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Top 5 Reasons For Claim Denials! You Cash In On Your Medical Practice

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Claim DenialsThough physicians are very careful in filing the claims to the payer, still most of their claims are denied.

Here are top 5 reasons for claim denials which most physicians face but either realise later or are not able to figure out:

Duplicate claims:

Have you ever tried to resubmit a claim for which you have not received any response? If yes then you shouldn’t, as it creates confusion for the payer and may ending up as a duplicate claim.

Claims/service lacks information:

Make sure you get CO16 code which says information is incomplete to process the claims. A remark code is required for additional information.

Benefit for this service is included in the payment:

The insurance company denies the claim for a service as it has already paid for another service on the same date (as a part of bundled service).

At least one remark code must be provided:

This may include either a Remittance Advice Remark Code or NCPDP Reject Reason Code.

The time limit for filing has expired:

The maximum filing limit of Medicare is 2 years and minimum 1 year. If you have filed your claim within the time limit then appeal it with a required proof.

Increased Reimbursement For Primary Care Physicians, A Closer Look !

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A welcome respite for primary care physicians !

Everybody knows that primary care physicians are struggling to stay in business. A mandate by the Affordable Care act has announced that Medicaid rates for certain primary care procedures will be paid on par with Medicare rates.

 To receive additional reimbursement physicians will have to fill out, a, state specific Medicaid self-attestation form.

Medicare

Who are covered ?

Family practices, pediatricians and general internal medicine physicians are eligible for increased reimbursement. So are several other sub-specialties and physicians who perform high levels of primary care services. The major criteria are that, physicians should be board certified and have a billing history that indicates that about 60% of their billing is for primary care codes.

The rate increase will be in effect till the end of 2014. Physicians, who’ve registered through MITS and are approved by the Office of Medical Assistance, can see more digits in their pay check from April 2013.

The code to more dollars !

Primary care physicians will be reimbursed in accordance to HCPCS codes related to primary care. Evaluation and management codes from 99201 through 99499 are eligible, as are certain vaccine administration codes.

The rough and tumble of practicing primary care…

Primary care physicians are working under heavy financial pressure. The sequestration cuts of 2013 have taken a heavy toll on medical practices. The sustainable growth rate formula has quickly turned in to a nightmare for physicians.

 Reimbursement cuts, operational pressures and complicated regulations scared the daylights out of physicians.

Quite arguably it was primary care practices that were the hardest hit. Primary care centers were soon shutting their doors as it became increasingly difficult to practice. Primary care practitioners were finding it almost unfeasible to take care of their elderly Medicare patients.

At a time when it was needed the most !

The increase in reimbursement has come at a time when physicians need it the most. The increased Medicaid reimbursement means physicians are offered a reprieve after all the financial pressures they’ve gone to.

Want a few tips to increase the revenue of primary care practices ?

Make Sure Your EMR Doesn’t Make You Face Medical Billing Malpractice Charges

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EMR-Overbilling

Beware your EMR could land you in a tight spot !

There is a lot of dust raised about EMR’s again. According to recent reports an EMR can lead to inflated costs and fraudulent billing. Allegedly, physicians have added about 11 billion more to their fees, over the last decade alone. The Center for Public Integrity’s “Cracking the code” series, has found that the usage of EMR/EHR’s have resulted in widespread billing malpractices.

More to it than meets the eye…

Healthcare experts argue that this a strong marker of the negative impact, wishy-washy rules can cause. It can not only make physicians vulnerable to fraud and abuse charges, but also be potentially life threatening for patients. Mostashari, the National Coordinator for Health IT rues that “documenting care that didn’t occur, that’s not just fraud, it’s really dangerous medicine.”

It is being argued that the system is flawed. And it is high time the government sat up and took notice before it snowballs into a huge issue and causes irrevocable damage.

Has coding higher become par for the course ?

Upcoding is rampant. And emergency rooms in particular have been pulled up for assigning high level codes, despite the treatment not warranting it. Whistle-blowers  worried physicians and confused patients are making one collective demand. For, strong auditing tools, and transparent uncomplicated regulations.

The new CMS directive !

The centers for Medicare and Medicaid have issued a new directive to restrict billing malpractices. Federal authorities will be keeping a close eye on EMR users to curb this unhealthy trend.

Where the cracks appear…

Physicians are unusually busy people. Most doctors fume that EMR’s have reduced them to efficient machinery. Nobody likes to sit, and copy paste information. Or, working with straight out of a can, point and click templates. Long loading times and a maze of options can drive physicians round the bend. Impatience with the system, more than the willful intent to over-bill  might be the reason behind improper billing.

A quick guide to bill right !

  • Train your billing team to work closely with your EMR/EHR system.
  • Use an accredited medical billing software.
  • Conduct regular in-house financial audits.
  •  Ensure the same information isn’t entered again. Redundant data is the major cause of over-billing.
  • Educate your practice about CMS guidelines and updates.