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Webinar Q&A

As a follow up to our recent webinar, Denial Management: Field-Tested Techniques that Get Claims Paid, speaker Elizabeth Woodcock and Kareo have answered the many questions posed by participants.

Q: Will you provide the slides from this presentation? A: Yes, you should have received an email with the link to the recorded webinar and slides. If not, here are the links to the recording and slides.

Q: Is there a way that I can get CEU credit? A: To apply for PAHCOM CEUs you have to register and attend the event with your name and email address. To request the CEUs, please email marketing@kareo.com. For more information about PAHCOM, visit their website.

Q: Can you provide the website with the list of codes? A: Yes, here is the link to the list of standard codes www.wpc-edi.com/content/view/695/1.

Q. Does this list of standard codes include specialties? A: The list is the Claim Adjustment Reason Codes (CARC); they are not specific to specialties.

Q: Where can we get top 10 denials with a reference to the source of this data? A: Many payers publish the top reasons for their participating providers. The American Medical Association produces an annual report card that includes the top reasons; please see http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/national-health-insurer-report-card/denials.page.

Q: If we look for patient info elsewhere (i.e., other medical office, hospital) would that be a privacy breach? A: One would only have access to a facility in which the practice saw patients. You would work with those facilities to determine if access could be granted. I would recommend consulting with an attorney regarding your question.

Q: What is a Specialty Society? A: Specialty societies are organizations that provide information, tools, education, etc. for specific specialties or other groups in healthcare. Examples of this are the American

Denial Management: Techniques to Get Claims Paid

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Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP) and American Congress of Obstetrics and Gynecologists (ACOG). These organizations often provide tools specific to your specialty regarding clinical issues, as well as management topics such HIPAA, ICD-10, and Meaningful Use. Q: What is the best solution for claims status—calling, online, or written correspondence? A: To review claims status, the most efficient solution is to make the query online. If there is a problem with the claim, then make contact by telephone. If the issue can’t be resolved with a customer service agent at the payer, then make your case in written correspondence. Q: When you find out that a payer is not paying for a particular service, such as what they consider investigational, do you then set up that service as a self-pay service? A: This is really up to you—if you feel that the service is best for the patient, then you would want to have the discussion about coverage with the patient before the service is rendered. The only issue that you may run into is that some payers may not allow “investigational” services to be billed to patient financial responsibility by participating providers. This is a very difficult issue, and I would recommend your physician contact the payer’s medical director to discuss how best to handle if he/she feels that the service is the best care for the patient. Q: Would you recommend calling United HealthCare and asking for reconsideration verbally, or completing the form? A: If you feel that the reconsideration will be handled effectively over the telephone, then that is certainly an option. It is my opinion that using the form is ultimately effective for most situations because it creates documentation and avoids having to be on hold, which can actually consume more time than creating a form particularly if you have a template built. Q: Most of our denials are the result of the incorrect information we receive from the payer when we verify benefits. Are there ways to help prevent this? A: Unfortunately, insurance companies don’t always have the most accurate information when you request benefit information. A patient may have left a job and that cancellation hasn’t shown up in the payer’s system yet. Or there has been some other change that hasn’t been processed. Although there are challenges, it is still always better to check eligibility and verify what you can. I also recommend asking patients when they schedule and when they check in if there have been any changes to their insurance. It never hurts to complain to the payer if you find this to be a problem, and please do have a process to swiftly contact the patient after receiving a denial despite the verification of benefits. Q: Is it okay to bill a patient if all the research has been made to get a denial paid and you cannot reach the patient by phone? A: No, unfortunately not. When you receive a denial returned to you, the Claim Adjustment Reason Code will be accompanied by a two digit alpha—CO for “contractual obligation” and PR for “patient responsibility.” If the denial is reported as a “CO,” the payer is indicating that you have a contractual obligation to accept the non-payment. Only if there is a PR can you transfer the balance to the patient. Now, you certainly can communicate with the payer and argue your case, but most denials must be handled directly with the payer.

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Q: Is there a tactic you would use when billing secondary payers in order to get paid without the claim being denied stating: Primary EOB needed. This happens even when Primary EOB is stapled with the claim. A: There is no universal tactic that will guarantee success, but I would suggest contacting the provider representative and asking them if there is another process by which you can send the primary EOBs (different address? Electronic transmission? etc.). If there is not, I would suggest documenting the problem in a letter, and carbon copy the state insurer commissioner so that he or she knows your complaint. Q: When you said 50-70 accounts per day, do you mean 50-70 patients a day? A: This is referencing 50 to 70 patients’ accounts. In general, that means one encounter/visit per patient. However, if you are in “clean-up” mode (i.e., you have old credits, old receivables, etc.), and you are going back and fixing a lot of issues that happened in the patients’ accounts in the past, you might not be able to reach the 50 to 70 mark. So, it’s important to recognize that this benchmark is for standard work, not trying to clean up a mess. Q: Will insurance companies ever have to use one standard EOB format electronically and on paper just as providers are required to use one standard form such as the cms1500? A: I am not aware of any efforts regarding this issue. There is a significant movement to standardize insurance cards, but I have not heard of any initiative to standardize EOBs. Q: We have many requests for medical records from one insurance company. They request medical records on almost all claims. Is this legal? It seems like a delaying tactic and am considering going to the board of commissioners. A: I assume that this payer is requesting medical records before payment. (If they are requesting them after payment, that is another issue.) If you feel that this payer is stalling, I would contact your designated provider representative and state your concerns verbally. Then, I would send him/her a letter. I would then ask your physician to contact the payer’s medical director and, again, report it verbally and in writing. Either on this letter to the medical director, or in a separate letter, I would carbon copy the state insurance commissioner. Q: Our provider sees a lot of out-of-network patients and has had trouble getting the patient payments. What would be your recommendation to collect this money more efficiently? A: There are many best practices for collecting patient payments. Here are a few suggestions. First, it’s important to have a patient policy in place that states that patients pay co-pays and other patient responsibility at the time of service. It can be at check-in or check-out depending on the situation. It should also lay out self-pay requirements. Preferably all self-pay amounts should be at time of service. Barring that, you might consider offering discounts for self-pay patients who pay within a period of time such as 30 days or charging late fees for those who don’t. You can also let patients know about balances due when they schedule an appointment. While there are other strategies, these are a good starting point.

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Q: What are your thoughts on working your A/R based on payer turnaround. For example, Medicare pays in 14 days and Blue Cross pays in 21 days so should we work these within 3 days after the normal clean payment? A: Following payers’ payment cycles is certainly “best practice”; I think it is reasonable to follow up three to five days after you expect the payment to arrive. Q: We are getting denials on the global time on in-office surgical procedures. Can you explain the modifiers that have to be used during the global period? A: In-office surgical procedures do often have a global of 10 days, so most services should be included (and thus, not paid separately) if they are provided within that “global” period. For the unusual time that you would bill a service outside of the global, you would likely want to use modifier -24, Unrelated evaluation and management (E/M) service by the same physician during a postoperative period. There may be other circumstances for a modifier; please see your CPT® Manual or this link for more information: http://www.palmettogba.com/Palmetto/Providers.nsf/files/Modifiers_Pertaining_to_Surgery_or_Services_Within_the_Global_Period.pdf/$FIle/Modifiers_Pertaining_to_Surgery_or_Services_Within_the_Global_Period.pdf. Q: What do you know about Medicaid not paying co-insurance and co-payments since 2012 for out-patient services? Is there any way you know to get paid? A: Medicaid plans normally don’t have coinsurance or copayments; there are a few states in which there is a cost-sharing arrangement with the patient, but it’s normally $1 to $3. Because each Medicaid plan is its own payer, and they are all different, you’ll need to check with that plan. Q: How do we avoid getting a denial for "Inclusive"? A: There are several scenarios in which a procedure may be legitimately denied for inclusive. (Please see the Correct Coding Initiative [CCI] at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/ for more information.) In some cases, you may be billing for a service that must be denoted or demarcated as separate and distinct. In this case, please consider CPT Modifier 59 – Distinct Procedural Service. It is defined as: “Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. CPT modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. When another modifier is appropriate it should be used rather than CPT modifier 59.” Q: How do I rebill a claim without getting denied for a duplicate claim? A: I would recommend following the procedure for resubmitting a corrected claim as outlined by the payer; this is often referred to as the “reconsideration” process.

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Q: How do I address a Medicare denial N103? A: This is a denial related to services provided to prisoners. Please see this memo for more information: https://www.noridianmedicare.com/provider/updates/docs/mm7678_RARC_N103_incarcerated_benes.pdf. When treating a prisoner, you need to determine with the prison directly how and when payment for your services will be processed, as Medicare will not reimburse for incarcerated individuals. Q: We are a behavioral health center and keep getting denials from Medicare about the patients SSN being reported in prison at the time of service, what can we do to address this? A: See the answer above regarding prisoners. Q: I get my EOBs by paper and find M81given as a reason for denial. What does this really mean? A: M81 is a denial that signals a need for a more specific CPT® code. I would review the CPT® Manual to ensure that you are using the right code, review the payer’s website to determine any policy or protocol regarding the coding of that service as directed by that particular payer, and contacting your provider representative directly in the event that you cannot locate any advice in writing. Q: We get a Medicare denial CPT 82947 because of CLIA. What do I have to do for this denial? A: Without knowing all of the details regarding the denial, I am not sure that this is the answer. However, you should review the opportunity to add the modifier QW to this CPT® code to indicate that it is a CLIA-waived test.

Q: We bill for a vendor that distributes a product that does not have an existing HCPC/CPT code. We use C9399 and payer is denying as "Not a valid CPT/HCPC code". How can we get the payer to accept the claim? A: For services that have no code, I find that practices (or their representatives) must negotiate a specific contract in writing in order to receive payment for those particular services. Q: If we bill the wrong code and realize it after the claim is submitted, how do we correct the claim and resubmit with the right code? I have had this happen and my appeal has not been effective. A: The “corrected claim” process is likely the correct route, although each payer may have a different process. Here is an example of one payer’s explanation of its process: https://www.cgsmedicare.com/jc/claims/reopenings.html.

Q. Some services are denied by Medicare because it is capitation patient. Is there something I need to do differently on the claim? A: We would need to know more information in order to respond to this question.

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Q: Does Kareo have any appeals templates? A: Kareo does not offer appeals templates at this time. Some payers provide appeal forms on their websites. The speaker for the webinar, Elizabeth Woodcock, does offer sample appeal letters at: http://www.elizabethwoodcock.com/resourceGuide.html. Q: Can you show the Kareo screen again where we can see denied/rejected claims easily? A: Yes. You will find the denied and no response claims on your to-do list in the Kareo PM dashboard. Q: My to-do list doesn't show any of the things you just showed on dashboard. Is there a setting I need to change for my to-do list? A: The to-do list is configured by user, so your user permissions are likely not set to have full access. Also, the to do list manages by exception, so if you don’t have any rejections for example, then rejections won’t show up as a line item on your list. If the items you need to see are not showing on your to-do list, talk to your system administrator about changing the settings. Q: Is there a global period pop up for Kareo? A: Not at this time, but this enhancement is on the Kareo development roadmap slated for end of 2013 or early 2014.

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Q: How can I generate the 100% Adjustment Report in Kareo? A: In Kareo, go to Reports>Payment Reports>Adjustments Detail Q: Are the denial reasons for Kareo classified based on the ERA responses or are they determined by the billing staff? A: They are based on ERA responses, which will include the denial reason code and denial remarks.

Q: How do you do a batch eligibility check in Kareo? A: The batch eligibility feature will be in an upcoming release of Kareo in the next 30 to 60 days. If you are a Kareo customer, you will receive an email with more details. If you do not, you can see the information on the release notes in the Help Center.

Q: I am finding that Medicare does not use the same EOB codes that Kareo's ERA uses. Will Medicare be getting copies of Kareo's codes in the future so this can be more streamlined between all payers and our billing software? A: The standard codes Medicare uses are matched to the ERA in Kareo. If you are having problems with your EOBs, please contact Kareo support. Q: Does Kareo software integrate with Wound Expert? A: Not at this time. For a list of our third-party EHR solutions, please see this webpage. Q: Is there a way to export the "no response claims" list from the to-do list? A: They cannot be exported at this time, but they can be printed. Depending on your computer and other software, you may be able print as an ADOBE PDF file.

Small Practice & Billing Company Resources Please visit Kareo Resources at www.kareo.com/resources for helpful tools, webinars, whitepapers, and tips for how to help small practices become best practices. You can also view recorded webinars or register for our next event at www.kareo.com/resources. About Kareo Kareo is committed to providing education and insights to small medical practices. We work with in-the-trenches influencers, consultants, and Kareo customers to provide relevant tips on how to successfully manage medical practices and medical billing services. Find out more at www.kareo.com. About Speaker Elizabeth Woodcock www.elizabethwoodcock.com

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Elizabeth@elizabethwoodcock.com Elizabeth Woodcock is a professional speaker, trainer and author specializing in medical practice management. Elizabeth has focused on medical practice operations and revenue cycle management for more than 20 years. Combining innovation and analysis to teach practice operations, she has delivered presentations at regional and national conferences to more than 150,000 physicians and managers. In addition to her popular email newsletters, she has authored 12 best-selling practice management books, and published dozens of articles in national healthcare management journals. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder.