The
fast pace of the medical office is the ideal environment for billing errors.
Patients are showing up in 15 minute intervals, the phones are constantly
ringing and not to mention several walk-ins have shown up and your office staff
is doing the best they can to still offer excellent customer service.
As
with anything else, when times are chaotic, something will slip through the
cracks or an error will be made. No matter how much you express the importance
of accuracy to your medical office staff, you can’t just stop there.
Assuming
that your medical claims are being billed error free is the surest way to
getting denials and delayed payments. Incorporating a chart audit
process in your day to day operations could be the difference between being
paid as early as 10 to 14 days instead of 45 days.
The
simplest way to audit charts is by creating a checklist. Be sure to include
information that could cause denials or delay payments. Simple
inaccuracies can make a big difference.
1.
Is the patient’s name spelled correctly?
2.
Is the patient’s date of birth and
sex correct?
3.
Is the correct insurance payer
entered?
4.
Is the policy number valid?
5.
Does the claim require a group
number to be entered?
6.
Is the patient relationship status
to the insured is accurate?
7.
Does the diagnosis code correspond
with the procedure performed?
8.
Does the procedure code performed
match the authorization obtained?
9.
For multiple insurances, is the
primary insurance accurate for coordination of benefits?
10. Is the Physician NPI number on the
claim?
Another
more unpleasant possibility is that a claim will be denied as “fails to
meet medical necessity”. In this case, just like the former examples, the
specifics of the denial are of the utmost importance. When you are certain of
the specific reasons for denial there are five simple steps you can take to
appeal a medical necessity denial.
1.
First, make certain all information
is correct and clear.
2.
Obtain specific plan information as
it relates to this diagnosis, treatment plan, or procedure.
3.
Familiarize yourself with the appeal
process for the specific insurance or payer you are submitting the appeal to.
4.
Verify the updated medical necessity
guidelines according to the payer’s policy.
5.
Be prepared to prove, through
documentation, the reason(s) that this procedure should be considered medically
necessary through case studies, scientific evidence, and common practice for
your specialty and locale.
While
a denial is frustrating for the physician, the clinic, the staff, or the
facility, remember that it is especially frustrating for the patient. Keeping
in contact with the patient regarding the progress of the claim is very helpful
in soothing jangled nerves and keeping dissatisfaction at bay. A level head
prevails in all matters related to insurance carriers and their policies.
Knowing the claim specifics, following up in a timely and consistent manner
shows the payer that you are dedicated to the positive resolution of the claim
for your office and your patient. The word to the wise is “documentation”. Always
document whom you spoke with, the date, the time, their title, and the outcome
of the conversation.
