Tag Archives: billing

Ask Lisa: Payer Notes Request: Now What Do I Do?

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stack of medicare insurance paperwork

With the increase in notes requested from third party payers, more recently Medicare secondary plans, it is good time to review the process once you receive a request.

First, do not ignore the notes request. You can call the payer acknowledging receipt of their request, or simply print or export the SOAP notes from your practice management program and send them to the payer. It is also highly recommended to include the initial patient intake form, or New Episode patient form, exam form(s), and care plan schedule including treatment goals which can simply be specific ADL functions pre-injury.

I also recommend looking to see what the most current Onset date is in your patient profile. Many recurring notes requests are due to the onset date going back two years and more. If this is the case, the patient is due for a re-exam and more than likely a new set of diagnosis codes, and you can include this information in your response to the payer.

If you need a review on what exactly to include in a SOAP note, click on this link HERE to access the checklist that complies with Medicare documentation requirements.

I use this checklist when I conduct onsite documentation reviews.

Questions? Need help with a documentation audit? Ask Lisa – I can help!

920-334-4561

lisa@pmaworks.com

Key Updates and Workarounds For the New ICD-10 Codes That Impact Your Office.

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icd-10, key updates for 2022Dear Chiropractors and Staff:

Are you having issues with not getting reimbursed due to the new ICD-10 codes and the deleted low back code? Having difficulty getting reimbursed from Humana and BCBS due to precertification requirements and other crazy denial codes?

Please read below where I provide you three key updates to the ICD-10 Codes and some workarounds that are of interest to your revenue cycle.

UPDATES: ICD-10 code Changes relevant to chiropractic

1. Deleted code: M54.5 low back pain.

2. NEW codes to replace the above deleted code include:
• M54.50 Low back pain, unspecified
• M54.51 Vertebrogenic low back pain
• M54.59 Other low back pain

3. Other Chiropractic-Relevant New codes added:
• M45.A0: Non-radiographic axial spondyloarthritis of unspecified sites in spine
• M45.A1 : Non-radiographic axial spondyloarthritis of occipito-atlanto-axial region
• M45.A2 : Non-radiographic axial spondyloarthritis of cervical region
• M45.A3 : Non-radiographic axial spondyloarthritis of cervicothoracic region
• M45.A4 : Non-radiographic axial spondyloarthritis of thoracic region
• M45.A5 : Non-radiographic axial spondyloarthritis of thoracolumbar region
• M45.A6 : Non-radiographic axial spondyloarthritis of lumbar region
• M45.A7 : Non-radiographic axial spondyloarthritis of lumbosacral region
• M45.A8 : Non-radiographic axial spondyloarthritis of sacral and sacrococcygeal region
• M45.AB : Non-radiographic axial spondyloarthritis of multiple sites in spine

NEW Cough codes:
• R05.1:Acute cough
• R05.2: Subacute cough
• R05.3: Chronic cough
• R05.4: Cough syncope
• R05.8: Other specified cough
• R05.9: Cough, unspecified

WORKAROUNDS
If you have claims to send (hopefully only a few) with DOS prior to October 1, with low back pain diagnoses, what should you do to ensure they do not reject by the clearinghouse and payer for adjudication? Your clearinghouse should, by now, be updated to include accepting claims with the old M54.5 code IF the DOS is prior to 10/1/2021. The commercial payer claims adjudication systems should also be updated now to accept claims prior to 10/1/2021 DOS if you billed with the old M54.5 code. Please make sure to get any outstanding claims with DOS prior to 10/1 submitted as soon as possible, if you have not already. If you only have a few claims going to commercial, you also have the option of sending these on paper instead of through your clearinghouse. Do not do both.

State Medicaid programs and Medicare will still require the use of the M99 codes for billing, so continue using those codes for these claims.

HUMANA is requiring pre-authorizations on all chiropractic therapy codes. The latest news is that starting in January, there will now be three entities that will be doing the pre-authorizations. a. Optum, b. Humana itself, or c. A new vendor, Cohere Health. Humana has advised us that the entity will be selected based on the patient’s policy.

When you verify a patient’s benefits you will need to make sure to ask:
if preauthorization on your therapy/rehab codes is required on the member’s policy,
which entity will be preauthorizing/reviewing,
and the process to follow when requesting services requiring preauthorization.

Not getting paid by BCBS, with crazy denial codes? No one at BCBS to help? You’re not alone. Offices across the country are experiencing this. So what can you do at this point? First, do a claims audit on your BCBS claims. Do you have the GP modifier attached? Is preauthorization on therapies required on the patient’s plan using AIM Specialty Health?

Your other option is to ask the patient to call into BCBS and advise that claims are being denied even though they have been billed out correctly. We do have scripting available to help your patients with the communication. Click here and request more information.

Questions? We’re here to help!

Lisa Barnett
PH: 920-459-8500
Email: lisa@pmaworks.com

“Increasing your collections through better billing and documentation”

Insurance Network Participation and Getting the Best Bangs for Your Buck

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Have you ever . . . Wished there was an easy way to make sense of the array of insurance networks out there? Should I be in? Should I opt out? Here’s a guide for you and your staff to follow to help you decide whether pursuing a specific insurance contract, and staying in, is worth your time and investment:

First, determine which companies you are in network with. Do you have a contract? What are your provider obligations? Are you getting reimbursed what the contract’s fee schedule says it will reimburse? Do you have a profile set up with the national Council for Affordable Quality Healthcare (CAQH) universal provider database and is the information current, and reviewed quarterly? There is no charge to create and maintain your profile in this credentialing database.

Second, make sure you know if you are currently enrolled in Medicare and if you are a participating or non-participating provider. Are you also currently enrolled as a provider in your state’s Medicaid program?

Third, audit your patient demographic. Run a report in your practice management software. What percentage of your reimbursement is coming from insurance? What percentage is coming directly from patients? Which payers are you mainly seeing patients from? Are you finding that patients are requesting you be in network with a certain company? Who are the main employers in your area insured with? Are you enrolled as a provider with the Veteran’s Administration in your area?

Fourth, develop a spreadsheet called “Insurance Networks” to help you and your insurance department keep the information organized and up to date.

Once you have a grasp on the above, you’re ready to determine if you need to pursue network participation with additional companies. Treating this like a sales or business venture, you’ll want to have insurance companies coming to you and requesting you be in their network. Remember, it is to their benefit and their obligation to keep their paying policyholders happy. Patients should feel free to call their insurer requesting you be on their plan. Patients have done this, and outcomes have been successful. Why? Because the worst phone call an insurance company can receive is from an upset policyholder who can’t afford to see their favorite doctor who is helping them (that’s you!) because the doctor is not on the plan.

Things to consider prior to enrolling in a plan include:

  • What is the reimbursement rate?
  • What percentage of the approved charges are taken out for contract discounts?
  • Is there a fee to join?
  • What are your provider obligations?
  • Do they want you to participate in their workers compensation, PI programs? (In our experience, opting in to the WC and PI products means no steerage to you, and cut reimbursements).
  • Are there pre-authorizations required prior to care? Is there a visit limit?
  • What is the initial credentialing and re-credentialing process?

Now, you are on all the plans that are making your pocketbook and your patient happy. What do you need to do to maintain your in-network status? You will need to notify a payer with updated clinic information anytime there is a change in information you submitted at enrollment. This includes phone number change, address change, adding a new provider to the office.

You will also need to make sure you are tracking re-credentialing timeframes for each insurance company. Typically, the recredentialing process for commercial payers is every three years but since your enrollments with each payer fall on different dates, your re-credentialing due dates will vary. Your Medicare re-credentialing is every five years. Re-validation with Medicaid programs is typically every three to five years, depending on your state’s standards. For example, it is every three years in WI and every five years in MI. Many of the larger commercial payers such as Blue Cross, Humana, United Healthcare/Optum Physical Health, use CAQH to approve your re-credentialing. Those who do not will send a written communication via mail or email letting you know your recredentialing is coming due and will include the applications and instructions. Make sure to track these dates in your insurance spreadsheet.

We’ve just touched the surface of network plans and credentialing. Email me for assistance with how these processes work for your practice. You may reach me at lisa@pmaworks.com
Happy Credentialing!

Lisa
“Increasing your collections through better billing and documentation”

Trizetto Moving to the Cloud

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I wanted to pass along the following communication from Trizetto to help you with a smooth transition.

Please share it with your insurance and billing team so they can plan accordingly. Remember, claims will not go, and EOBs will not be accessible during the time-frame of 11:59 p.m. CST on March 14, 2019 until approximately 11:59 p.m. on March 17, 2019.

If you are not a Trizetto/Gateway EDI client, you can disregard the information below.

Sincerely,

Lisa Barnett

“Increasing your collections through better billing and documentation.”

=====================

Important Message from Trizetto Electronic Claims Submitter

RE:  Microsoft Azure® Migration

Dear Valued Client,

In order to ensure the most secure, reliable and highest performing platform for our services, TriZetto Provider Solutions, a Cognizant Company, will migrate data from our St. Louis data storage facility to the Cloud-based Microsoft Azure® platform.

Why Are We Migrating?

A cloud-based data center will align data transport security protocols to industry standards while also providing significantly enhanced information security and opportunities for growth. We believe the benefits of this migration far outweigh the costs, and that our clients will benefit greatly from this transition. Benefits include:

  • Increased speed
  • Consistent, reliable storage capabilities
  • Higher levels of security

How Will Your Organization Be Affected?

The transition of data will have a direct impact on our clients. Because of the migration, clients will experience an extended outage starting at 11:59 p.m. CST on March 14, 2019 until approximately 11:59 p.m. on March 17, 2019. During this time all applications will be inactive and no incoming transactions will be accepted for processing.

TPS is working diligently to ensure a seamless transition. We have chosen to put this project into effect over a weekend to minimize impact to our clients. We apologize for any inconvenience this may cause.

If you have any questions or concerns, please reach out to our customer service team at 800-556-2231 or physiciansupport@cognizant.com. Thank you for your patience and support during this time.

-TriZetto Provider Solutions

Preparation for the September 7 switch to NGS Medicare

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This shouldn’t be too big a deal, but there are a couple steps I want to make sure you are on top of. Obviously it would be best if you can attend one of the Wisconsin CSW Medicare seminars (here), but these are the basics:

  1. Make sure you have talked to your billing software company and your clearing house and that you have made any changes needed so that your Medicare claims goes to the correct place as of Monday, September 9.
  2. Do your final billing to WPS Medicare on Friday, September 6. That is the last day you can bill to them. Starting with dates of service September 7 or later, send those to NGS Medicare.
  3. You and the doctors should review the diagnosis that NGS Medicare allows for chiropractic claims. I have heard that there are slight differences, so this all has to be reviewed prior to submitting claims after the switch. Medicare Allowed Diagnosis Codes
  4. The new chiropractic policy for Wisconsin, Minnesota and Illinois is L27350 (here:LCD for Chiropractic Services) and has all the diagnosis allowed. Double check these on your Medicare patients. Any Dx not on this list will be denied.
  5. Doctors need to review all onset dates for all current Medicare patients to make sure that they are under active care, that they have an updated onset, and that documentation is in order (see #4 above).
  6. In order to document your objective goals and functional impairment, I strongly suggest you start using an outcome assessment tool every 30 days with all Medicare patients. In speaking to several clients, they like the Functional Rating Index. It is quick, easy for a Medicare patient, and very fast for the staff to score.
  7. You can find the FRI form for free at http://www.chiroevidence.com/FRI.html. There is a two page version or a one page version.

As always, call me if you have any questions, but these are the minimum basics that we have to be ready to move on.

Best, Dave

Billing Audits and “Red Flags”

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Angie’s Angles
From a Chiropractic Billing Consultant

For your protection, you should be aware of the Top 10 Red Flags for a billing audit in a chiropractic office. Here they are.

Since this is the beginning of a new year, I will start with the Top 10 Red Flags for a billing audit (in no particular order):

1.  “Phantom Billing”—Billing for services not rendered.

2. “Double Billing”—charging more than once for the same service, e.g., using an individual code again as part of an automated or bundled set of tests.

3. “Clustering”—Using only a few codes on the theory that it will average out.

4. “Upcoding”—Using a higher reimbursement code than the code reflecting the service rendered; e.g., billing for complex services when only simple services were performed, billing for brand named drugs when generic drugs were provided, listing treatment as having been for a more complicated diagnosis than was actually the case.

5. “Unbundling”—Using two or more billing codes instead of one inclusive code where
regulations require “bundling” of such claims. Submitting multiple bills in order to obtain a higher reimbursement for tests and services that were performed within a specified time period and which should have been submitted as a single bill.

6. “Code Jamming”—Inserting or “jamming” fake diagnosis codes to get insurance coverage.

7. Billing for non-covered services

8. Billing for services that are not reasonable and necessary.

9. Inappropriate balance billing—billing Medicare beneficiaries for the difference between the total provider charges and the Medicare Part B allowable amount.

10. Routine waiver of co-payments and billing third-party insurance only.

The complexity of managing a practice is not a walk in the park. As a Billing Consultant with PM&A, my job is to free doctors from the worries that can accompany running the financial end of a medical practice.  I can review and streamline your billing department, train staff, and credential doctors with insurance companies, among other services.

Questions on how any of these might apply to your office? Contact me and I will let you know.
Next month – look for tips on nailing your Financial Consultations!!