Develop your own provider profile — before the feds do
Develop your own provider profile — before the feds do
Where Medicare and its various federal watchdogs are concerned, a billing mistake isn’t always just a mistake — especially when the government’s high-tech computer software decides it’s spotted a suspicious pattern in the claims filed by your practice.
"These days, we find more activity — and, in turn, focus more attention — on what seem to be suspicious instances of claims submitted for services that don’t meet Medicare guidelines or do not appear to be medically necessary," says Patricia A. Williams, senior vice president of First Coast Service Options (FCSO), Florida’s main Medicare administrator.
It’s well known that Medicare payers keep detailed profiles of questionable claims submitted by each provider. Indeed, Williams credits FCSO’s recent success in recovering inappropriate payments ($107 million last year alone) to its use of computer programs designed to pinpoint both outright fraud and "wasteful activities" by comparing the billing trends of targeted providers against "bona fide" Medicare claim profiles.
In light of the tactics of Medicare carriers, it only makes sense for practices to use similar techniques to spot patterns and weaknesses in their own coding and billing operations, experts say.
In profiling your practice, experts recommend addressing the following areas, all of which appear in FCSO’s review strategy:
Poorly documented and/or outdated diagnosis codes.To avoid unintentional mistakes, make sure your diagnosis codes have been updated. Physicians and staff, and even computers, should be tested on the use of codes, specifically on making them as complete and specific as possible.
The more details and documentation you have, the harder it is for the government to rule that the procedure wasn’t medically justified based on the information presented. If you have had problems with frequent denials based on questions of medical necessity, check with the carrier on its policies regarding coding for that particular set of problems. Also, check on what protocols the carrier considers appropriate regarding how often a service should be performed over a specific time period and alternate ways to treat that particular medical condition.
Medicare is the beneficiary’s secondary payer.One of HCFA’s new policing priorities when it comes to processing claims is to ensure it doesn’t get stuck paying the bill for patients who are also covered by private insurance. However, Medicare’s information about a beneficiary’s employment and third-party insurance status often is outdated. This makes it even more important that patient files be kept updated with patients’ most recent employment/retirement status and alternative coverage before submitting a claim. To avoid possible denials, you might consider asking patients to call Medicare and update their files on their own.
Duplicative claims.If you are receive a number of denials because these claims were duplicates of claims already being processed, first check your computer software and billing system for a glitch. Second, remember that it takes time for a claim to move through the system. It is best to wait at least 14 business days to resubmit an electronic claim or 28 days for paper bills.
Coding miscues for services performed several times on the same date also can produce a duplicative claim denial. One way to avoid having your claim rejected is to log the procedure code only once, then enter the number of units provided in block 24G of the HCFA 1500.
Incomplete or inaccurate physician ID and referral numbers.A simple cross-check of your claims processing software will determine whether the various physician identification and referral numbers (PIN, UPIN) required by Medicare have been correctly logged for every physician in the practice. Also, remember that after hiring a new physician, you must submit the new physician’s group PIN before filing claims in the physician’s name.
Well-designed forms and office procedures will help eliminate the referral problem. For instance, patient registration forms should have a space to list the physician who referred the patient to the practice. Likewise, a similar line should be included on charge slips so the treating physician can note to whom the patient was referred. This information should automatically be logged into the patient’s computer file with a cross-check to ensure the data are complete and included on the claim.
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