Practice Perfect - Nov. 2003

Coding & Reimbursement

10 Ways to Win the Claim Game

By Chris McDonagh, Associate Editor

Whenever payment is delayed because your initial claim wasn’t clean, the carrier—rather than your practice—accrues interest on the money. Two experts share their ideas on minimizing both delays and outright denials. Michael D. Brown is president of Health Care Economics Inc., an Indianapolis-based consultancy. John Segal is a board director of the AAOE, an organization dedicated to efficient practice management. They suggest 10 tips to speed up payments.

1. Know your coding. “I know from audits I’ve been involved in that many claims aren’t paid because of very simple mistakes,” said Mr. Brown. Make sure, for instance, that you link the ICD-9 code to the right CPT code. Reviewing your payers’ Explanation of Medical Benefits will help you to spot problem areas. (See the current series of “Savvy Coder.”)

2. More billing, less haste. “Because you’re hurrying to get to the next patient, some of the doctor’s findings or services might not make it to the superbill; and you can’t get paid for a service if you haven’t billed for it,” said Mr. Segal, who is an administrator in York, Pa. “In our practice, every chart receives a second review prior to running claims to verify that the inside documentation matches the bill. We have netted another 10 to 15 percent in revenues by billing and collecting for what we did.”

3. Cut out careless mistakes. “If slop goes in then slop comes out—and you won’t be paid,” said Mr. Brown, who pointed out five common errors that should be avoided:

missing signature
missing modifier
missing UPIN
missing CLIA
transposed numbers

4. Send claims out promptly. If you’re slow in billing for a service, you create your own internal money float. Mr. Brown suggested that you review office work flow with a mind to speeding up billing. In terms of documentation, for instance, if physicians dictate notes, how long is it before they sign them?

5. Know your payer. “To play the claim game,” said Mr. Brown, “you need to know your payers and the games that they’re playing. If you have four or five major carriers that constitute 90 percent of your income, tell your administrative people that one of their clear objectives is to meet with these people. If you don’t spend time getting to know people at the carriers, they will blow you off.” You need to find a “go-to guy or gal” at each of your significant payers, said Mr. Segal. “Every practice has a certain number of claims that are irresolvable by the line representative. If the issue is systemic, it may be that even the supervisor is unable to correct the problem. Find the go-to person who can cut through the issues and get it paid. It has taken some time to work our way up the food chain with each company—even Medicare and Medicaid—to find that person. Now when all other avenues have been exhausted, the relationship with our go-to person gets the claim paid.”

6. Watch for denial patterns. If you spot a pattern of denials, you can then try to avoid the problems that are causing them. But a pattern of denials doesn’t necessarily mean that you are doing anything wrong, said Mr. Segal. “Remember that insurance companies strive to deny claims, even ones that are legitimate.” You may not, for instance, get any notice that your payer is changing policies and procedures or implementing a new software system. “New software creates system-wide glitches that will deny claims until those glitches are flagged by providers,” he said. “Sometimes it is as simple as a missed diagnosis code, but it costs money to correct it on a claim-by-claim basis. Denial patterns indicate systemic problems; be a white knight and work to fix it for everyone’s benefit.”

7. Be persistent. “The first thing any insurance company teaches its claims staff is how to say ‘no,’ even in the face of a logical argument,” said Mr. Segal. “‘No’ is never an acceptable reply when you have the information and documentation to support a ‘yes.’ Working on a legitimate but denied claim is the best way to work up the food chain and find that go-to person. Don’t get mad or personal. Calmly ask for their supervisor and keep doing it until you get someone to say ‘Yes, it will proceed correctly today.’” You should “call insurance companies daily, if necessary,” added Mr. Brown. “Remember, it’s the squeaky wheel that gets the grease.”

8. Review all denied claims. “Don’t automatically write the money off,” said Mr. Brown. “Payers do make mistakes.” Given the volume of claims that payers process, it is not surprising that they make more mistakes than you and your staff, noted Mr. Segal. “Remember that the staff reviewing and denying your claim are not ophthalmologists and rarely—unless you get to the medical director—doctors,” he said. “Neither they nor the software reviewing the claim actually understand the diagnosis or service provided. Use that as a powerful tool—dazzle them with your knowledge.”

9. Copy everything. If you have to contest a denial, you will need the documentation to back your case. Wherever possible, press your carrier to give you information in writing. Keep copies of correspondence, document phone conversations and note the name and title of people you speak to over the phone. And if you don’t already have one, purchase a Dictaphone, urged Mr. Brown. “When you’re talking over the phone, you can ask the carrier’s representative if you can make a tape copy of the conversation—often, they’ll say ‘yes.’”

10. Offer extra training. “Train all of the front office staff to understand the services that your practice provides,” said Mr. Segal. “Stockpile articles and association policy statements to support claims for services that may be questioned.” Give staff time to familiarize themselves with office policies and payers’ contracts. Offer billing staff additional training to stay up to date—for instance, the AAOE and JCAHPO have organized a “Coding Camp” to take place before this year’s Academy Annual Meeting (see www.aao.org/aaoe) and also are developing an Ophthalmic Coding Specialist Exam (phone JCAHPO at 800-284-3937 for more information).