Posted by Carl Mays on Mon, Jul 27, 2009 @ 08:51 AM
A series of successful class action lawsuits have led to positive changes for physicians - in theory. I say in theory because medical billing companies and medical billing departments must be vigilant to make sure that payers are living up to the promises they have made as part of their settlement agreements.
It is critical that quick action be taken each and every time that a settlement agreement is violated. If you believe that Unicare, Humana or BCBS are in violation of their agreement then you need to file a compliance dispute form. Each company requires a different form - of course - but there is no charge for filing a dispute. These forms can be found on the HMO Settlements Web site in the Compliance Center.
This dispute process has teeth and physicians have recovered millions of dollars in previously denied and underpaid claims. In addition, they have also saved millions more by avoiding repaying amounts that payers asserted were overpayments.
An example of the rules by which BCBS has agreed to conduct business will demonstrate how significant the changes have been. As a result of its settlement BCBS:
- May not seek overpayment recovery beyond 18 months (six months for insured plans) unless fraud is implicated;
- Must use a clinically based definition of medical necessity;
- Must adhere to most CPT coding rules, including payment for evaluation and management codes appended with modifier 25 and payment for add-on codes without reduction for Multiple Procedure Logic;
- Must pay for codes submitted with 59 modifiers to the extent they follow CPT rules regarding designation of separate procedures,
- Must provide 90 days advance notice of material adverse changes;
- May not require physicians to participate in all products,
- Must disclose their methodology for determining "usual, customary, and reasonable" amounts.
- Must not utilize global periods for surgical procedures longer than CMS', and
- May not automatically reduce CPT codes to codes of lesser intensity
In order for your practice to fully take advantage of these changes it is critical that you put in place processes to spot violations so that you can pursue the remedies that are proven to work (as described earlier). This is a great opportunity to take advantage of a more level playing field between providers and payers- do not let this pass you by. Make sure that the medical billing service or employee responsible for your medical billing is taking full advantage of these opportunities.
To put this into action you need a systematic process (such as automated reporting) to identify violations by the payers. This process needs to be as automated as possible so that you can catch all violations and not just catch them when they have occurred in volumes o large to miss.
Next you need a process to easily file disputes if a violation has occurred. Again, this must be automated so that it does not always end up at the bottom of the "to do" list. Finally, you need to have a system to follow the disputes to their conclusion.
With these elements in place you can be confident that you are taking full advantage of the agreements that have been made by payers. In addition, you will have a new and powerful weapon in your arsenal to maximize the legitimate collections you are owed for the high value services you provide and the hard work that you perform.
2009 copyright by Carl Mays II and the ClaimCare Medical Billing Company
Posted by Carl Mays on Mon, Jun 15, 2009 @ 12:08 PM
I am taking a brief respite from the previously mentioned outline for the series of posts on allowables and fee schedules to mention a key point about allowables - they are often ignored by insurance companies. If you are not systematically comparing your payments to your contracted allowables you are losing thousands of dollars. Most likely, your revenue is 7% lower than it should be - that is right 7%!
A recent National Health Insurer Report Card compiled by the American Medical Association measured payment accuracy of seven major payers: Aetna, Anthem BCBS, Cigna, Coventry, Human, United Healthcare and Medicare.
All of these payers to some degree strayed from contracted payment rate. The worst offender was United (did not pay contracted rate in 38.4% of cases), followed by Cigna (did not pay contracted rate in 33.8% of cases), Aetna (did not pay contracted rate in 29.2% of cases), Anthem BCBS (did not pay contracted rate in 27.9% of cases), Humana (did not pay contracted rate in 15.8% of cases) and Coventry (did not pay contracted rate in 13.3% of cases). Even Medicare missed contracted payment rates in almost 2% of cases.
It is hard to methodically track these underpayments. From our experience at ClaimCare Medical Billing Services, as we look across multiple clients we will see the exact same CPTs being underpaid by the same amount by the same payer in a given month across all of our clients. The following month we will see the same payer switch to underpaying a different set of CPTs. These under payments are not huge but they add up quickly to big dollars for a medical practice. The combination of switching the codes being underpaid from month-to-month and keeping the underpayment amount "under the radar" can make this difficult for an individual practice to spot. It is also difficult for a billing office to spot if they are not comparing your payments to your contracted rates (and dealing with multiple procedure complexities properly).
At ClaimCare Medical Billing Services we have found that comparison of payments to allowables can increase a medical practice's collections by 5 to 10 percent. This of course requires a strong process, powerful reporting technology and the ability to track complex procedures methodically-in the end, it can however add thousands of dollars to your bottom line.
Copyright 2009 by ClaimCare Inc and the ClaimCare Medical Billing Company
Posted by www.claimcare.net Admin on Sun, Aug 10, 2008 @ 08:24 AM
Texas has one of the most helpful and powerful clean claim laws in the United States. The penalties for a clean claim violation can go all the way up to the payer being required to pay billed charges; that's right billed charges. The basic idea of the law is that a payer has to respond to a clean claim within 30 days (45 days if it is not submitted electronically). In order to utilize the clean claim law effectively you must have a tracking system built into your medical billing process that flags:
- Which payers are subject to the clean a claim law (not all are),
- When a claim was submitted,
- When a request for information was received from the payer (if you receive one then it stops the 30 day clock until you respond),
- When your office responded to the information request (this starts the 30 day clock again), and
- When you received a payment or denial.
The design and implementation of the system and reporting can challenging, but it will pay huge dividends in terms of the penalties from payers and in the way in which you will make payers take notice of your claims next time. At ClaimCare Medical Billing Services we have used our clean claim tracking system extensively and have seen significant rewards for our clients - especially our Texas Medical Billing clients. We have actually received calls from managers at some of our payers that have assured us they would process our claims quickly and asked if we would please stop submitting complaints.
If you would like more information on this please fill out ClaimCare's Contact Us page.
Copyright 2008 by Carl Mays II