Appealing Denied Insurance Claims: An Overview

The process of appealing a denied insurance claim is complicated but can be effective if done correctly since there are numerous reasons for claims to be denied by an insurance company. The payer or insurance company receives thousands of claims everyday and the claim can be quickly denied if there has been an error in any aspect from diagnosis to medical billing and coding. The reason for a denied claim is given in the Explanation of Benefits or EOB and is the most crucial aspect when appealing a denied claim. Moreover, there is also a need to comprehend if the claim is worth appealing since a claim that amounts to just $1 is not worth appealing but one which is worth a substantial amount needs to be investigated. Here are some of the reasons for claims to be denied and how to go about appealing such denied claims. 

Services not covered
The insurance company can rightly deny a claim if the services rendered to the patient are not covered under the insurance plan. In such cases there is not much a person or a medical biller and coder can do to get paid since this is a legitimate reason for denying a claim. Therefore it becomes important for a physician or health care provider to determine if the services provided are covered under the insurance plan before commencing to provide such treatment. There is no point in wasting time and money if such a scenario occurs and appealing and re-appealing would only result in denials and re-denials. 

Errors in Clinical Documentation
Errors in documentation can lead to denied claims and such claims have a good chance of a successful appeal if there are no other reasons for the denial. These errors can range from not specifying the correct codes or even mistakes in spelling and procedure to be followed. The error can arise from the physician’s office or due to a mistake in medical billing and coding. These errors can easily be rectified by professionals who understand the CPT codes and ICD codes involved in the procedure. However, time is of essence here and if the claim is not appealed within the stipulated period of time, it cannot be appealed after such time has elapsed after the claim denial. 

The Appeal Process
The process of appealing a denied claim can differ from one payer to another and it is important to understand the correct procedure for appealing the claim in order to be successful. If the claim is not appealed in a manner which the policy describes, it can be turned down by the payer. For instance, the procedure for appealing a denied claim by Medicare is different from other private insurance companies. Even under Medicare there are different ways to appeal a claim which depend on the type of coverage chosen. There are different procedures for appealing a claim for Original Medicare, a Medicare Health Plan, and a Medicare Prescription Drug Plan. The appeal forms are available on the Medicare website and can be downloaded or printed for appealing a claim. A Medicare Redetermination Request form is available on the CMS website and can help you understand the procedure and file a claim according to this form. 

Medically necessary claims
In many cases appealing a denied claim hinges on the fact if the treatment provided is medically necessary or scientifically proven. This means that the insurance company regards the claim as medically unnecessary or the treatment is scientifically not proven to provide better health outcomes for the patient. In such a case the help of recognized medical journals such as Pubmed.com can be used as evidence to prove the necessity or the scientific viability of the treatment. Physicians can make an undeniable claim based on such evidence in order to get paid in a timely manner. 

Medicalbillersandcoders: an ideal ally to handle claim appealing process
The reason and the process of appealing a claim can be time consuming and complex since there are many grounds on which the claim can be denied. Some of the common reasons include policy limitations or guidelines, untimely appeals of claims, denied authorization for prescription drugs, denied the transportation to an Emergency Hospital, services received without a referral or authorization, and denied due to the physician being out of network.

The complexity in the reasons for denials and the appeals process makes it a task in itself requiring in-depth knowledge of such processes. This problem can be solved by medical billers and coders who are experienced and know the usual pitfalls and reasons for claims being denied. Utilizing the services of medical billers and coders can help physicians and patients in saving time and money which have become an important issue in the light of recent health reforms.

For more information about better solutions for issues related to appealing denied claims and professional medical billing and coding services, please visit medicalbillersandcoders.com, the largest consortium of medical billers and coders in the United States for all specialties. Our medical billing experts – who are adept at accurate charge-capture, intricate procedure coding, electronic filing of claims, patient billing, multi-tiered appeal process, denial elimination initiatives, and compliance standards – have been crucial to physicians/clinics/hospitals’ operational efficiency and revenue maximization.

Under-Coding: Financial Repercussions and Solutions

Under-coding can be defined as the procedure of medical coding where the codes do not reflect the full extent of the treatment provided to a patient. This can usually happen due to many reasons but the most common are errors or misreading of codes or because of the misconception that the chances of insurers paying would increase because of under-coding. The truth is that under-coding can affect your revenue in a negative manner as a health care provider and even get you into the habit of chronic under-coding which can lead to losses and improper patient care in the future.

Reasons
Under-coding can occur due to numerous reasons such as lack of skilled staff, the fear of rejection of claims by payers, or errors in understanding the correct codes. The skill of the physician staff can be increased by providing proper training which would also ensure lesser amounts of errors. Another situation which can lead to under-coding can be avoided by providing uniform coding for patients who are fully insured and those who choose to pay cash for smaller illnesses or visits. Discrepancy in the codes for the same procedure provided to an insured patient and cash-paying patients can be termed as discriminatory billing by payers. 

Avoiding under-coding
Under-coding can be avoided by familiarizing with the latest codes and hiring or training the staff and hire professional medical billers and coders who have tested the new codes with other entities such as payers and clearinghouses. This would ensure that the performance of physicians and the treatment is correctly captured. Another way of avoiding under-coding and mistakes in coding is to refer to the annual updates of ICD-9 codes and identify the most under coded procedures using ICD-9. In times where ICD 10 implementation is just round the corner, the threat of under-coding is at its peak. Proper training and implementation can help in avoiding these mistakes when the use of ICD-10 codes becomes imperative. 

Legality
The fact that under coding is seen as an unethical if not an illegal practice even when revenues for health care providers decrease may implicate negligence on the part of physicians, clinics, or hospitals. While under-coding for cash patients is on no account correct, in the case of Medicare, it can be seen as inducement, which could then be regarded as fraud or abuse or both. According to Medicare, inducement is “offering any free service to a patient to encourage providing a service that would be covered by Medicare.” Such abuse can lead to legal actions since these indicate non-uniformity and providing of free goods or services to patients in order to influence future purchases by consumers of the covered services. 

Training
Training for proper coding procedures is an integral part of avoiding under-coding and such training can be provided to assistants, while physicians themselves can train on basic codes that are often needed and encountered. CMS provides training as far as the technology is concerned and this can also help in familiarizing with EMRs and EHRs which can be an added advantage for health care providers, especially solo practitioners or physicians working as a small group. 

Revenue
The most important aspect as far as under coding is concerned is the amount of revenue which can dramatically decrease due to incorrect coding for multiple reasons. The easiest way to make sure that revenue is not affected in a negative manner is to familiarize you as a physician with some of the most commonly used codes and hire medical billers and coders who can provide relevant advice in order to use the correct codes. Dedicated medical billers and coders are aware of the pitfalls and the areas where mistakes are often made and can ensure these errors are not repeated. 

The migration from ICD-9 to ICD-10 codes
The reason for migration from ICD-9 to ICD-10 codes is not just because they are extensive but also because of the sheer volume of codes and the extent to which they can cover the treatment that is provided. However, on the other hand, ICD-10 codes are so extensive that payers can deny claims that do not accurately reflect the treatment or diagnosis provided. The scope for mistakes and under-coding is becoming a growing concern among physicians and health care providers since payers would be happy to deny claims based on a technicality. Since the number of codes have increased almost 9 times compared to ICD-9, it becomes imperative to train the in-house staff cope with the ensuing changes at various levels, while the core process of medical billing and coding can be outsourced to professionals who are specialized in this area.


For more information on how under coding is likely to impact physicians and their billing processes, and how to cope with it in an effective and pro-active manner, or to know more about our coding services and coding training services on how physicians can handle such and similar issues in their practice, please visit medicalbillersandcoders.com, the largest consortium of billers and coders in the US across all specialties.

Revenue Cycle Management – prescription for optimum medical claim realization

“Despite such volatile environment, physicians have to find means to realize their each and every dollar owed them as their very sustenance and growth hinges on efficient reimbursement of medical bills”

Unlike other professional services that realize their professional fees instantly, without having to rely on a third party (insurance carriers), physicians have to go through an intricate process to realize their fees for medical services rendered. And, with every citizen resorting to healthcare insurance, the physicians will have no recourse but to realize their claims through insurance carriers alone. But, the prevalence of complex regulations, multiple payers, and stringent reimbursement environment have altogether made their task even harder. Despite such volatile environment, physicians have to find means to realize their each and every dollar owed them as their very sustenance and growth hinges on efficient reimbursement of medical bills.

As physicians find the intricate process involved in revenue reimbursement too hot to handle, there is growing inclination to outsource solutions under the umbrella name, ‘Revenue Cycle Management’, a comprehensive procedure – Patient Enrollment, Insurance Enrollment, Scheduling, Insurance Verification, Insurance Authorizations, Charge Entry, Coding, Billing and Reconciling of Accounts, Denial Management, Appeals, and Physician Credentialing – for optimum realization medical claims from insurance carriers. While market is replete with numerous Revenue Cycle Management providers, physician practices would do well to source those that devise integrated approach: advising on internal adequacies (both human and technology), seamlessly integrating RCM process with compliant norms (coding and reporting) and technology interface (billing and coding software), and recommending innovative business models that are more efficient, scalable and flexible.

Having been a niche Revenue Cycle Management service provider for small and large practices alike, Medicalbillersandcoders.com has a unique Revenue Cycle Management capable of custom-delivering optimum reimbursement of their clients’ medical claims at incredibly less turnaround time (TAT).

Features of Medicalbillersandcoders.Com’s Revenue Cycle Management (RCM)

• Improving Patient Experience: Our transformational solutions that improve efficiency of patient-facing functions help in enhancing the ease with which patients can be enrolled and treated at your facilities.
• Technology Interface: Infusing technology, both at clients’ facilities as well as centralized control, ensures fast, reliable and efficient functioning of RCM for our clients.
• Regulatory Compliance for Reimbursement: Our proactive outlook to updating competence in congruence with evolving Regulatory Compliance (ICD-10 and HIPAA 5010) mitigates the probability of undesirable delay, denial, resubmission, or audit issues on clients claim sheets.

Therefore, our unique Revenue Cycle Management – enriched with end-to-end revenue cycle transformation, improved patient experience, integrity in charge capture, billing and coding, proven operating models, enabling self-pay collection through better analysis and management practices, and inspiring your staff with innovative training models – should greatly appreciate your bottom-line through:

• Realization of additional recovery of 5-10% claims, which would have gone unrealized without a proper Revenue Cycle Management Cycle (RCM) in place.
• Expedite Account Receivables through timely follow up and persistence with insurance carriers.
• Substantial reduction in operating costs through innovative business models, and appreciable increase in revenues through seamless reimbursements.
• Expanding practice without additional outlay on human resources; our recommended technology interface can withstand your growing business/practice needs.
• Last but not the least, enhanced patient satisfaction through unprecedented patient experience

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Increasing Demand for Certified Coders in Healthcare

The year 2010 has set a premium on the coding professionals, registering a rise in their average salaries. And as expected, the salaries for certified medical coders are higher as compared to the non certified ones.


According to a salary survey of nearly 12000 coding professionals, the average salaries for credentialed coding professionals have increased by 1.5 percent to $45,404 while non-credentialed professionals saw a 1.2 percent increase to an average salary of $37,746 in 2010. This underscores the rising demand for certified billing professionals in the dynamic healthcare industry which has seen a spurt of health reforms in the recent times.




Overall, the healthcare employment has risen by 306,000 in the last 12 months; it rose by 30,000 in the month of August itself. The Ambulatory health care services and hospitals have added 18,000 and 8,000 jobs to the health care kitty, respectively. (Source: Bureau of labor statistics)

Looking at the trend, the healthcare industry seems poised on the brink of expansion, underlining the potential requirement of effectively trained professionals in many fields. Medicalbillersandcoders.com has registered a spike in the demand of certified billers and coders across many specialties recently. Hence, it is advisable for coding professionals to get themselves certified in order to participate competitively in the professional coding market.

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CPT Category II code updates by AMA

The American Medical Association (AMA) has released an update of CPT Category II code list, which will first appear in CPT 2012, with an implementation date of 1st Jan, 2011.

The CPT Category II codes are supplemental tracking codes that can be used for performance measurement. The use of tracking codes for performance measurement will decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians, their staff, and other health care professionals. These codes are intended to facilitate data collection about quality of care by coding certain services and/or test results that support performance measures and that have been agreed upon as contributing to good patient care.

Medical coders and providers should take a note of this update as there are many revisions, significant new codes and deleted codes based on previous updates that AMA has released this year. The major information on CPT Category II code about performance measurement exclusion of modifiers, measures, and the measures’ source(s) is listed below:

• Composite measures 0001F-0015F
• Patient management 0500F-0575F
• Patient history 1000F-1220F
• Physical examination 2000F-2050F
• Diagnostic/screening processes or results 3006F-3573F
• Therapeutic, preventive or other interventions 4000F-4306F
• Follow-up or other outcomes 5005F-5100F
• Patient safety 6005F-6045F
• Structural Measures 7010F-7025F

Source: AMA
Expert medical billing and coding requires consistent updating with the current industry trends to be effective and pre-emptive; MBC is a well-entrenched association of highly experienced billers and coders who can provide denial-free multispecialty billing and coding services to ensure a healthy revenue returns for healthcare providers.

Standards of ethical Medical coding: Part 1

Coding is one of the core functions of healthcare providers and, due to the complex regulatory requirements impinging upon the health information coding process, coding professionals are frequently faced with ethical challenges. There are stringent medical guidelines in place for the entire gamut of coding practices which include issues such as the privacy of patient healthcare data, accuracy, and regulation compliances.

This series of tutorials will help medical coders get comprehensive information about the standards of ethical medical coding norms and assist them in making ethically decisions in the workplace; these parameters can help evaluate the coding professionals’ commitment to integrity during the coding process.

Following are the set of guidelines recognized by AHIMA for ethical medical coding:

Accuracy and Consistency:
Coding professionals and managers shall apply accurate, complete, and consistent coding practices for the production of quality healthcare data. They should

• Support selection of appropriate diagnostic procedure and other types of health service-related codes such as type of disease, admission indicator, and discharge status
• Develop and comply with comprehensive internal coding policies and procedures that are consistent with official coding & regulation guidelines,
• prohibit coding practices that misrepresent the patient’s medical conditions and treatment provided or are not supported by the health record documentation
• Promote an environment that supports honest and ethical coding practices resulting in accurate and reliable data, irrespective of the purpose for which codes are being reported
• Refrain from alteration, or suppression of coded information

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Are You Prepared to Deal with Patient Information Breach?

‘The readily available sources for implementing security-rich technology platforms should not only make your search easier but also ensure Patient Privacy Compliance by sage-guarding critical information against undesirable proliferation, and sharing information only at the behest of patients’

Although there have been sporadic incidents of patient privacy breach, yet, the recent episode reported in a recent New York Times article (September 8th, 2011) – wherein Stanford Hospital and Clinics was quoted as saying that a spreadsheet of patient medical information, including names and diagnoses of more than 20,000 emergency room patients, was accidentally posted to a website, and remained posted for a more than a year – shows the extent of its severity. Whereas most of the hospitals, clinics, and physician practices have a secure system in place to safeguard privacy of patient information, still, the technology vulnerability, along with human negligence, remains a major impediment to shielding patient privacy from undesirable proliferation.

Technology Vulnerability has many faces

• Unsecure technology interface: Often, unsecure technology is the reason for breach of patient privacy norms as they inherit intrinsic lacunae in system security. It is usual to find such unsecure technology interface in low-budget healthcare centers. Further, technology, being a subject of perpetual innovation, your existing technology interface, despite being highly secure, can be shown to have security deficiencies by generation-next technology platforms.
• Fear of data high-jacking: As most of the data centers are centralized, it takes one unauthorized access for high-jacking your entire patient-centric data in a jiffy.

Human Negligence

• Untrained staff: Sometimes internal staff is not fully trained, do not have proper orientation to maintain patient information on technology-enabled platforms.
• Lack of responsibility: Coupled with lack of proper training, an overtly compromising attitude on the part of your internal staff may sometimes be the reason for breach of privacy of patient information.

Irrespective of whether the violation is technical or human, HIPAA has a very strict regimen in place, which is authorized to impose both criminal penalties and monetary penalty (amended from $250,000 to $1.5 million through the recent HITECH Act) on the violating institution and the individuals.

Apart from negative repercussions on the patients concerned, any breach in confidentiality – even the one that seems minor – can spread mistrust, and affect your credibility in the medical fraternity. Therefore, physicians/hospitals/multispecialty groups have a greater responsibility in not only safeguarding their patients’ confidentiality, but also keeping their credibility unblemished. Alternatively, they can, if hedged with limited resources, apprise their patients of their limitation in patient privacy practice, to avoid facing embarrassment subsequently.

Although HIPAA has authorized, under certain exceptional circumstances, covered entities to release protected health information without authorization only to facilitate treatment, payment or health care operations, usually physicians are prohibited from disseminating patient-centric information that can have emotional, personal, social, financial, and ethical repercussions. Thus, the onus is substantially on the physicians/clinics/hospitals/multispecialty groups to safeguard their patients’ confidentiality.

Given the history of unimpressive success rate from internally implemented Patient Privacy Regime, it is advisable that physicians consult proven sources that have competencies in installing secure technology interface, and properly orienting your staff to the requisite operations – which is likely to result in best practices in Patient Privacy as mandated by the HIPAA, and render transition to the ensuing HIPAA 5010 easier.

The readily available sources for implementing security-rich technology platforms should not only make your search easier but also ensure Patient Privacy Compliance by safe-guarding critical information against undesirable proliferation, and sharing information only at the behest of patients.

Medicalbillersandcoders.com, who have a unique approach – combination of implementing security-rich technology platforms with prior orientation to your in-house staff on operational and administrative issues – that can mitigate the probability of embarrassment emanating from undesirable breach of patient privacy.

Small Practices: Adapting to the Challenges of Healthcare Reforms for Better Revenue

The major challenges faced by physicians who run a small practice or clinics that have less than four or five physicians are expanding exponentially. Many physicians find themselves worrying and spending time on administrative processes and interacting with payers rather than spending some quality time with their patients. The recent health reforms including the HITECH Act, implementation of EMR and EHR, the overhaul in medical coding and billing procedures, Medicare cuts, and the added burden of incorporating new technology in the face of increased patient volumes have brought single physicians and small clinics to the end of their tethers.

However, the challenges are difficult but not insurmountable and health providers who work as a small group or on their own or are Individual Practice Associations (IPAs) are finding solutions to these myriad hurdles. Here are some simple steps that you can take as a single physician, an IPA or a small group of physicians in order to increase the revenue without sacrificing the quality of services provided.

Technology
The use of Electronic Medical Records and Electronic Health Records has become a feature of the recent health reforms. However, many physicians and clinics are struggling to understand and use the healthcare technology, either because it seems too cumbersome or due to the inevitable resistance to new technology. This problem can be circumvented by partially or completely outsourcing your healthcare IT-related requirements to an entity that understands the changes and has had hands-on experience in using the latest technology for such processes. These experts can also support your staff in up grading the relevant skills for routine usage of these processes.

Medicare
Small practices and clinics usually find it difficult to balance the administrative processes and patient care without either dropping some insurance providers or putting in more time and effort that is not justified. Moreover, the looming Medicare cuts that seem inevitable along with increasing number of baby boomers have made many physicians and clinics consider dropping Medicare patients as well. The time and effort put into interaction with payers and delays in reimbursements cannot be justified if quality of patient care drops along with the revenue. An alternative would be to outsource such processes to medical billers and coders experienced in latest Medicare regulations, who can save time and effort for the physicians and their staff and ensure minimum losses by utilizing their experience and skills in this area.

Rural Physicians
IPAs or physicians practicing in rural areas are the ones who are going to be most challenged by the reforms since these are either nurse practitioners or single doctors with a small staff. The burden of implementing and testing the new technology according to CMS and HHS guidelines and handling claims denial, interacting with payers while providing patient care in relatively poor localities can take a toll on the revenue. Moreover, since there is a dearth of health care providers in rural areas it becomes difficult to just drop patients because of delayed claims or due to Medicare cuts since this would put patients’ health in jeopardy and lead to decreased revenues for physicians as well. The need for dedicated medical billers and coders who can also handle claims denial along with other tasks such as charge entry and payment posting can be felt in such times. These medical billers and coders would ensure that you as a health care provider dedicate most of the time to patient care instead of interacting with insurance companies and worrying about various guidelines to be followed.

The Solutions
There is no question that small practices and solo physicians would need to adapt to the reforms in the health care system. There are many ways of doing this and some small practices have joined bigger health care providers for training as far as the new technology is concerned. Other practices are grouping together in order to share knowledge about the changes and search for solutions. Another solution is to form a medical group so that you as a physician receive better benefits and pay by without worrying overmuch about routine administrative hassles all by yourself. These mergers can help solo or IPA physicians in understanding and sharing the risks and benefits of the health reforms, share resource expenses and also improve the quality of care for their patients.

Another feasible alternative is to tie up with a standard healthcare consultancy provider such as medicalbillersandcoders.com, for effective and customized solutions in healthcare IT, Revenue Management and strategic operational areas for small practices. This consortium is preferred by smaller practices due to its reach in all 50 states across

Visit medicalbillersandcoders.com for more information.

Decoding Common Billing Blunders & Devising Ways To Quell Them

The growing incidence of delays, denials, audits, and resubmission of physicians’ medical bill claims is reason enough to have a relook at the way physicians’ services are billed and coded. In a medical insurance environment, characterized by stringent billing and coding compliance, inherent billing and coding errors are easy to catch. Further, lack of knowledge or negligence can be no excuse as payers go by the set rules that govern medical bill reimbursements.

As physicians try to figure out lacunae in their billing and coding practice, researchers have traced the reasons to lack of knowledge, negligence, outdated coding knowledge (physicians still trust what they learned 10 years ago!), inadequate in-house billing and coding competence, and, sometimes, incompetent outsourced medical billing and coding solutions. Delving further, they have even identified patterns of usual billing blunders.

• Failure to document services billed: A common error, physicians often forget to bill for incidental services while addressing the main medical disorder, which can substantially reduce the final realization. Therefore, physicians should realize the importance of billing for medically necessary, though incidental, services also.

• Failure to provide signatures: There have been instances of medical claims being returned unpaid and to-be-resubmitted again on account of omission of signatures by the physicians billing for their medical services. As physicians’ signatures only can validate the medical services that are billed for reimbursement, it is important that physicians, while submitting claims, do not forget to sign in wherever required so as to avoid being embarrassed with notices for resubmission.

• Consistent assignment to the same level of service: It is inviting suspicion as your payers might term ‘consistent assignment to the same level of service’ as duplication, and return the subsequent claims as invalid. Further, they may ask for explanation on the efficacy of repeating the same service again. To avoid, such undesirable scenario, a higher order coding is advised for subsequent services.

• Billing as a consult rather than an office visit: Although, at the outset, they might seem similar, consulting fee is deemed higher than regular office visit. Misrepresenting your manner of service will have a direct bearing on the outcome of reimbursement, and upon being found out by the payers’ audit checks, you may be called upon to furnish a suitable explanation. Therefore, code for the correct context to avoid being exposed during audits.

• Use of invalid codes (for example, codes taken from an outdated resource): The prime reason behind most billing blunders is the physicians’ perception that billing and coding standards are permanent; whereas there have been as many reforms as one can think of in billing and coding. Therefore, they need to keep themselves abreast of frequent changes in coding.

• Unbundling of procedure codes: Physicians, albeit unknowingly, or their billers, tend to fragment their procedure into parts, and assign codes accordingly. Whereas insurance companies, which feel such fragmentation tends to disproportionately increase claims, are known to have sent notices requesting physicians to not to unbundle their services.

• Misinterpreted abbreviations: Abbreviations, meant for reducing description, need to be used suitably to avoid a billing lapse.

• Failure to list chief complaint: Physicians, sometimes, looking for incidental charges may forget to state the chief medical complaint itself. Such mistake can render your claim as ‘insufficiently substantiated,’ and returned with audit remarks.

• Billing as a separate professional fee for those services included in a global fee: Physicians – not knowing the extent of coverage that their patients insurance schemes allow – sometimes, tend to club additional professional services while billing for certain cases that carry global-fee tag. As the insurance companies are obliged to reimburse only the global fees, physicians might not get the reimbursement for what they claim to be additional services.

• Use of an inappropriate modifier or no modifier for accurate payment of a claim: Modifiers – which play an important role in suitably modifying codes for incidental medical services – need to be used with discretion. Rampant and indiscriminate use of modifiers can be termed as ‘unacceptable practice’ and be eligible for ‘audit notes’ from your insurance carriers.

Given the pattern of billing blunders, and their consequences on claims realizations, individual physicians, clinics, hospitals, and multispecialty groups should look at devising a preventive program that can mitigate the recurrence of billing blunders in the larger interest of their sustainable practice and growth. Consequently, the preventive program entails 

• Educating themselves and their staff on proper coding
• Continuous upgrades in terms of latest updates in coding
• Continuously assessing the coding procedures to identify the most common errors and reduce them

Whereas these positive measures can be practiced internally, yet, physicians – who tend to be wary of exhaustive billing management practices – can fall back on proven outsourced solutions to meaningfully streamline their billing processes for optimized reimbursements. Medicalbillersandcoders.com, who a have long-standing reputation of being the largest medical billing consortium with a substantial presence across all states of the US, should be of immense help in devising a comprehensive program that can effectively quell billing blunders.

 

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Superbill Analysis – an imperial stamp of authentication

“Consequently, physicians’ medical bills get an imperial stamp of authenticity, and nullify the chances of undesirable delay, denial, resubmission, and audits from highly stringent medical insurance companies”

Notwithstanding physicians’ integrity in preparing honest Superbills, comprehensive analysis has become imperative before these can be submitted to payers for reimbursement because of the highly dynamic nature of US healthcare industry. Apart from being assured of the accuracy of the bill, a routine analysis saves the healthcare providers from being embarrassed with undesirable delay, denial, and resubmission notices from insurance payers on account of factual errors in the claim forms. Considering the efficacy of such a convention, the question is who should carry out Superbill analysis? Well, it is immaterial whether physicians get it verified in-house or outsource the procedure to an expert third party as long as it serves the purpose of authenticating medical bills.

But, judging from the historic reference of failed in-house verification experiments, outsourcing Superbill analysis, from proven Medical Billing Management providers with their professional expertise, seems an ideal solution.

How is Superbill analysis carried out?

Having established the wisdom in outsourcing Superbill analysis, it would make sense to highlight how Superbill review vets out the accuracy of various crucial pieces of information contained in the document. Well, getting to the crux of the matter, Medical Billing Management specialists scrutinize the Superbills for accuracy of:

• Provider Information, wherein last/first name and degree, service location, and signature are verified
• Ordering/referring/attending physician, wherein last/first name and degree, NPI (national provider identifier) are scrutinized.
• Patient Information, wherein patient’s first and last name, patient DOB, insurance information (insurance name/and id), date of first symptom (upon necessity), and last date seen (upon necessity) are checked.
• Visit information, wherein date of service; procedure codes (CPT) – list of commonly used codes by medical provider according to the provider specialty; diagnosis codes (ICD-9) – list of commonly used codes by medical provider according to the provider specialty; modifiers (location and conditions modifiers); time (for timed codes); units and quantity for drugs, and authorization information, (if applicable), are cross- verified.

Thus, Superbill review and analysis process culminates in authenticating the Superbills for claim submission only after ensuring the following:

• Establishing the legitimacy of the bills in terms of signature by provider of service
• Filling up of required fields for information
• Legibility of the information
• Apt CPT and ICD-9 codes with corresponding description of service/diagnosis

Physicians can hire outside services for the entire process of Superbills preparation, verification, submission, and realization of medical bills from the insurance companies. Such services come with utilities such as preparation of super bills from the physician notes and transcriptions that are available in their system; utmost care while coding; adherence to HIPAA compliance and CPT, ICD-9, and HCPCS coding; and assigning of appropriate modifiers and related information into the Medical Billing Software accurately.

Consequently, physicians’ medical bills get an imperial stamp of authenticity, and nullify the chances of undesirable delay, denial, resubmission, and audits from highly stringent medical insurance companies.
Medicalbillersandcoders.com, being the largest consortium of medical billers in the US, has made Superbill analysis – comprising coding of the diagnosis and the procedure, checking the compatibility of the diagnosis with the procedure code, checking for the modifiers in relation to the procedure, quality checking before the generation of the claim – an integral part of its comprehensive Medical Billing Management Services.