Change It!

When I was 18 years old, my boss (at that time) gave me some advise. Obviously, as a know-it-all 18 year old, I didn't appreciate the advice then, but as the years went by, I realized how valuable was. Today, I use this advice to guide many decisions.  I decided to share this story on my blog because it complements some of the job advice articles I have written and it will show you a lot about what makes me tick. So back to the advice…

Years ago, my boss and I ended up in a conversation about the lack of opportunity for those who have less money. He was a physician who had come from a well-to-do family. I came from a typical, well educated middle class family. I believed that opportunity was directly linked to financial situations. The debate got pretty heated. I really believed that the rich could never understand the struggles of the middle class and my boss felt that anyone could do better with a little effort.

Finally, realizing that we weren't getting anywhere he decided to end the conversation with a very powerful statement. He leaned back against the desk, took off his glasses, crossed his arms, looked me straight in the eyes, and said with a very serious look on his face “Holly, this is the most important thing I will ever teach you so listen to me carefully. You have two choices in life… only two. Accept it or change it” with that, he walked away.

It took me years to really understand what he said. He was right. There are only two choices – you either accept it or change it. I still do not believe that people who struggle want to struggle. Rather, I think there is a another piece to the puzzle. I think many people don’t understand two key facts. First, some people become demoralized not realizing that we have the power to choose between accept it or change it. Second, some people don’t know how to change it - no matter how much they want to.

I believe the key to changing circumstances is education and today, more than ever, free education is readily available for those who want it thanks to some truly amazing people. I have no affiliation with any of these free educational sources. I simply wanted to take the opportunity to give a personal thanks for the effort they put in to making it easy for those who choose to ‘change it’.  As well, I wanted to help spread the word about the opportunity available to everyone who wants it.

This list of educational resources is not comprehensive. These just some really amazing sources. I am sure there are a lot of others that I just don't know.  If you know of others, please feel free to add them in the comments. If you weren’t aware that these sources existed, check them out!

The Gutenberg Project: free e-books

The Khan Academy: free educational videos about everything from A-Z

Open Culture: a large list of links to free college courses, free books, free videos, free text books, etc. from top ranked universities and well known educators

Librivox: free audio books

Federal Resources for Educational Excellence: learning resources from the federal government

Free Online Education.com: a directory of free educational resources

University of the People: Non-accredited (but apparently they are working toward accreditation) online university

To the people who offer these free educational resources, thank you for giving so much value back to society. Your work is truly inspiring and greatly appreciated. 

To those who feel stuck - remember you can change it... It will take time, dedication, and effort but if you want it GO GET IT!

Want a job? Really? Here's Some Straightforward Employment Advice

I was just on Linkedin reading through discussions. As always, there are a lot of conversations about how to write the perfect resume, how to conduct yourself during the interview, how to dress for an interview, etc. These articles are very informative and the advice makes sense... But, (yes, there is a but) there is one secret key to success that is rarely mentioned.

If you include this secret all the rest will fall in place. If you include this secret you WILL write the perfect resume, you WILL be confident and act appropriately in the interview, and you WILL dress for success. Further, your chances of getting the job increase exponentially. In the long term, you will have job satisfaction, job security, and work-life balance.

Now you are probably thinking, ‘what’s she selling?’ I am selling simple, plain-old common sense. It cost you a little bit of time and effort but ultimately, the return on investment is massive. It will benefit you as an employee and it will benefit the employer to whom you dedicate your career. So, are you ready for the secret?

The secret is a question you must ask yourself before applying for a job. After you have asked yourself this question, we will need to put a little effort into answering it. DO NOT jump to conclusions answering the question without due diligence. Most importantly, DO NOT apply for a job without answering the question first. Ok… without further ado, here is the question…. Do you want the job? That seems pretty obvious, right? Well, it’s not.

Let’s think about the word ‘want’. Many make the mistake of mixing up ‘want’ with ‘need’. You ‘need’ a job; therefore, in desperation you apply to anything and everything never considering what you really want or whether you really fit. So you get a job and you fulfilled the need, but it really wasn’t what you wanted. You are miserable and unmotivated. The dissatisfaction and lack of fulfillment makes you resent your job, your managers, and your coworkers.  Perhaps your performance is adequate… but don’t shine. Who is benefitting? If you are only adequate, what job security do you have? If you are miserable, do you really have work-life balance?

So, how do you know what you want? How do you find what you want? Lastly, how do you get what you want? Let’s start with the first question – What do you want? The answer to this is all about your personality type. Are you a creative or analytical? Are you a team player or do you fly solo? Are you competitive or not? Do you prefer privacy or wide-open workspaces? Are you outgoing or introverted? Are you one who prefers sameness or do you thrive on change? Be truthful, there are no right or wrong answers. Keep asking yourself questions until you know your personality – until you know what you want.

To give you a good understanding of how this works, I will tell you about my wants. I want a job where I can be creative and analytical at the same time. I prefer wide-open workspaces where I can work with a team to produce amazing things. I compete against myself and therefore embrace change with the goal of constant improvement. Perhaps your is the exact opposite and that’s great too. It is all about finding what YOU want and matching it to what a company wants.

Now, on to the next question: How do you find what you want? Did you know that businesses have personalities too? In fancy terms, it is called the corporate culture. Finding the perfect job is like finding someone to marry. While you are dating (looking for a job/interviewing) you are looking for someone who shares your core values and someone who has a personality (corporate culture) complementary to yours. Notice here, I said complementary not the same. Remember, sometimes opposites attract. For example, introverts often work very well with extroverts… somebody has to do all the talking :). Creative people can open new doors for those who are super-analytic and the super-analytic can add direction the creative person’s ideas.

When you are looking for a job, do your research! Get to know the company the same way as you would a date. Learn about their core values and find out whether you and the company have complementary ‘personalities’.  There are a ton of company personality indicators if you just look. First, start by reading the job description. This is not a passive, quick review…really read it. What type of language do they use? Does it have a lot of business jargon, is it hi-tech , is it youthful? What are the requirements and the ‘preferred experience’ for the job? This is important, but not only to determine if you have those skills/traits/education (obviously), but also the requirements of the job tell you what the company values. Is a bachelors degree required and an MBA preferred? Clearly they value education. Do you value formal education or do you value the school of hard knocks?

Next, look thoroughly read the company’s website for clues. What are their mission, core values, long-term goals? How do they describe themselves on the career page? What benefits do they offer? Again, there is more to this than the obvious. Benefits show you what they value most.  Check out recent press releases to understand how the company works toward their goals. Look at their advertising to understand the brand image. Look the company up on websites like Glassdoor to see what employees say about the company (Remember though, you must take everything employees say with a grain of salt. Some people have axes to grind. Look for trends rather than specific complaints). 

Now that you have gotten to know the company, would you 'marry' them? (Remember you will spend as much time at work as you do at home - so isn't a job like a marriage). Does your personality complement their personality? If the answer is no – move on. If the answer is yes, apply for the job.

The best part of all this corporate personality research is that you have now learned how to write your resume and cover letter to really grab their attention. Make sure your resume and cover letter are truthful and tailored show how you are a perfect fit for their culture. In the cover letter, take the opportunity to tell them about the personality similarities and use your prior successes to support that idea. Yes, this means you may have to rewrite your resume/cover letter for each job to which you apply… but if you really want something – you are willing work for it, right? I don’t know about you, but my successes weren't handed to me on a silver platter.

When it finally comes to the interview, ask questions about the corporate personality. Get to know the employer more intimately. Interviewing should be a two way street. In the best situation, the employer interviews you and you interview the employer. Don’t be arrogant about it, but there is no harm in getting to know someone. Best of all, it shows that you are genuinely interested, that you researched, and that you want to make sure that you will be perfect for the company. No one wins if you don’t love your job. Perks, benefits, and corner office may sound great but they are not necessarily fulfilling.

The upshot… stop acting desperate and stop being lazy. Sending the same resume to hundreds of jobs that don’t fit (personality or experience for that matter) – is just plain-old lazy. If you want a job, really want a job  – work for it!

Denial Management (Part II)

In general, claims should be paid within 30 days of the date they were send to the insurance. Some claims will not be paid and those unpaid claims must be worked on so that the appropriate reimbursement is received. Unpaid claims are caller accounts receivable.

In order to get theses claims paid, the biller must contact the insurance to find out what happened to the claim and what steps are necessary to get payment.

There are many reasons why claims are not paid. Below you will see a spread sheet for reference of common denial reasons, the associated actions and reference locations to help in the reimbursement process. This is not an exhaustive list, but will act as a help guide as you are learning more and more about medical billing.

Remember denial follow up and following up on accounts receivable must be done constantly to make sure that the practice is getting all the reimbursement they deserve.


To help the reader get a good idea about different denial reasons, their meaning, how to correct denials, and various resources you can use to address denials, follow this link to my 
Denial Management Resource Sheet. 

or

https://docs.google.com/spreadsheet/ccc?key=0As3FvNjmAaz_dGdTUE9pRlUyQ0c5VnFNam12SHhCTnc

Managing Denials and Appeals (Part I)

Denials are claims which have been adjudicated (fancy word for processed) by the insurance but not paid. A denial usually comes to the provider in the form of an EOB. The denial can be on an entire claim (meaning all of the services billed) or a single claim line item (each individual service).

First, let’s have a refresher on line items. Sometimes when a doctor sees a patient s/he will perform multiple services. Each service is billed with a separate CPT code within the confines of the Correct Coding Initiative (CCI – more on this later).  So, for example, if the doctor examines a patient for diabetes and performs an EKG for a complaint of palpitations, the biller will bill two different CPT codes. One CPT code will indicate the examination and the other will be for the EKG. Each CPT is billed on a separate line on the claim form. Since they are on separate lines, they are referred to as line items.

It is also possible to use the same CPT on separate lines, if, for example, the same service was billed on different dates. As an example, consider a patient in the hospital. The doctor will examine the patient on 1/2/2012 and 1/3/2012. Since the dates are not consecutive, you cannot bill a date range therefore, the two dates may have the same CPT code but must be billed on separate lines. There are other examples, but for now understanding that will suffice.

So back to the main point. A denial can be for the entire claim (all claim lines) or just one claim line from a claim with multiple lines.

Some denials are legitimate due to quirks in patient’s policy or insurance guidelines. Other denials are insurance processing errors and yet others are errors by the doctors billing staff or the doctor. Regardless, it is imperative that denials be followed up on.

So what is ‘following up’? Basically, it means action! Some denials are obvious and you can correct it without much ado. Other denials are more confusing. Following up on a denial may require a phone call to the insurance to discover the nature of the problem. If the error is on the insurance side they will usually correct the error over the phone and automatically reprocess the claim.  If you find that the error is due to a billing mistake you made will have to make the corrections and resubmit a corrected claim.

Some insurance, such as Medicare, will allow an electronic resubmission of a corrected claim without you including any indication about the correction other than the correction itself. Other insurances will require that you send a paper claim with a note stating that the claim is corrected. For these carriers, if you do not indicate that the claim has been corrected, they will reject the new (corrected) claim as a duplicate.    

In some situations the practice will receive a denial on a claim that the insurance insists is valid according to their rules or the patient’s policy. You may not agree with the denial. In that case you can have a claim reviewed at a higher level through a process called an appeal. A couple of examples of claims that may require appeal are timely filing denials (claim not sent to insurance within their contractually specified claim submission time frame) or sometimes medical necessity denials (diagnosis doesn’t justify the service rendered).

Before you appeal any claim, check first that you didn’t make any errors. Don’t waste your time filing an appeal if the problem is a simple error. Generally, appeals are pretty uncommon.  For example in the event of a timely filing denial, check your records to verify that you did in fact send the claim initially within the period allotted by the insurance. If you receive a denial if for medical necessity, check if you linked the correct diagnosis to the procedure. Once you are sure that there is no billing error, you must write a letter to the insurance to request that the claim be reviewed by the appeals department.

An appeal will include a letter or appeal form, a CMS 1500 claim form and sufficient proof that you have a valid request for appeal. The proof can take the form of documentation from your doctor, or a trusted medical source and for timely filing appeal, you must send a printed copy of the electronic claim report (EDI Report) showing a clean claim submission and insurance acceptance.  Medicare has a specific form that they require you to use for appeal. The form can be downloaded from your local Medicare web site. Here is a sample Medicare appeal form. You can create your own appeal form for most other insurances. Use Medicare’s appeal form as a template / guide.

Payment Posting and How to Read an EOB / ERA

A couple of weeks after claim submission the medical practice will receive a correspondence from the insurance company to tell you their decisions as to whether the claim will be paid. This is called either an explanation of benefits (EOB) or electronic remittance advice (ERA). The difference between the two is the delivery method. An EOB comes via traditional mail and an ERA is delivered electronically. If there is a payment (money) associated with the EOB or ERA, it will either be sent as a check via traditional mail or delivered by EFT (electronic funds transfer often known as direct deposit). 

The purpose of an EOB and ERA is to explain payments and denials for the claims you previously submitted. The EOB/ERA will also tell you about the amounts, such as deductibles, coinsurances and copayments, that the patient is responsible for paying out of pocket. Finally the EOB or ERA will show you how to properly apply the payments to patient’s accounts so you can keep track of what is paid and what is outstanding.

To keep track of payments and outstanding balances the biller must enter information from the EOB into the practice’s medical billing software. This is called payment posting.  This is very important for three reasons. First the payments and accounting data entered in to the billing software will directly affect the practices overall accounting and taxes. Next, the accounting will directly affect the patients billing (patients do not like to receive medical bills that are not legitimate). Finally, payment posting will directly affect your job. Unpaid or incorrectly paid claims need follow up. It is a waste of your valuable time to call on a claim that was already paid claim in the event of an accounting error.  

Previously we discussed the “allowed amount” as it pertains to the insurances fee schedule. Just a brief refresher, the allowed amount is the amount the doctor agreed to accept as full payment when s/he signed a contract to participate with the insurance company the time of credentialing. Again you’ll recall that the insurance allowed amount is not usually the same as the amount you billed because traditionally we bill at a rate higher than insurance fee schedule as to avoid any underpayments. With that refresher done, we’ll begin.

The EOB or ERA may have information for just one patient’s claim or it may contain information regarding many patients. The EOB/ERA shows the patient’s name, the account number assigned by your medical billing software, the allowed amount, the patient responsible amounts such as copayment, deductible, and coinsurance, the payment amount, and messages from the insurance about the claims processing. Each CPT procedure code is processed separately and shown on the EOB/ERA as a separate line item.

The allowed amount is the maximum payment that you can receive on each line item. The difference between the insurance’s allowed amount and your charge amount is called the contract adjustment. The contract adjustment is a write off. It is a breach of contract and against the law to bill the patient for this difference, billing a patient for the contract adjustment is called balance billing. If you are caught balance billing you can loose your contract with the insurance or even be prosecuted for fraud.

Many times there is also a difference between the allowed amount and the payment amount, that balance is the patient’s responsibility (out of pocket). The EOB or ERA will usually give some detail about why this balance is due by the patient, such as deductible, copay, coinsurance or non-covered item or service. We will review each but first you must understand exactly how the EOBs are calculated and presented. Closely review the example and my mark ups to follow on the sample EOB from Medicare:

To follow is a sample from Aetna that we can look at item by item. Medicare’s EOB and Aetna’s are quite similar in contents (even though they look a little different). You will find that all EOBs/ERAs have the same basic information.  

In the center of the page, number 21-35 is the line by line detail. Each line is called a claim line and indicates a service rendered to the patient. The date of service is in box 21 and service code (CPT) is listed in box 23. Box 25 shows the provider’s charge and boxes 26, 27, 31, 32 and 33 show the payment and its distribution.

As I mentioned before, the doctor’s office sets its own prices for the services that they provide but if the doctor is in contract with the insurance he/she is obligated to accept the allowed amount noted by the insurance in box 26.  The allowed amount is the total payment the doctor will receive for each service.  The difference between the doctor’s charge and the insurance’s allowed amount is written off. That write off amount is called the “contract adjustment”.

That total payment (allowed amount) is divided between the insurance responsibility and the patient responsibility as shown in box 32 and 33.  The patient’s responsibility may be further divided by the reason why the patient is responsible as noted in boxes 27 (showing patient’s copay), 28 (showing non-payable services), 30 (showing deductible amounts), and box 31 (showing co-insurance). The total of these fields will equal the total patient responsibility listed in box 32.  

A deductible is a patient’s annual out-of-pocket payment before insurance will being paying. The deductible amounts vary based on policy. But a deductible can also be a sign of a problem in claim processing. If a patient’s policy doesn’t usually have a deductible but an EOB shows the patient responsible for a deductible, chances are the claim was processed out-of-network. Out-of-network processing can indicate that your claim did not have a referral, or that your practice is not the patient's chosen primary care physician (PCP) or a problem with the practice’s credentialing. This is not to say that some deductibles are not legitimate, many are... When in doubt, call the insurance and ask.

A copay is a small out of pocket amount due for each visit. It is usually paid prior to seeing the doctor. You will note on the insurance card examples in the reading insurance cards section that copays vary, not only be patient but also by provider type. Many policies will have different copays for primary care providers, specialists, prescriptions, mental health, hospital, emergency room, and urgent care. Remember that some insurance require a selection of a primary care provider prior to processing claims for the PCP. If your practice is not the PCP the patient is expected to pay the specialist copay. Some examples of specialists include surgeons, cardiologists, and neurologists.

The patient’s co-insurance is a share of the bill. It is usually a percentage of the allowed amount. For example Medicare requires a co-insurance of 20% from their patients. Here’s an example: Medicare will allow $100 for a service of that amount Medicare will pay 80% or $80 and the patient is responsible for 20% or $20. The coinsurance is usually applicable for all visits for that patient.

If there is a patient balance, the patient should receive an invoice or statement from the practice asking them to pay their portion. Usually statements are issued once per month and if the patient fails to pay the balance the outstanding amount is referred to an outside collection agency for follow up and collection. 

Finally the totals listed in box 32 (patient responsible) and 33(insurance responsible) will equal the total allowed amount as listed in box 26. The insurance payment is listed in box 35 and if there is a positive payment due, the EOB will be accompanied by a payment.

The payment listed on the EOB, would be posted in to the doctor’s office practice management system to keep track of which claims have paid and which have not been paid in addition to record the practice’s revenue.

You will notice that line item 3, CPT code 82541 is not paid by insurance. That is indicated both by the fact that the allowed amount is listed in the “not payable” field, box 28. In order to explain why this service is not paid, the insurance will include a “remark code” as indicated in box 29. That code refers to a description of the non-payment reason further down on the EOB or sometimes on a later page of the EOB.

In some cases the reason for non-payment may be due to a claim submission error by the doctor’s office or a processing error on the part of the insurance. Either way, claims that are not paid should be followed up on. In this sample the insurance states that the patient is responsible for paying for this serviced, but why? Could this be a processing error or maybe the office made a mistake with the CPT code. Although this line says that the patient is responsible, you want to avoid billing patients when it is not necessary for the sake of good relations with your patients. If this line was denied because of some error, the patient may be angry by an unwarranted bill. When in doubt, call the insurance.

Again, I will stress that it is imperative that someone follow up on unpaid claims or practice revenue will be adversely affected (and that means no money to give the biller a raise). 

If you would like to see the entire Aetna EOB and the detail about each field check out this website: How to Read an EOB

Electronic Claims

Claims sent electronically are often sent through a clearinghouse and transmitted via EDI (electronic data interchange). First, a clearinghouse is an agency that receives the claims from a lot of different doctor’s offices and distribute all of those claims to the correct insurance companies. This makes it so each doctor doesn’t have to connect electronically to every insurance, but rather the doctor connects only to one clearinghouse. The clearinghouse develops ‘connections’ with thousands of insurance companies to be able to send claims on doctor’s behalf. Two of the largest  clearinghouses are Emdeon and Relay Health but there are many others also.

The doctor’s office uses its medical billing software to create claims (medical bills to the insurance) for every patient who the doctor treats. The medical billing software also creates electronic files for those claims so you can send those claims to the clearinghouse in a common computer readable format. Each claim within the file contains information about the insurance company to which the claim will be sent, information the doctor sending the claim, and information about the patient and the patient’s condition/treatment. As you will recall from looking at the paper claim, the information is very similar in nature; however, the electronic version is hard for a human to read.

As with paper claims, the electronic claim’s address is VERY important. IF the claim doesn’t make it to the right ‘address’ for the insurance company, it cannot be paid. Every insurance has an electronic address and sometimes multiple electronic addresses depending on how they route their claims internally. While the electronic address is different in many ways, you can think of it as like an email address. The address is called a Payer ID and it is alpha-numeric. This Payer ID  tells the clearinghouse the electronic ‘mailing’ address for the insurance company. If you are curious about a Payer IDs, you can look at them on Emdeon’s web site (when you get to Emdeon's site, type Aetna in to the box titled payer name, then click the button titled view list).

The claims submitted electronically will produce two types of reports that tell you about the status of the claims you sent. These are clearinghouse reports and carrier reports. Both are referred to as EDI Reports (electronic data interchange). You can expect to receive these reports electronically within 24-72 hours after sending the claim. Although there are many different clearinghouses and many different insurance companies, the reports are basically pretty standard. These reports are VERY important.

The reports that come in reply to the claims you send will detail which claims that have been accepted sent forwarded to the insurance and which claims are rejected. If a claim is rejected it will not be sent to the insurance. The report is the only denial you will receive. If the rejection is not fixed, the claim will never be paid. In order to make sure you are collecting all the money due to the doctor’s office, you must review the reports daily, make the necessary corrections to denied claims and resubmit those corrected claims back through the clearinghouse for submission to the insurance.

The reports from electronic claims can be a little intimidating at first. They are a little tricky to read, but once you get use to them, it is really easy. To follow are a couple of example clearinghouse EDI reports for your review. In these examples, I have marked the reports to help you read them.

First is a clearinghouse rejection report. Review it carefully and notice the most important fields circled in red. There is a letter next to the field which corresponds with a description below in the legend.

This is another type of clearinghouse rejection report:

Next is an acceptance report. These claims will be forwarded to the insurance for adjudication also known as processing.

Carrier Reports are the second report you will receive. These come from the insurance company and this set of reports will only contain information about the claims that the clearinghouse accepted. Since the insurance has much more specific information about the patient and their policy, rejections from the insurance may be much more patient/policy specific. If a claim is rejected in an EDI report, this is the only rejection that you ever receive for a denied claim. Therefore the EDI reports must be reviewed daily and any errors must be corrected. After correcting the errors, the claim must resubmitted (sent to the clearinghouse again) if you wish to secure payment. Since most insurance companies EDI systems are separate from their processing / adjudication system the insurance claims department will have no record of claims that denied in the EDI reports.

So, if you ever call the insurance to ask why a claim is unpaid and they tell you that they never received it…

1. Ask the insurance to confirm their payer ID and compare it to what you have in your medical billing software. Then correct it if necessary before resubmitting the claim through the clearinghouse. Or, if the Payer ID is correct in your medical billing program…
2. Check your EDI reports to see if there is a rejection for that claim.

To avoid problems, be sure to review your EDI reports every day!

Sending Claims to Insurance

There are two ways to send medical claims to the insurance company, electronic and paper. The paper method is outdated. Very few paper claims are being processed anymore in the electronic age. However, if you have to send a paper form, sending them  is fairly simple…mail it. Still, there are problems with paper claims that make conversion to electronic claims very worthwhile. Sending a paper claim is more expensive than an electronic claim. Many do not consider the costs in their entirety. Remember that the mailing costs more than the stamp, the cost of the claim form, printer toner, the cost of the envelope and the cost of a biller’s time to prepare the claims. Unfortunately paper claims won’t go away just yet as they are still required by some smaller insurance carriers, for appeals and some corrected claims, But, try to avoid them when/if possible.

An important part of sending a paper claim is the address to which you mail it. Incorrect mailing addresses it the number one reason that claims are “not received”. Most patients’ insurance cards have a claims mailing address on the card, but just because it is there doesn’t make it right. The card may be old or the insurance changed office locations and the patient has not yet received the new insurance card. After a while you will become familiar with your practices most common insurances and their mailing address. But here are a few hints about sending paper claims to the right place.

·                       Pay close attention to the mailings, updates and letters that your insurances send to you. Most insurances will announce a change in their mailing address in advance with an effective date.

·                       Understand Medicare’s claims submission rules. Medicare and Medicaid are government programs (governed by CMS). The programs hire other agencies to process claims for them, these other agencies are called fiscal intermediaries. The contracts for a fiscal intermediary are awarded and change from time to time. With the change of fiscal intermediary the claims mailing address will also change. Watch your Medicare updates carefully. Remember, too, Medicare and Medicaid HATE paper claims and have limitations regarding who can send them. So before you bill Medicare/Medicaid on paper check to see if you are eligible.   

·                       Medicare requires that claims be sent to the Medicare fiscal intermediary responsible for the location where the services were preformed. For example, your practice has two locations one in New Jersey and one in Pennsylvania. On January 1 the patient John Doe was seen in the New Jersey office - send the claim to New Jersey Medicare because the doctor treated the patient in New Jersey. On January 2 the patient John Doe was seen in the practices Pennsylvania office – send the claim to Pennsylvania Medicare because the patient was seen in Pennsylvania. The place where the patient lives or which is the doctors “primary” office has no bearing whatsoever on claims to Medicare only where the patient was seen. A final example on this point, the patient John Doe lives in Florida and is visiting New Jersey for the week, he sees a New Jersey doctor for a head cold. The doctor will send the claim to New Jersey Medicare.

·                       Understand Blue Cross Blue Shield claim submission rules. Blue Cross has a program called the “Blue Card Program”. This entitles eligible patients claims to be submitted to the “local” Blue cross Blue Shield. The local Blue Cross is the doctor’s local Blue Cross. Blue Cross Blue Shield has offices in every state in the union your local is the state or local Blue Cross for the location where the services were rendered. The insurance card will indicate the words “Send to your local Blue Cross blue Shield Carrier” and usually have a blue suit case on the card. The local Blue Cross address is usually not the same as the in-state claims addresses although electronically they usually are the same, so call Blue Cross and ask for the Blue Card address and phone number. For example, a patient is covered under Blue Cross Blue Shield of Maine and is seen by a New York doctor, the doctor will send the claim to the Blue Card address assigned to New York Blue Cross providers.

·                       Blue Cross Blue Shield very often divides their claims by policy type and different policy types have different addresses. For example, HMO claims go to a different address than PPO claims. Pay attention to the address on the card!!!!!!!

·                       Understand an “administrator”. An administrator is a company the processes some claims for special groups within an insurance network these claims often go a different address that regular claims. A good example is Amerihealth, as of now Amerihealth PPO and HMO claims are sent to one address. There is a division of Amerihealth called Amerihealth Administrators who processes claims for small groups and unions. Amerihealth administrators, although a division of Amerihealth is a different insurance company as far as claim submission and phone calls go.  If you see the word Administrator on the insurance card, pay close attention to the mailing address and don’t assume that it is the same as the regular insurance that you are familiar with.

·                       Confirm claim submission addresses while you are checking patient’s eligibility. This small step can alleviate a lot of problems and really takes very little time.

·                       When in doubt - CALL and ask the insurance. Have the patient’s policy number and the provider tax ID or provider number ready and ask where they want claims to be sent.

Many of these same rules will also apply to electronic claims. Even though there is no envelope and no paper claim, the address to which you send the claim is VERY important. The electronic address is called a payer ID and will be discussed in length in  the next post.  

How to Complete a CMS 1500 Form

Preparing a claim for insurance billing is very easy but requires utmost accuracy. Even a minor error in this part will result in claim denial. Today most claims are billed electronically. Electronic billing consists of entering the billing information in to the practice management system and sending the claim electronically via EDI (electronic data interchange). The data that you enter in to the practice management software can also populate the CMS 1500 form. Although EDI and the paper form are different in many ways you cannot see, the basic premise is the same and best taught using the paper form.

You can break down the form in to three sections. At the top, you must enter the patient’s personal information, like name, date of birth, insurance information, etc.. At the bottom of the form you enter information about the visit to the provider including diagnosis, procedures, etc.. Last, there is information about the doctor who provided the services.

Here is an image of the CMS 1500 form used for medical billing:

CMS (The Centers for Medicare and Medicaid Services) provides a detailed, line by line explanation on how to complete the form. Rather than trying to retype all that info, I will provide you with the direct link to instructions on completing the form. Those instructions can be found at How toComplete a CMS 1500 Form. 

Types of Insurance

There are three basic types of medical insurance plans. They are Managed Care Plans, Indemnity plans and Combination Plans.  The three plans are very different in method and focus, here’s how:

Managed Care Plans	Indemnity Plans	Combined Plans
Focus on preventative care	Focus on present illness	Any combination of the managed care and Indemnity plans as written by the insurance carrier
Strict authorization/referral guidelines	Fewer requirements for service authorizations. No referrals
Limited list of physicians covered in network	Larger list of network physicians. Policies sometimes have out of network benefit coverage
No deductible	Has deductible
No coinsurance	Has co-insurance
Small out of pocket costs for the patient in the form of co-payments	Larger out of pocket expense with deductibles and coinsurances. No co-payments
Summary	Summary	Summary
More rules less expense	More expense less rules	Depends on the plan and benefits

In some situations patient's who have been injured will be covered by a “liability carrier”. This may be the auto insurance or workman’s compensation carrier.

Liability insurance does not have traditional insurance card. The information will be provided by the patient initially. The patient should give you the name and contact number for an insurance representative called the “adjustor” in addition to their id number called by the liability carrier the “claim number”. The adjustor reviews the accident details and handles the medical claim payment. When you speak to the adjustor for the first time to confirm coverage be sure to obtain the following information:

A.                The “claim number”. This number is in place of a medical insurance policy number. The liability carrier will refer to the accident and injury as a “claim”, don’t get confused.

B.                 The accident date. This information will be required on the claim form for an accident.

C.                 Documentation requirements. It is a pretty safe bet that the liability carrier will want documentation or doctor’s notes with every medical bill.

D.                Their fax number. This will help when you have to send documentation or forms and sometimes they will allow claim submission via fax too. 

Reading an Insurance Card

The patient’s insurance card contains valuable information such as the policy type, copay information, and claim submission address. Take a look at the insurance card below to become familiar with them. Remember that cards differ from insurance to insurance, but the basic information will always be present, so even if the cards are different you'll have an idea what to look for.

Front: On the front of the insurance card you generally will find the insurance company name, coverage type, patient name, patient policy number, and co-payment amounts.

  

Back: The back of the card will usually contain pre-certification contact information, contact telephone numbers and the claims submission address. 

Patient Check-in / Registration

When the patient comes in to the office you must collect information needed for medical billing. You will see what that information does in the next section. If the patient information is not accurate the doctor will not be paid for the office visit. Since people move and change jobs frequently, you can not confirm the information too often. Some patients get a little annoyed by this but they are even less happy when they get a bill because you have incorrect information on file.

To follow is a list of information you will need:

·                     Patient name, accurate spelling is imperative

·                     Patient insurance card(s)

·                     Patient date of birth

·                     Patient gender

·                     Patient address (street, city, state, zip)

·                     Patient Phone number

·                     Patient social security number. Some patients are not comfortable providing this information. That’s ok. If they refuse, get a copy of their driver’s license. Be sure that the copy is clear and you can read the drivers license number. If the patient’s account becomes delinquent, you will need this information to refer the patient to a collection agency.

Most practices have the patient complete a patient registration form to obtain all of the information necessary for billing.  Follow the link for an example of a patient registration form: Patient Registration Form

Precertification

In some cases the insurances require the provider to obtain permission prior to performing a procedure. This is called precertification, preauthorization, prior authorization, and precert or preauth for short. Precertification is required by some insurance companied prior to inpatient admission, some out patient procedures and tests. You should check with the insurance when in doubt about a procedure’s requirements for precertification and keep a master list of what does and does not require authorization for future reference. Update the list frequently and watch insurance updates for changes.

So here’s how it works. As noted in the eligibility post, check with the insurance during an eligibility check to see what type of procedures require authorization. The insurance representative will not give you a full detailed list of every procedure, but the information they provide will act as a guide. A good rule of thumb is that HMO plans often have strict precertification regulations whereas PPO plans are more lenient and traditional Medicare never requires authorization or referrals at all. Remember that Medicare patients may choose a Medicare HMO, which is a Medicare replacement not Medicare. Medicare HMOs will follow HMO rules.  

Here’s how the process works: The doctor will tell the staff to schedule a procedure for a patient. The medical office professional knows that means that they must contact the insurance company’s precertification department and request the authorization before the procedure date. There are three ways of obtaining precertification; the method you choose will depend on the insurance’s requirements.

The first way is by phone. To do this, call the insurance, provide the necessary information about the patient’s condition and the planned treatment, your request will be reviewed and an authorization is generated. Alternatively the insurance may require/allow authorization via fax or electronically. Insurances that require a faxed request submission often have specific forms that they will provide for your submission. Complete the form accurately and fax it to the insurance company. If your fax machine is able to provide confirmation of a successful transmission, you should print that and keep it. Documentation is important if the insurance claims that the request was not received in time. Some insurance companies are now accepting electronic precertification requests through their web sites. Any web-site transactions with insurance require pre-registration, but the registration time will save you a ton of time in the end.

Precertification can take time depending on many circumstances, such as the insurance’s requirements and patient’s diagnosis. Be sure to precertify the procedure as much in advance as possible to avoid any problems. Keep a log of the amount of time that precert takes listed by insurance carrier and record the insurance’s preferred method (phone, web-site or fax), insurance contact information and the usual procedures that require authorization so that you can be prepared in the future.  If you are not sure if a procedure requires authorization, call the insurance. It is better to err on the side of caution than to run the risk of the claim denying for no prior authorization.

If a procedure is not precertified in advance of the procedure date, the claim will be denied. Very few insurance carriers will allow a retroactive (after the procedure) authorization and if they will most reduce the payment amount since you did not adhere to their guidelines. 

To follow is a list of the information that you will need to have ready to precertify a procedure.

• Doctor’s name
• Practice name
• Provider  and group NPI numbers and tax id
• Patient name
• Patient date of birth
• Patient’s insurance identification number
• Procedure to be preformed
• Date of the procedure
• Both primary and supporting diagnosis
• Symptoms, clinical indications or descriptions such as size or location
• Facility or location where the procedure will be preformed
• Supporting documentation (office notes)
• The patient’s chart. Since insurance requirements vary, it is best to have the chart available to refer to for questions.

Most insurance companies have dedicated precertification departments. The department is usually staffed with both clinical and non-clinical members and directed by a physician. When you call you will speak with a person who will take the information about the precert and review the insurance rules as they apply to this situation. In some cases, you may be told that the procedure doesn’t require precertification, the request may be immediately approved (depending on the diagnosis, procedure and insurance company) and in other instances the request will be reviewed by the clinical staff or even the physician medical director.

You must understand, a procedure is not authorized until the insurance representative gives you the authorization number. If they collect the information and say that they will call you back after medical, clinical review the procedure is not authorized until they call back. Many times in the case of an expected call back, the representative will give you a reference number, this is not a precertification number just a request tracking number. When in doubt ask the insurance representative for clarification. Again, if a procedure requires authorization and authorization is not obtained prior to the services being rendered, the procedure will not pay!

• Important to remember precertification rules:
• Make sure that you have all of the required information before you call.
• Get the insurance representatives first name and last initial (at least).
• Always insist that precertification requests be checked with the CPT code NOT the name of the procedure as there can be errors with the name alone.
• Be prepared to provide clinical information like symptoms, locations, size and severity.
• Have chart notes ready for submission to the insurance for review.
• Listen to the representative carefully and take notes on what they are saying about the insurance requirements.
• Know the difference between a reference number (for tracking you request) and a precertification number (approving your request).

You should keep eligibility and precertification information either electronically or in the patient’s paper chart. If you choose to store it in a paper format, make up a form to be completed so that your inquiry and information is consistent. To follow is a link to examples of forms that will help to maintain the information from the eligibility or precertification calls. Eligibility and precertification Forms

Checking Eligibility

Before a provider sees/treats a patient, the office staff must check the patient’s insurance eligibility. Checking eligibility is the process of contacting the insurance to inquire about the patient’s coverage. You will want to know if the insurance policy is effective and what benefits the patient has for what types of services.

There are several ways to check eligibility from a phone call to electronic verification. Some practice management systems have an EDI eligibility checker, these are usually very easy to operate and often work based on the daily schedule. Check your practice management systems manual to see if your system has this capability and how to use it. If that is not an option, your clearinghouse may have the capability on its web site.

Eligibility via your clearinghouse may be an additional charge so be sure to ask first. Understand that the practice management system eligibility is run through your clearinghouse, so there is no reason to try both the practice management system and the clearinghouse. Choose the one that is available and most functional.  The one drawback to the practice management system and clearinghouse eligibility check is the limited insurances that are available for the direct connection for eligibility. This is really not too much of a problem though, because the fewer insurances that you have to call the better.

The next method for checking eligibility is via the insurance’s web site. This often requires advance registration but is very useful. The drawback here is that you have to keep moving between web sites and not all insurance web sites have this capability yet (especially smaller insurances like local union carriers). Lastly, is the good old fashioned phone call, this is the least efficient way to perform eligibility checks but a method that cannot be totally avoided.

I recommend a combination of the above. If the practice management system or clearinghouse has the ability use it for as many patients as it is able to do. Chances are several patients will not be reviewed, so for those try the insurance web site or a phone call.

Regardless of how you find the information, checking eligibility is an important step. Many patients do not understand their insurance and therefore they may give you the wrong information. That wrong information will result in claim denial. Also, there are patients who will provide expired insurance knowingly to avoid having to pay for the visit. The information you need to check patient eligibility will vary depending on the provider specialty, what procedures may be preformed, and the insurance company’s requirements.

Here’s what you will need to check eligibility.

• Your practices name and the doctor name
• Provider’s tax id number and /or NPI numbers
• Date of service
• The procedures that are going to be preformed on the patient (If you are not sure, check the chart to see if the last visit made any indication and if there is no previous entry ask the office manager what the usual protocol is for a new patient.) 
• Patient name
•   Patient date of birth
• Patient’s insurance identification number
•  Patient’s insurance group number

Once you have the necessary information contact the insurance. If you need to call them, the telephone number is generally listed on the back of the patient's insurance card. Here are some examples of what you need to ask the insurance about the patient's coverage prior to the patient's appointment:

• What is the insurance policy’s effective date?
• Who is the patient’s primary care physician?
• To what address should claims be mailed?
• What is the patient’s co-payment amount? Is there co-insurance?
• Is there a deductible due? Has the deductible been met (paid)?
• Does the patient’s policy require referrals for specialists?
• Does the policy require precertification?
• What number do we call for precertification?
• Is the patient required to go to a specific laboratory for blood work?
• Is the patient required to go to a specific facility for radiological tests?
• What is the insurance representative’s name?
• Be sure to date and initial your notes from this conversation.