APPROACHES TO INSURANCE FILING AND TRACKING

Rebecca H. Wartman OD Heart of America Contact Lens Society 2015

Disclaimers for Presentation

1.

All information was current at time it was prepared 2.

Drawn from national policies, with links included in the presentation for your use 3.

Prepared as a tool to assist doctors and staff and is not intended to grant rights or impose obligations 4.

Prepared and presented carefully to ensure the information is accurate, current and relevant 5.

No conflicts of interest exist for the presenter financial or otherwise

Disclaimers for Presentation

6.

Of course the ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services 7.

AOA, AOA-TPC, HOACLS, its presenters, agents, and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained herein

What we will cover today

 CMS 1500 Revised Form Changes  Electronic Filing and Payment   Clearinghouses Claims Filing   Claims Resubmission and Appeals Top Denial Reasons   Fees, copayments and deductibles Fee discounting  Insurance overpayments

CMS 1500 Form 2/12 Revision

   Developed by National Uniform Claims Committee (NUCC) Medicare began accepting, 02/12 version 1/2014 Medicare began only accepting 02/12 version 4/2014

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CMS 1500 Form 02/12 Version WHY?

Adds functionality Indicators to differentiate ICD-9-CM & ICD-10-CM diagnosis codes Now can use 12 diagnosis codes Ability identify provider roles (on item 17):   Ordering Referring  Supervising Align CMS 1500 02/12 with changes in 5010 837P electronic standard

CMS 1500 Form 02/12 Version

New QR code at top of form

CMS 1500 Form 02/12 Version 12 diagnosis places

CMS 1500 02/12 Changes

Box 1

CMS 1500 02/12 Changes

  The following have been deleted & changed to “Reserved for NUCC Use”  Deleted : 1.

2.

3.

4.

Box 8: Patient status Box 9b: Other insured DOB & sex Box 9c: Employer’s name or school Box 30: Balance due

CMS 1500 02/12 Changes

Box 14

CMS 1500 02/12 Changes

Box 15

CMS 1500 02/12 Changes

Box 17 If one or more providers involved- priority Referring then ordering then supervising

CMS 1500 02/12 Changes

Box 19 Use Taxonomy OR provider identifier

CMS 1500 02/12 Changes

Box 21

CMS 1500 02/12 Changes

  Diagnosis codes added without decimal points Example Acute atopic conjunctivitis   372.14 37214 ICD-9-CM H10.13 H1013 ICD-10-CM

CMS 1500 02/12 Changes

Box 22

CMS 1500 02/12 Changes

Electronic Filing And Payment

  Electronic Data Interchange (EDI) for Medicare Fee For Services  Must enroll via paper or on PECOS  Provider EDI number and password issued  Permitted to use     Billing agent Clearinghouse Network services vendor A/B MACs Direct Data Entry (DDE) system Requires electronic transfer of claims from Medicare to secondary payer(s) ► coordination of benefits

Electronic Filing And Payment

  Electronic Remittance Advice (ERA) Agreement executed by each provider to receive ERA  Required to retain electronically filed claims same as hard copy claims

Electronic Filing And Payment

  CMS ►free downloadable translator software  Read the ERA  Print SPR (Standard Paper Remittance ) CMS ►free downloadable billing software (PC-ACE Pro32) via contractors  ERA functions via ANSI-835 ER Module

Electronic Filing And Payment

 Electronic Funds Transfer  payments directly to provider’s financial institution  WHY 1.

Reduce amount of paper in office 2.

3.

4.

5.

6.

Time savings for staff Avoidance of bank deposit hassle Eliminate risk of checks lost or stolen Faster access to funds Easier reconciliation of bank statements

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Clearinghouses Defined

Aggregators electronic claim information managed by software Clearinghouse scrubs claim checking for errors  Average error rate reduced 28% to 2-3% 

CAUTION:

 ensure they are properly scrubbing claims Eliminated quality measures  Incorrectly editing diagnoses

“Clearing house hell” = your clearing house tells you that ‘you absolutely have a billing software problem’ while the claim software provider assure you that the problem is the clearing house

Round and round you go….

Clearinghouses Offerings

3.

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5.

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7.

8.

9.

1.

2.

Eligibility Verification

- Determine copays before appointment

Electronic Remittance Advice (ERA)

– Payments/Adjustments

Claim Status Reports

- Know the status of claim at all times

Rejection Analysis

- Error codes explained in plain English

Online Access

- Edit/correct claims online

Printed Claims

–If needed but still track/ manage them online

Patient Statement Services

–patient statements automatically

Real-time Support

–personal support and training provided

Affordability

– services will not “break the bank”

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Clearinghouse Checklist

Payer List:

ensure insurances typically file are on list

Nationwide:

Consider nationally operated rather than regional clearinghouses

Claim Software:

Ensure experience with your medical billing software to avoid issues

Easy-out Contract:

month to month subscription

Support:

Contacting their support before you sign up to assess help levels

Error Reports & Control Panel:

reports Look for easy navigation clear, concise claim errors and rejections

Monthly Fees:

cost Typical charge of $75-$95 per month (per doctor or provider) Eligibility typically additional

Prompt Claims Filing & Follow Up

  Know appeal time limits for each plan  Some are 120 days for appeal    Know the filing time limits for each plan  Medicare: 12 months from date of service  Some private as short as 30 days Some private as long as 24 months Some BCBS carriers allow 120 days Ensure claims leave clearinghouse  Clearinghouse rejections not counted as filed

Prompt Claims Filing & Follow Up

     Original filing not typically the issue Develop a plan for correcting rejected claims Monitor claims rejections for common errors   Closely monitor for inappropriate write offs Monitor for “dumping” insurance balances into patient accounts Monitor “Over 90 day” insurance receivables Do not allow re-filing to be delayed

Claims Re-filing vs Claims Appeal

Appeal = action taken if you disagree with coverage or payment decision  Understand why claim rejected  Correct claims and re-submit if simple error   Omission of modifier Omission of NPI number   Incorrect diagnosis codes Etc

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Claims Re-filing vs Claims Appeal

Avoid future denial by submitting claims accurately Some Medicare denials can be adjusted

via telephone reopening

Medicare appeals - complete forms electronically  Print and sign - attach supporting documentation – mail Level 1 appeal: Redetermination  

120 days

from the date of the initial determination Remark code MA130 corrected-resubmitted, not appealed Level 2 appeal: Reconsideration  

180 days

from receipt of Redetermination Submit to the Qualified Independent Contractor

Common Denials for CMS

   Hospice care patient denial  Services unrelated to the patient’s terminal condition may be paid separately  File with GW modifier 'Noncovered services' are never covered  Includes eye refraction  File for denial only- file with GY modifier Services bundled per National Correct Coding Initiative  Know when exceptions allowed   Use 59 modifier appropriately Understand 25 modifier use for E&M code

Common Denials for CMS

  Medicare is secondary payor Medicare replacement is primary  Verify which is primary or replacement and which is secondary insurer for specific patients  Pre- and post-op visits included in global surgery package  Understand when to use 24 modifier for E&M  Understand when to use 79 modifier for procedures

Approach to Denials

      Review all EOB as soon as arrive Post all payments Cross file any required claims Bill any outstanding balances to patients Understand when appropriate to collect and when have to write off balances

REVIEW ALL UNEXPECTED DENIALS IMMEDIATELY!!

 Reason for denial    Error in claim Change in policy Incorrect claim information

Approaches to Denials

       Saving denials to do later -- well….never done?

Contact patients if incorrect insurance given Contact patient if need further information Correct any obvious errors and resubmit Investigate all other denials for reasons Contact insurance if required Avoid repeating same errors

ABN Criteria

Advance Beneficiary Notice of Non-coverage (ABN)

    MUST USE THE OFFICIAL FORM May be used for voluntary notifications Mandatory field for cost estimates of items/services New beneficiary option  Patient may choose out-of-pocket payment and not have a Medicare claim submitted

Option 1: Probably most common Option 2: CANNOT bill Medicare Option 3: Patient rejects service

ABN Criteria

    Form in English and Spanish Must deliver before service rendered Copy must be provided to beneficiary ABN never delivered in emergency situations

ABN Criteria Modifier Use

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GA Modifier

 Expect denial item/service not reasonable/necessary  ABN signed and on file

GZ Modifier

 Expect denial item/service not reasonable/necessary  No ABN signed and on file

GY Modifier

 Indicate service is statutory excluded/non-covered  File claim only if patient requests or need denial

Medical vs Well Vision Plans

     How to handle telephone quotes How to code How to differentiate How to be consistent How to “play by the rules”

REMEMBER:

 Be consistent when coding across the board , REGARDLESS of payment method

Medical vs Well Vision Plans

  Some vision plans have coordination of benefits Medical first → secondary → well vision plan  More paperwork involved  Many vision plans trying to cover medical conditions      Some providers give new patient option to bill vision plan if already know visit is medical  Bring back for other testing Discuss in detail with patient May bill procedure to medical plan on same day-copays!

Cannot duplicate bill for same examination Educate patients for future examinations if medical

Medical vs Well Vision Plans

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Communication is the key

    PR issue and Patient cost issue Decide how office will handle Provide all staff with training Develop patient materials

Medical vs Well Vision Plans Telephone Quoting

 Call any Primary Care Office  Ask the cost of an exam  What is the answer?

 THAT DEPENDS ON WHAT YOU NEED Develop staff scrip to answer pricing issues Consider ranges of fees Ask questions of patient before you answer

The Fee is THE Fee

     Your fees for each CPT code set and standard Review fees annually Understand major insurance allowables Review your chair costs   Ensure your fees align with national and regional Relative Values (RVUs) Ensure CPT ® and ICD codes updated Ensure you are properly applying all rules

Co-pays and Deductibles

      Know what patients will owe in advance You are obligated to collect all copayments You are obligated to collect all deductibles Exceptions ►rare and well documented Collect all applicable fees at time of visit Expect payment at time of visit  Some even collect PRIOR to visit  Set office policy for non-collectable accounts   Write off after billing “x” times Send balances over “x” amount to collections

Discounts and Fee Waivers

 Cash Payment Discounts You are allowed to discount for cash payment BUT 

Rule of Thumb

  Discount no more than 20-25% for no more than about 20-25% of your patients- cash- no insurance Does not apply to Contacted Plans  Each plan has fee schedule you contract to accept    Discounting insurance co-pays and deductibles should be rare and well documented for specific reasons  Hardships Consider avoiding any “professional” discounts Save discounting for truly needy

Insurance/Patient Overpayments

    Promptly handle any overpayments Do not wait Options   Notify patient  May ask to

apply as credit toward next visit

Patient must agree If patient does not agree  Immediately send refund with explanation

Responsibility to KNOW rules

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No excuse for not knowing rules

1.

Contractor published requirements 2.

Previous review, hearing decision, or other notice informed of requirements 3.

Reasonably expected to know requirement based on standard medical practice 4.

Physician received denial/reduction for same or similar service

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Responsibility to KNOW rules

National Carrier Determinations Local Carrier Determinations Local Carrier Policies Local Carrier Bulletins Local Carrier Email Notices National Correct Coding Edits Private Insurer Medical Polices Lectures ** (“Danger Mr. Robinson”) Periodicals State and National Associations (AOA)

Resources

 CMS Medicare https://www.cms.gov/Medicare/Medicare.html

 American Optometric Association http://www.aoa.org/coding  AOA Coding Today http://aoa.codingtoday.com/  Local Carrier Websites

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QUESTIONS?

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THANK YOU!!