How Communications Affects the Relationship Between a Provider and a Medical Billing Service

In order for the billing to be done effectively it is crucial that the relationship between the billing service and the provider's office is a good one. Frequent communications with your providers is key to a good relationship. It is important to keep them abreast of everything that is going on with their billing and all that you are doing. When we first started our business we didn't see the point in telling a provider that we were taking care of a denial or appealing a particularly difficult claim. We assumed he knew we were taking care of it. But experience showed us that this is not necessarily true and you need to find a way to keep your providers up to date on the status of their accounts without bothering them.

Some providers say they don't want to know about the issues, but someone in the office should be watching for what the issues are. You don't have to speak to the provider every time you communicate. You can have a weekly fax or email that just gives the highlights of the issues for the week. It is important that they know that any issues that come up are being taken care of and you are showing them this by your weekly communication.

When there is no communications between the provider and the biller, the provider may assume that the biller is not doing that much because the biller isn't telling the provider about all the things that he or she is doing. It is amazing how many things we do for providers that they never realize. If you don't let them know then they don't know you did it and they don't realize all the services they are getting.

We work for many small providers who don't keep track of their claims payments. Their whole perception of what is getting paid and what is not getting paid is based upon two things. Do they have any money in their checking account and the explanation of benefits they get from the insurance carriers. They rip open envelopes and tear off checks. If there is no check some only wonder what happened. They often do not understand the reason codes and have no idea why there isn't a check attached. While we may be resubmitting a claim with a corrected diagnosis or ID#, one eob comes through as a denial before the second one comes through paid. Some doctors never notice that they were for the same claim. They only notice that one didn't get paid.

To keep our providers updated of what we are doing, we send a simple fax or email when we complete the billing for the week letting them know what the issues were. It might read something like this.

Dorothy Winn-has incorrect ID# - do you have a copy of her ID card?

Melvin Black-appealed denial for timely filing with electronic reports

Mara Rosen-clearing house report states she no longer has that Blue Cross policy-so you have new info?

Much of the work you do is not just the data entry of the claims and payments but your providers may not have a clue as to the extent of this other work. If you are in the habit of letting the provider know, they will value you even more.

A lot of times billing services think that if they are not hearing from the provider then he/she must be happy. That is a really bad assumption. They may be thinking anything from "Wow my billing service is great!" to "Man, what are they doing over there? Sitting around playing solitaire?" If you want to be successful you really need to know what they are thinking. The best way is to ask. There is nothing wrong with getting in touch with a provider and saying "things appear to be going pretty smooth from our end. How do you feel they are going? Is there any areas you are concerned about?"

If they are worried about something they should tell you. Then you can either rectify it if it is something wrong, or clarify it if it's a misunderstanding. Many billing services have lost clients based on lack of communication. It's something that can be easily rectified.

Training a Medical Biller

Training to become a medical biller can be overwhelming. Whether you are an employer who needs to train employees or you are looking to become a medical biller, good training is crucial. When we have a new employee the training process is intense. It is important that the new employee learn how we do things, and become as self-sufficient as possible as quickly as possible.

Of course in the beginning mistakes are going to be made. We start out by having an experienced biller sit directly with the new employee and have the new employee watch what the experienced biller is doing while taking notes. The whole time, the experienced biller is explaining step by step what they are doing, why they are doing it, how they accomplish it, and every other detail that the new employee may need to know. They are also explaining our practice management system, our filing system, our system of receiving information, and how we communicate with our providers. There is so much to show them.

Once we feel that they have observed enough, the experienced biller switches places with the new person and gives them a chance to try things out for themselves. The amount of time that a new person watches before they are ready to try it varies greatly depending on their previous experience and how quick of a learner they are. Once they switch places the experienced worker watches every keystroke to make sure they truly understand. Many times they give verbal instructions the whole time until they are sure the new person has grasped the task.

Once they are able to observe without having to give verbal assistance they will allow the new worker to complete a task and then check it over after they are done. This is still time consuming as it's being done twice basically. But we feel it is necessary in order to be sure the new person is doing things correctly. The experienced worker will check over each item and bring any mistakes back to the new person and show them what they've done incorrectly. We find this is a great tool. Learning from visually looking at your mistakes is the best experience you can give someone.

As you can see the training process (at least in our office) is very intense and very disruptive to normal work flow. It takes two people to do the job of less than one really. The process is slow but if you want the person to be effective you need to take the time in the beginning to make sure they are trained properly. When we bring on a new person it is usually several months before they are up to speed and the person involved in their training can go back to their regular duties.

If you want your employees to be good quality employees then you need to take the time to train them. You can't expect them to give you excellent quality if you haven't taught them how to do that. We find that mistakes take a lot more time to correct on the back end than they do to avoid them up front. If you take the time to properly train the person, it will pay off in the end.

The Basics of UB04 Claim Forms

UB04 claim forms are use by facilities such as hospitals and clinics to submit medical insurance claims to insurance carriers as opposed to CMS1500 claim forms which are used by doctors and other medical providers to submit their claims. This includes drug and alcohol rehab facilities, eating order facilities and surgery centers. When a medical office is classified as a facility with an insurance carrier it is necessary to submit the claims on the UB04 which is much less familiar to most than the CMS1500 form. While most medical billers are very familiar with the CMS1500 form the UB04 form can seem very complicated.

The facility forms look similar to the CMS forms in that they are printed in red ink on white paper. They can be purchased where most CMS forms are available and they can also be submitted electronically as well as on paper.

The UBO4 requires a few fields which are totally different than fields required on the CMS form. Some of these fields include Rev Codes, type of bill, condition codes, and value codes which can make it terribly confusing to the biller only familiar with CMS forms. In order to get UB04 claims paid, the biller must learn what these fields are and how to complete them correctly for their situation. Many of the other fields on the UBO4 form are similar to the CMS form but these few different ones must be completed correctly.

Many of the boxes on this form are not required for other than hospital billing so the biller must know which boxes must be filled. In order to avoid time consuming resubmissions for denials of these claims you want to make sure they are completed correctly. Charges for claims files on UBO4 forms generally are higher than charges billed for many medical specialties so the amount of money tied up when claims are denied for incorrect information can be substantial.

It is not unusual for many of the clinics and facilities to be out of network with most insurance carriers and therefore not billing on the UB04 forms as they are not billing the insurance carriers, they are collecting the payment from the patients. But some of these patients are finding out that they have out of network benefits which means the insurance carrier would reimburse them for all or part of the expenses. The patients are then responsible for billing the insurance carriers. The insurance carriers may then demand that the claims be submitted on UB04 forms and it ends up the responsibility of the confused patient.

Stop the Bleeding! - Ways to Prevent Unnecessary Loss of Income During These Hard Times

For most Americans, whether or not the government has officially declared these times as a recession or a depression, things are a little tougher than they were 10 years ago. This includes doctors. Many patients think that all doctors are living good and aren't hurting like "the rest of us" but that isn't true. Doctors are feeling the pinch now too. After all there are a lot of expenses in running a medical office, especially with all of the changes going on with EMR and ICD 10.

They have the normal expenses of office space rent, taxes, receptionist(s), nurse(s), physician help (NP's or PA's), insurance, office supplies, utilities, computers, software, and the list goes on. In addition to that many are faced with needing to buy new software to be compliant with the EMR laws and training expenses to prepare their staff for the switch to ICD 10. Most patients really don't have any idea how much a doctor has to pay just to keep their office open.

Now more than ever medical providers need to "stop the bleeding" by plugging the holes in their office that are causing them to lose money. One of those holes for many providers are denials. I read a statistic a while back that said that 47% of denied claims are never appealed. To me, that number is staggering. Sure there are claims that are denied correctly, the services may not be covered, or the patient may have met a maximum and the patient is responsible for the charges. But I don't believe it can be that many. And unfortunately, I've been in enough medical offices to know that many have office staff that are just not dealing with the denials.

I have found there are a couple of different reasons why denials in an office can go neglected. One of them is due to lack of time. Many offices are chaotic. They not only have the regular patient load, which in and of itself is enough to keep them running all day, but they have the add on patients who just have to be seen immediately. In addition, they've got the phones ringing, someone has called in sick so they are short handed, and they've got pharmaceutical reps coming in. You get the picture. They barely have time to get the billing out, possibly record the payments that have come in, but handling denials? Maybe they will get to those tomorrow. Unfortunately tomorrow never (or at least not usually) comes.

The staff isn't purposely ignoring the denials. They truly think they will get to them. The problem is that many insurance carriers have time limits on when a claim can be appealed. Most allow 60 or 90 days from the date the claim was processed to file an appeal. Also, if the denial means that a different insurance needs to be billed the timely filing limits on that carrier may be reached if the denial isn't handled quickly. If the denial means that the patient needs to be billed, the odds of getting payment are greater the closer it is to the date the services were provided. The doctor usually isn't even aware there is a problem. Many times, neither the doctor nor the staff have any idea how much money the office is losing due to these denials not being handled.

Another reason that denials go unresolved is if the staff in the doctors office doesn't know how to handle them. It's not always that they don't have a good comprehension of medical billing, but they don't always know what needs to be done in the case of certain denials. It may be a denial they are unfamiliar with or haven't run across before. Or it may be an insurance carrier that they haven't dealt with much. If they don't know how to handle it then it may go unresolved.

In some cases, doctors hire people to do their billing that don't have a good comprehension of medical billing. In this case not only do the denials go untouched, but there are a larger number of denials than there are in an office with an experienced biller. It is unfortunate, but some providers don't understand the importance of the billing.

No matter the reason that the denials are not being handled, the important thing is that the doctor do something to change it. There are a couple of things that can be done. First, see if there is anything that can be done on the initial billing to prevent any of the denials that are being received. If a doctor is receiving a lot of denials for terminated insurance plans then the staff needs to do a better job of verifying the insurance with the patient at the time of their visit. Maybe they are not asking the patient when they come in if there are any changes in their insurance information. Many patients forget to inform their doctor when they change policies. Having the receptionist ask will cut down on these denials.

Another thing that can be done is to develop a system for handling each denial. Having a system will eliminate the need for the staff to determine what needs to be done each time a denial is received. For example, if the doctor receives a denials for timely filing the staff should know exactly what to do. First, check to see if the claim was originally submitted in a timely manner. If it was, a claim should be reprinted along with proof of the original submission. If the claim was submitted electronically that proof may be an electronic report verifying the first submission. If it was a paper claim, it may be a patient ledger printed out from the practice management system.

In addition to the claim and the proof, an appeal form should be attached. It's best to design a generic one for the insurance carriers that don't have their own adjustment forms. This will cut down on time since the staff can just simply grab the generic form and attach it to the claim and the proof instead of writing up new one each time one is needed. For the carriers that have required adjustment forms, they should be kept handy for quick and easy access.

Having a system in place for each denial will greatly reduce the amount of time needed to file the adjustment request or submit an appeal. It will also make the process easier for the staff so it won't be such a dreaded task. Reducing the number of denials received and having a system for handling those denials will help the staff be able to deal with them in a more timely fashion.

Handling Denials For No Coverage or Coverage Terminated

One of the most important parts of billing is handling denials. Many providers' offices don't handle denials and end up losing thousands of dollars a year as a result. In fact, I saw a statistic once that said that 47% of denied claims don't ever get appealed. That is outstanding! Obviously based on that statistic the insurance companies have a great incentive to deny claims.

There are three reasons that denials don't get appealed. The first is that the denial is correct and there is nothing to appeal. In that case, there is nothing to be done except bill the patient if that is appropriate. The second reason is because the person responsible for handling the denials doesn't have the time to handle them. This problem can be rectified. If the right systems for handling denials are put into place then they can be handled in less time. Most time spent on denials is figuring out what to do about them, which brings us to reason number three.

The third reason that denials don't get appealed is that the person responsible doesn't know what to do about it. Many times they understand what the denial is for, but aren't sure what steps to take to rectify it. So over the next several months we are going to be covering the most common denial reasons and how they can be handled.

One denial that is very common is "denied for no coverage or coverage terminated." Seems pretty straight forward. But what do you do? There are actually a couple of things. First of all, receiving this denial does not mean that it is correct. Our local BCBS denies claims for this reason more often than I use a restroom. Many times it is just because BCBS issued the patient a new ID number or changed just the 3 letter prefix. It can actually be quite frustrating. If we receive a denial from BCBS for this reason we go to the BCBS website and do a search on the patient. In most cases we can pull up the correct ID number and resubmit the claim.

If the denial is for a company that does not have those issues, the next thing I do is look at the patient's claim history. Has the payor been making payments but suddenly stopped? In some cases the payor may have paid claims before and after the date of service they are denying. In that case a call must be made to the insurance carrier to question the denial. Hard to believe but they actually do make mistakes! (sarcasm)

Lastly, if the denial appears correct, or if we cannot find any additional information thru the website or a phone call, then the patient must be contacted. Usually we send out a patient statement with the charges, and a note stating "Your insurance carrier states your coverage was terminated. Please contact

our office with updated insurance information." Many times patients forget to notify the provider when they do have an insurance change. Receiving a bill will prompt them to notify you. Usually they call us and give us the updated information over the phone and the claim can get resubmitted.

The Advantages of Flat Fee Billing

The most common way billing services charge providers for their services is with a percentage of the receivables. This is often based on what is actually paid by the insurance carriers and sometimes the patients depending on the agreement between the billing service and the provider. This type of arrangement often works well for both as it is an incentive for the billing service to do a good job as their pay depends on it. There are both advantages and disadvantages to this way of charging the provider.

First of all, in some states it is illegal for the provider to enter into such an agreement as it is considered fee splitting and prosecutions have resulted. It is not common for providers to be prosecuted for entering into this sort of arrangement but it is a possibility and should be considered. Two states we know of that have fee splitting laws in effect are Florida and NY. So as a billing service you may think you are off the hook because it is only illegal for the provider to enter into this sort of arrangement but not so. The problem for the billing service is that you have entered into a contract that is illegal and unenforceable. So if you end up in court for any reason such as the provider didn't pay you for the last three months, basically your contract may not even protect you at all. It can be found to be an illegal contract and not enforceable.

So what's a billing service to do? Why not consider flat fee billing? Most billing services do not want to consider it as they don't know how to come up with a reasonable flat fee and providers are used to being quoted a percentage so they can't compare your price as easily. So if we tackle these two objections, you can start offering a flat fee instead of a percentage and you may find many advantages.

When a doctor objects to a flat fee for his billing instead of a percentage it is usually just because he can't compare it to other offers. Some providers are not aware that this practice is illegal and when they find out that it can get them in trouble they want to hear about other alternatives. A billing service can explain to the potential provider that they do not ever want to steer a provider toward an action that could be considered illegal or get them in trouble. They are here to help the provider and to keep the provider from doing anything that unintentionally that could be considered a problem later on.

Even if you are in a state that allows percentage billing it can be an advantage to the provider to know up front what it is going to cost him or her every month to have someone taking care of the billing outside of the office. From a billing service standpoint I much prefer a flat fee so I know what I can expect each month. With a flat fee I have a much better idea whether or not we are making a profit on that account. When charging a percentage it can fluctuate enough to leave you wondering if the account is worth the work. There are many circumstances that can affect payment that were in no way caused by the billing service who still did the full amount of work, but because the income was down that month, the billing service doesn't get paid either. Here's an example.

We had a provider sent his information by fax a couple times a month so we didn't see him often. He moved his office and didn't tell us. By the time we found out, so did Medicare who stopped his payments as they will if mail can no longer be delivered to the address they have on file. We filed a new 855I for him and waited three months for his application to process before he started receiving Medicare money again. We also waited three months before we could bill him again.

HIPAA 5010 - What It Is and How It Will Affect You

This is a basic breakdown of the HIPAA 5010. There are much more technical requirements, information and explanations.

Well, most of you should know what 5010 is and how it will affect you. If you don't you must have at least heard about it. It seems that all insurance carrier publications are overflowing with confusing information on this transition and the quickly approaching deadline. So we are going to try to break it down for those who still don't really understand what it is and if they need to do something.

First - what is it? HIPAA 5010 is a federal mandate that requires health plans, clearinghouses, and providers to use new standards in electronic transactions including claims, remittance, eligibility, and claims status requests and responses. HIPAA 5010 is an upgrade from the current mandate, or HIPAA 4010A. The new mandate is supposed to increase transaction uniformity and streamline reimbursement transactions.

The deadline for this new mandate is January 1, 2012. All affected organizations and providers should have long ago begun at the very least testing if they are not already compliant with the 5010 mandate or as Ingenix says "As the deadline approaches, affected health care organizations need to upgrade and test their claims management systems to accommodate 5010 and prevent operational disruptions." This means that if your current software is not compliant with 5010 then you will need to upgrade. And before we reach the deadline you will need to have tested your system to make sure it is compliant. Not doing so before the deadline may result in "operational disruptions" or in terms the provider will understand, mess up the accounts receivable.

So how do you know if you need to do something to prepare for HIPAA 5010? Well, if you submit all claims on paper and you don't receive any ERA's then you don't need to do anything. HIPAA 5010 is for electronic transactions only. That was pretty easy.

If you do submit claims electronically or do receive ERA's then you need to see if your system is compliant. Most people submit claims thru a clearinghouse. If you use a clearinghouse then you need to check with your clearinghouse to make sure they are compliant or to see where they are in the testing phase. Most of the major clearinghouses are prepared. You should also make sure that the practice management system that you use to create your electronic batches is going to be compliant as well. Make sure there is nothing that you need to do on your end.

If you receive your ERA's thru a clearinghouse, again you just need to make sure that they are compliant or are on track to be compliant. If you receive any ERA's directly from the insurance carriers you should check with them to see if there is anything that you need to do on your end.

Some providers or billing services submit claims using their own software as a clearinghouse. If you are one of these people you will need to make sure your software is updated by checking with your vendor.