Verifiying patient insurance eligibility details - Medical billing - important process

VERIFICATION OF INSURANCE INFORMATION 

During patient registration, it is important for front office staff to identify whether a beneficiary’s expenses should be covered by other insurance before, or in addition to, Medicare. This information helps the office determine who to bill and how to file claims with Medicare. 

This is not an easy task. There are many insurance benefits a patient could have and many combinations of insurance coverage to consider before determining who pays and when. Depending on the type of additional insurance coverage a patient has (if any), Medicare may be the primary payer for a patient’s claims or be considered the secondary payer.

The office staff should:

* Copy the Medicare card and/or other insurance cards.

* Obtain essential patient information through use of completed medical information/history and insurance forms.

* Determine Medicare eligibility.

* Determine “other” insurance coverage, claim submission guidelines and limitations to coverage.

* Determine the proper order of claim submission, who is primary and who is secondary payer. Obtain appropriate information to allow the claim to be submitted to the appropriate insurance payer.

A good practice to incorporate into the patient screening process is to make copies of the patient’s insurance card(s).

COPYING THE MEDICARE CARD

Verification is important since the information from the Medicare card should be obtained during the patient’s initial visit. Medicare also recommends that office personnel periodically verify a beneficiary’s insurance information to determine if any changes have occurred. Rev. 9/2010 3 Patient Registration/Screening

Pay close attention to:

 *Exact patient name.

* Claim number.

* Type of insurance coverage.

* Effective date of coverage.

Claim rejections or denials could occur if complete information is not obtained and supplied on the Medicare claim form submitted. 

The accuracy and verification of the Medicare card information is extremely important because this information will be used on many claim forms and medical documentation materials throughout the patient’s history with the provider’s office. 

Need of General equivalence mapping - ICD 10

Why Do We Need the General Equivalence Mappings?

*  ICD-10 is much more specific:

For diagnoses, there are 14,025 ICD-9-CM codes and 68,069 ICD-10-CM codes; and

For procedures, there are 3,824 ICD-9-CM codes and 72,589 ICD-10-PCS codes (in the 2009 versions of ICD-9-CM, ICD-10-CM, and ICD-10-PCS).

*  One ICD-9-CM Diagnosis Code is represented by multiple ICD-10-CM codes:

 82002 Fracture of midcervical section of femur, closed

— From S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture

— From S72031G Displaced midcervical fracture of right femur, subsequent encounter for closed fracture with delayed healing

— From S72032A Displaced midcervical fracture of left femur, initial encounter for closed fracture

— From S72032G Displaced midcervical fracture of left femur, subsequent encounter for closed fracture with delayed healing

— And other codes from the GEMs

*  One ICD-10-CM Diagnosis Code is represented by multiple ICD-9-CM codes:

*  E11341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy

with macular edema

* To ICD-9 cluster:

— 25050 Diabetes with ophthalmic manisfestations, type II or specified type, not

stated as uncontrolled

— 36206 Severe nonproliferative diabetic retinopathy

— 36207 Diabetic macular edema

General Equivalence Mappings of ICD 9 to ICD 10

What are the General Equivalence Mappings?

The GEMs are a tool that can be used to convert data from ICD-9-CM to ICD-10-CM and PCS and vice versa. Mapping from ICD-10-CM and PCS codes back to ICD-9-CM codes is referred to as backward mapping. Mapping from ICD-9-CM codes to ICD-10-CM and PCS codes is referred to as forward mapping. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM-based data, including data for:

*  Tracking quality;

*  Recording morbidity/mortality;

* Calculating reimbursement; or

*  Converting any ICD-9-CM-based application to ICD-10-CM/PCS.

Getting Patient information - What information need to collect in front office

INTRODUCTION

Patient screening is a vital step that is critical to every type of practice. Providers should establish a process to adequately screen all types of patients. There are several steps that need to be incorporated into the patient screening process. Some things to consider when initiating or updating existing office practices: 

*  Complete patient profile for the office files (name, address, insurance, etc.).

*   Determination of primary insurance benefits.

* Office staff awareness of those insurance plans that the office “does not have provider/network participation.”

* Identify if the patient has a supplemental insurance plan.

* Identify any instances where the patient has an extenuating circumstance that could cause a change in the insurance currently on file (accident/injury)

* Eligibility information, deductible and coverage limitations.

* Special billing requirements based on where the patient resides (consolidated billing).

Front office staff plays a key role in the success of claims being filed correctly and timely, based on a few minutes spent up-front with the patient or the patient’s responsible party. These tasks that are handled by the front office personnel or person who receives initial patient information become vital to the efficiency and financial welfare of the health care organization to which they belong.

One of the first steps to consider during patient registration is to obtain important patient profile information for the office.

OBTAINING ESSENTIAL PATIENT INFORMATION

Office staff should obtain complete patient information when registering new patients. Usually this is accomplished by the patient completing a medical information/history and insurance information form.

Pay close attention to:

 * Obtaining the patient’s full name directly from the card (use of nicknames on Medicare claims will cause unprocessable claim rejections).

* Patient address and phone number.

* Obtaining the name and identification number of other insurance (Medicare or other type of insurance plan involved).

* Date of birth.

* Emergency information.

Understanding EFT enrollment process

ELECTRONIC FUNDS TRANSFER (EFT)

Medicare offers all providers the option of having their Medicare Part B payments sent directly to their bank account via EFT.

There is no electronic claim submission or electronic remittance participation requirement to be eligible for EFT. It is a CMS goal to increase the utilization of EFT and reduce the number of checks printed and mailed. It is now a requirement to enroll in EFT for providers and suppliers initially enrolling in Medicare or who make changes to their enrollment information. EFT is a direct deposit into the provider’s bank account for payments on claims that have finalized and met the payment floor.

This option allows providers to be paid electronically on a daily basis for the claims that have finalized and met the payment floor. This eliminates manual handling of checks and mail time to receive payments.

EASY PRINT - ERA Medicare software

Medicare Remit Easy Print

Since ERA 835 files are not suitable for viewing, CMS has approved a new software package called Medicare Remit Easy Print (MREP). MREP is user-friendly software that will allow the user to convert an 835 file into a readable Standard Paper Remittance (SPR). There are also reporting features that will summarize the ERA data.

Providers can take advantage of free MREP software now available for viewing and printing the Health Insurance Portability and Accountability Act (HIPAA)-compliant ERA. The MREP software gives providers and suppliers the following abilities:

• Easy navigation and viewing of the ERA using a personal computer.

• Printing of the ERA in the SPR format.

• Search capability that allows providers and suppliers the ability to find claims information easily.

• Print and export reports about ERAs including denied, adjusted and deductible-applied claims.

• Easy-to-use method to archive, restore and delete imported ERAs.

ELECTRONIC REMITTANCE ADVICE (ERA) overview - basic tips

What Is ERA?

All Medicare Part B providers are eligible and can take advantage of ERA.

• ERA files are produced daily and include all claims and adjustments for both electronic and paper claims.

• The GPNet communication platform is used to provide a direct mailbox system for ANSI X12 835. Providers will need a single analog telephone line, asynchronous modem and communication software that support X-modem, Y-modem, Z-modem or Kermit protocol.

• GPNet supports Medicare Part B electronic remittance in the ANSI X12 Versions 4010/A1.

• Providers can save time and money by using ERA to eliminate manual posting of claims payments. Medicare Part B payments can be posted to patient accounts automatically by programming an interface that will allow for the exchange of data.

• Electronic remittance files not downloaded remain in the mailbox for 14 days from the date of the file. Upon request, files can be reloaded into the mailbox as far back as 60 days.

Different way of electronic claim submission EDI

How Does It Work?

Providers have several alternatives for entering and electronically submitting claims data:

• Providers may work through a software vendor who can provide the level of practice management system support they need for their practice.

• Providers may submit their Medicare Part B claims directly to TrailBlazer Health Enterprises® or choose to submit claims through a clearinghouse.

Providers may choose to have a billing agent handle all or part of their Medicare billing.

• If the provider’s office has the required hardware, it may choose to use Medicare’s free billing software.

Welcome to the exciting world of electronic billing! If a provider is new to the concept of electronic claims submission or has never used a computer, the following tips and hints may make the transition to a computerized billing system easier.

• When buying or leasing a system, deal with a knowledgeable, established vendor. Avoid the temptation to base a buying decision solely on price. Ask for references from current users of the systems considered and check them. Providers should try to find another provider in their specialty that is using that particular software or someone who has billing practices similar to their office.

• A dedicated phone line is recommended; this will eliminate interrupted transmissions.

• Regularly make backups of all patient and claim data. Disaster-recovery procedures suggest two backup files be kept – one on-site and one off-site. Keep backups in a safe and protected place. In the event of fire or system problems, a current backup will enable a provider to reconstruct his office’s records.

Electronic claim submission basic overview

INTRODUCTION TO ELECTRONIC DATA INTERCHANGE (EDI)

EDI is the process of transacting business electronically. It includes submitting claims electronically, or “paperless” claims processing, as well as electronic remittance, Electronic Funds Transfer (EFT) and electronic inquiry for claim status and patient eligibility.

What Are the Benefits of EDI?

The benefits of EDI are as follows:

• Medicare Part B claims process faster and providers are reimbursed sooner, improving their cash flow. Payment for electronic claims may be released after 13 days; payment for paper claims can be released after 29 days.

• Mailing and administrative costs are significantly reduced.

• Because of GPNet editing, fewer claims are returned with development letters, saving staff time and effort (refer to the GPNet Edits Manual on Medicare’s Web site at http://www.trailblazerhealth.com/Publications/Training%20Manual/GPNetEditManual.pdf in the “EDI Publication” section for a list of GPNet edits).

MISSING EFT ENHANCEMENT - Medicaid denial

DESCRIPTION OF THE ISSUE

The Medicaid claims statuses states; the pay to provider is not eligible for direct payment.

CONCEPT

Any carrier should possess EFT enhancement during enrollment process inorder to obtain any claim status during verification.

SOLUTION

Upon verification with the Provider enrollment @ Medicare, the EFT Authorization form was submitted. Later the Billing Indicator was changed to "Yes" and the necessary billing information was updated. Finally all the claims were processed and paid

RAIL ROAD MEDICARE REQUESTS FOR PROVIDER’S PTAN#

DESCRIPTION OF THE ISSUE

PTAN# was not issued for Dr. .  Hence all the RR MCR claims were in pending for long duration.

CONCEPT

RRMCR requests for appropriate PTAN# for processing its claims.

SOLUTION

After regular follow-ups with the Insurance on request to issue PTAN#, we received the same after 60 business days and all the outstanding claims were processed and paid.

INCORRECT TIN# FILED FOR A CAPITATED CARRIER

DESCRIPTION OF THE ISSUE

The claims of Wellcare were initially denied for “No Authorization on file”. {submitted with the Tax-Id# 123456789}.

CONCEPT

If a provider is capitated under a plan, we need to verify on all the information of the provider with the concerned Insurance records to avoid denials of missing/incorrect provider’s information.

SOLUTION

Upon verification with Wellcare we found Dr.  had separate Tax-Id# 987654321 and was capitated with this plan. Hence all the claims were refiled and processed under capitation

PROVIDER INELIGIBLE TO FILE CPT 81001 - Denial reason

DESCRIPTION OF THE ISSUE

We received denials for the CPT 81001 as “Provider is not certified eligible to perform this procedure” - CPT 81001 (Urinalysis with microscope) 

CONCEPT

Any provider should be aware of his eligibility of the services to be performed for appropriate reimbursements. 

SOLUTION

Per Coding Dept’s advice we changed CPT from 81001 to 81002 (Urinalysis without microscopy) and refiled all the denied claims for reprocessing.  The refiled claims were paid successfully. 

REJECTION OF WHOLE CLAIMS WITH J CODES FOR NDC# UPDATE cpt code - j7613, j7609

DESCRIPTION OF THE ISSUE

Claims filed without or incorrect NDC#s, MCD HMO carriers (Staywell/Health Ease) rejected entire claim for NDC# updates, instead of processing denial only for J Codes.

CONCEPT

All injection drug codes should be billed along with NDC# updates for the claims to be reimbursed.

SOLUTION

Carriers’ database setup has been modified to reject the entire claim when filed with J Code without/Incorrect NDC#s, instead of processing denial only for the J Code.  So we segregated J code as a separate claim.  This enhanced payment for rest of the CPTs and the J code alone was denied for need of NDC#.

IS cpt code 81001 valid - replacement code G0431

CPT G0431 replaces CPT 80101 for Drug Screen Testing 

 

Change Request 6852 addresses CPT G0431 "Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class" as a direct replacement of CPT 80101.  

The following conditions become effective on April 1, 2010: 

Providers must use CPT G0431 when billing for these services CPT 80101 will no longer be covered by Medicare for dates of service January 1, 2010 and after

For complete information, refer to the CMS Medicare Leaning Network (MLN) article MM6852 "Clinical Laboratory Fee Schedule (CLFS) - Special Instructions for Specific Test Codes (CPT Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW, and G0431QW)."

HOSPICE CLAIMS SUBMITTED DIRECTLY TO MCR INCORRECTLY

DESCRIPTION OF THE ISSUE

Previously we had billed Hospice covered patient claims to Medicare with GW modifier to get quicker payments. Balance of 20% coinsurance was billed towards patients. Client raised an issue to file the claims to the concerned Hospice care itself instead of billing Medicare.

CONCEPT

Whenever we find patients with Hospice coverage for a particular service date, we must check with Hospice whether the patient was in Hospice for the specific DOS, if yes we must bill that concerned Hospice care and not Medicare, if not we could bill Medicare with GW modifier (which indicates the claim not related to Hospice).

SECONDARY MEDICAID CLAIMS DENIED AS “MEDICARE COVERAGE IS PRESENT”

DESCRIPTION OF THE ISSUE

Secondary Medicaid denied claims as Medicare coverage is present/ Crossover data missing at detail level. As per our conversation with Medicaid they do not cover the balance left from Primary Medicare HMOs.

CONCEPT

If patient have Medicare HMO as primary Insurance and Medicaid as secondary, such scenario claims have been denied like this.

SOLUTION

Before we bill claims to Secondary Medicaid we need to check the paid amount of the primary carrier with Medicaid fee schedule and if the amount greater than the Medicaid allowable we could waive the balance off

PSYCHIATRIC REDUCTION ON MEDICARE CLAIMS - PAYMENT REDUCED

DESCRIPTION OF THE ISSUE

Whenever we use Psychiatric related diagnosis as primary one on a claim, this will cause a payment reduction from Medicare. The reduction has covered by some of the commercial secondary Insurances and if the patient does not have such, we could not bill the balance amount fully to the patient responsibility, we can only bill the 20% of the Medicare balance to patient not the reduced amount.

CONCEPT

If a patient treated for an Office/ Hospital visit based on the Psychiatric problem and if the patient needs specialty treatment, this would cause reduction on payment.

SOLUTION

Once we receive a claim with primary diagnosis related to Psychiatric (ICD Starts from the numeric 3) we need to check with Client Office whether there is any alternative primary Diagnosis. If reduction done by Medicare then we should correct primary ICD through Medicare IVR Telephone Clerical Reopening option

W9 FORM IS NOT REACHING THE CARRIER

DESCRIPTION OF THE ISSUE

All the claims under Orlando Health care are awaiting for W9 form from the provider.

CONCEPT

Carriers request on any information should be submitted for the claims to be reimbursed.

REASON

Upon several submission of W9 form of the provider either through fax and despatch haven’t reached the carrier.  We are in process of getting approval of receiving W9 form from the Carrier.

ADVANTRA CLAIMS WERE NOT REDIRECTED TO COVENTRY HEALTH CARE

DESCRIPTION OF THE ISSUE

Advantra was undertaken by Coventry beginning of 2010.  This was not noticed and the forwarded claims of Advantra were in pending for long duration.  Upon notification and filing of claims towards Coventry resulted in TFL denials.

CONCEPT

Carrier updates should be carefully noticed and gathered from the Dr’s office by the Billing office.

SOLUTION

After a long follow up we started filing claims towards Coventry Healthcare which resulted in TFL denials.  These denied claims were appealed with appropriate proof and the claims were reimbursed by the carrier successfully

IMPROVING SELF-PAY PATIENTS PAYMENT COLLECTION

DESCRIPTION OF THE ISSUE

Self-pay uncollected balances were not directly moved towards Collection Agency.  We made an analysis from our end to find reason for unpaid balances and came with appropriate solutions to gain payments to the provider.

CONCEPT

Unpaid Patient balances not to be moved directly towards Collection Agency.  Even we could make a research on the reason for its non-payment from our end.

SOLUTION

We started verifying patients’ addresses from Hospital’s website and updated new addresses for the patients and forwarded statements.  Also verified whether those patients had any coverage information, if so, we started filing those claims to the carriers for reimbursement.

NPI# MISMATCHED FOR MEDICAID CLAIMS

DESCRIPTION OF THE ISSUE

Per Master claim set up in the software we have filed all the claims with provider’s group NPI#.  But per Medicaid records, provider was enrolled with Individual NPI#.  Hence claims did not reach Medicaid.

CONCEPT

Before transmission of any claims, the concerned carrier’s claims acceptance set up should be checked and verified.

SOLUTION

We had sample cross over claims which were processed by Medicaid. Based on these sample claims we placed an enquiry with MCD executives as to why they haven’t received any of our MCD claims though we receive acceptance reports from our Clearing house agent. They insisted that the claims should be filed with provider’s individual NPI.  Since the NPI records were missed, they haven’t received any of our claims.

Based on the given information we changed our Carrier’s claims submission master up from Group NPI# to Individual NPI# and transmitted all our claims.  The refiled claims were reached and processed for reimbursements

PAYMENT MADE TO PATIENTS BY THE NON CONTRACTED CARRIERS

DESCRIPTION OF THE ISSUE

Dr.  is non-par with Blue Cross Blue Shield, so the Hospital claims which were billed to the carriers were reimbursed to the patients directly. Since there are no payments received from the patients we are unable to collect those payments from the patients.

CONCEPT

In order to received payments from the carrier, the provider should be contracted with the Carrier.

REASON

Since we are unsuccessful in retrieving patient payments through statements we are waiting for the documentation process to get completed with the Collection Agency for further go.

Can we bill for missed appointments

Charges for Missed Appointments

Physicians and suppliers are allowed to charge Medicare beneficiaries for missed appointments if they also charge non-Medicare patients for missed appointments. The amount charged for the missed appointment must apply equally to all patients (Medicare and non-Medicare). Charges to beneficiaries for missed appointments should not be billed to Medicare.

PRIMARY CARE OVERVIEW

A primary care physician is defined as a general practitioner, family practice practitioner, general internist, obstetrician or gynecologist.

Primary care includes health promotion; disease prevention; health maintenance; counseling; patient education; and diagnosis and treatment of acute and chronic illnesses in a variety of health care settings such as office, emergency room, hospital, home, skilled nursing facility or nursing home.

what is electronic prescribing and how to do for part B drugs.

Electronic Prescribing

Electronic prescribing (e-prescribing) is the transmission of prescription or prescription-related information through electronic media. E-prescribing takes place between a prescriber, dispenser, pharmacy benefit manager (PBM) or health plan. It can take place directly or through an e-prescribing network. With e-prescribing, health care professionals can electronically transmit both new prescriptions and responses to renewal requests to a pharmacy without having to write or fax the prescription.

E-Prescribing for Part B Drugs

* Reviewers will accept as a valid order any Part B drugs, other than controlled substances, ordered through a qualified E-prescribing system. For Medicare Part B medical review purposes, a qualified E-prescribing system is one that meets all 42 CFR 423.160 requirements.

Provider signature - electronic in Medical record

Electronic Signatures

Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternative signature methods. The individual whose name is on the alternative signature method and the provider bear the responsibility for the authenticity of the information being attested to. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.

The following are examples of acceptable electronic signatures:

Chart ”Accepted By” with provider’s name.

** ”Electronically signed by” with provider’s name.

** ”Verified by” with provider’s name.

** ”Reviewed by” with provider’s name.

** ”Released by” with provider’s name.

** ”Signed by” with provider’s name.

** ”Signed before import by” with provider’s name.

** ”Signed: John Smith, M.D.“ with provider’s name.

** Digitalized signature: Handwritten and scanned into the computer.

** ”This is an electronically verified report by John Smith, M.D.”

** ”Authenticated by John Smith, M.D.”

** ”Authorized by: John Smith, M.D.”

** ”Digital Signature: John Smith, M.D.”

** ”Confirmed by” with provider’s name.

** ”Closed by” with provider’s name.

** ”Finalized by” with provider’s name.

”Electronically approved by” with provider’s name.