recent editions.

The editorial comments in the CPT® book are critical to correct and accurate coding.  Be sure to read them.  The AMA isn't paying me to say this: buy new books (for CPT®, buy the AMA's Professional Edition) and don't leave them in their plastic wrappers!

Paper?

And, oh the joys of the paper encounter form!  Yes, we know there are deleted codes on the form, but we have 10,000 of them in the basement, and they are expensive and our doctor wants us to use them up!  Burn them!  Update your paper encounter form every year.

While you're at it, take out all of the shortened descriptions and abbreviations for minor surgical procedures.  This is the biggest source of errors I find in primary care practices: wrong CPT® codes for minor procedures, linked directly to wrong, incomplete and confusing descriptions of minor procedures, medications, and ancillary services.  Develop a separate charge slip for these, that lists all of the procedures and services your clinicians perform with their full descriptions.
Remind the MDs and NPPs in your office that they are paid based on CPT® codes, and not on the number of diagnosis codes they circle.  Eight diagnosis codes do not increase the payment for the service.  It does give the charge entry person heartburn: which of these eight should I list (I can only enter four) and which should be first?  Ask the clinician to number the  most relevant diagnosis codes.  Only four.

Our goal: coding accuracy. One step to achieve it is accurate charging documents, whether on paper or on line.

Physician code selection is as accurate as the tool used to select the code.

The code is as accurate as the tool: no more, no less.