Optometry Coding & Billing Alert

Published on Mon Jan 04, 2010 PDF

Don't wait for MACs to alert you to errors.

If you don't nip a computer glitch in the bud, you may be plagued with improper denials and other claim holdups. Your best defense against reimbursement-robbing errors is being proactive.

Glitches can cause erroneous denials, unnecessary rejections, lost crossover claims, and frustrating delays. But if you don't notice the problem, you could kiss your reimbursement goodbye. That's because the payer won't always alert you to a mistake that its computers made. "If a computer glitch was due to a widespread

problem, like there was no remittance generation for an entire day, there will usually be an announcement in the MAC's Web site," says Zia Clarkson, a coding, reimbursement, and practice management consultant in Long Island, N.Y. "They do not notify practices or providers individually."

Example: Earlier this year, thousands of Medicare recipients in one state were wrongly told their benefits were being cut by $300 -- but the state decided not to notify those affected with a letter. Instead, the state told only those who called in to complain that the notification of benefit cuts they received was the result of a simple computer glitch.

Although payers may perform notifications on largescale errors, "accidental denial on an entire batch of claims for an area would probably be considered a small glitch and no announcement issued," Clarkson says.

"Providers would find out by following claims,noticing that those claims were never addressed, and inquiring about them to find out that there had been a problem that was being corrected. Medicare will usually correct the claims in a sweep in cases like that," he says.

Tip: Watch your payers'Web sites. Some payers that have experienced computer glitch problems have put up "error resolution reports" on their sites. You can look up each problem and see an estimated date for repair. If that date has passed, you should resubmit any claims affected by that glitch.

When you click the send button and the claim is off to the payer, you'd like to assume your payment is coming, but if you're not vigilant, working your A/R, your claims can disappear into your carrier's computers, never to be seen again. Therefore, you have to stay on top of your claims, advises Kathy Philp, CPC, director of billing with Praxis Health Group in Oklahoma City.

Here's how: Watch your explanation of benefits (EOB) forms, and keep your eyes open for denials and downcodes that don't look correct. Often, you can catch glaring computer errors simply by reading your EOBs.

You should also always review your accounts receivable (A/R) to ensure that you've received the payments you're due. If a computer glitch kept an insurance company from paying you, don't hesitate to point it out to the payer.

"If we have any claims outstanding for 30 days that we sent electronically to that carrier, we contact the carrier right away," says Ginny McManus, billing manager with BergerHenry ENT Specialty Group in Pennsylvania.

"If we are told there is no record of receiving the claim(s), we will rebill immediately," McManus says. "It is definitely up to the practice to catch these problems. I have run into this scenario before and the carrier has never automatically reprocessed any of our claims. Good followup is everything in a billing department."

Additionally: You may also want to check your claim confirmations from the payer if you are consistently getting the same information from them saying that they do not have your claims on record. In this case, you should meet with the provider representative, talk with your state insurance representative, and consider contacting your state medical society.

If you contact the insurance company and the representative tells you that the payer plans to reprocess all claims affected by the glitch, always recheck that they've followed through.

"Once I've submitted the claim, I will have our collector call back in two days to see if the claim has been received by the payer," Philp says. "I have the collector explain to the representative that by law they have to pay within a certain timeframe, which is usually 30 to 45 days, depending on the state."

In many cases, the insurance company will not reprocess the claims, and you'll have to resubmit them. "I would have the collector speak to a supervisor to find out whether the insurer will deny the resubmitted claim as a duplicate, which would cause further delay in payment," Philp says.

If the payer experiences a computer glitch, "then you need to follow the trail to find out where it started -- was it during transmission, or is the insurance company stating this as a stall tactic and delaying payment?" Philp says.