Podiatry Coding & Billing Alert

You know all too well that problem payers can wreak havoc on your practice's income. In part one of our twopart series, we'll show you how doing your homework can take the pain out of working with problem payers -and start the wheels turning to bring in cash for your podiatrist's services.

Your first step when you discover that you have a problem with a payer is to do research. If you're facing payment delays, find out why. If you're receiving improper denials, look at the denial reasons the payer is giving you on your explanations of benefits (EOBs).

"My first step is to review the status of that claim. I try to gain the 'what and why' of the situation and then address the particular issue," explains Cheryl Nash, director of operations and senior account rep at American Physician Financial Solutions in Colorado Springs.

Payment delays: Check online to see if you can find any relevant information about current problems with particular payers.

Example: Cigna has been delaying payment for all State of Illinois patients, says Gaye Pratt, coder/biller for Vincent P. Miraglia, MD, in Stuart, Fla. "I have claims from December that still haven't been paid," Pratt laments.

"Cigna has posted a letter on their Web site, dated 2/23/09, stating the delay is because the State of Illinois can't pay their bills. And although that letter was dated 2/23/09, when I called Cigna [recently], they stated the claims were still on hold since they still had not received money from the State of Illinois to date."

Improper denials: You first need to determine if the payer made an error. If you receive a denied or underpaid claim, you have to make sure that the denial isn't a result of the way you filed the claim. To do so, follow these steps:

1. Read denial codes on the remittance advice to determine the payer's reason for denial or underpayment.

2. Audit and review all of the coding documentation.

3. Make sure the documentation supports what was billed.

4. Determine that the payer made an error. Once you've determined that the payer made an error, you can write a letter expressing why you think your payer should pay the claim. Just remember that Medicare requires you to file your request within 120 days of the date of the initial determination notice. Check with private payers to find out their time limits for payment appeals.

For example, Arnold Beresh, DPM, CPC of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. illustrates how persistence pays off. "We were getting denied for 64640 (Destruction by neurolytic agent; pudendal nerve; other peripheral nerve or branch). Once our office was able to talk to the right person, a medical director who handles peer reviews, we were able to determine that this carrier did not have this code listed as one that would be used in podiatry. And, once we explained what the procedure involved, the carrier agreed that this code was in fact a code that could  be used in podiatry. As a result, the code was added into their system, and the change was made on a national level. It took eight months, but paid off in the end."

Your second step should be to contact your payer. Call either the provider relations number or your payer representative to discuss the issues your practice is facing. "I have found that 90 percent of denials, improper payment amounts, delayed payment, etc. can be turned over by a simple (or not-so-simple) phone call," Nash says. "The reps at the payer are not as well-trained as we would like to think, but we are." Usually by just quoting terms of your provider's contract, Correct Coding Initiative (CCI) edits, proper coding, timely processing and review guidelines, etc. you can get your claim issues taken care of. You may also want to ask to speak to the provider representative's supervisor or manager.

Don't be shy: Persistence is often the key in billing and collections efforts. "If you know you are right, then you have to fight for it," Nash says. "Call and demand that the issue be addressed and insist on speaking with people who have authority to make changes."

Have a set schedule in your practice that establishes when you will follow up on a claim and when you will follow up with a payer about payment issues and appeals as well. Also, make sure you know what you're talking about. "Knowing how something works is more than half the battle," Nash says. "Remember, the reps at the insurance company do not have the experience or education that the coders/billers have. You are the expert."

Important tip: Document as much information as you can, Nash stresses. "The name of the rep, reference number for [the] call, everything they told you, etc. These are your 'weapons' for later use in the appeals process." If possible, get the rep's email address, and send her a confirmation email restating the final resolution of your call, so that you have everything in writing relating to your follow-up.

You should also remember that if the payer made the mistake and incorrectly processed your claim, you should not have to appeal. "If the insurance incorrectly processed a claim, due to incorrect contract rate, improper bundling, etc., it is their responsibility to process it correctly according to the CPT/ ICD-9 rules," Nash explains.

However, if the payer refuses to reprocess, you may have to appeal. If this is the case, experts recommend that you copy your state medical society and possibly your state department of insurance or equivalent department. In the letter you can state that you should not have to be appealing, since the payer incorrectly processed the claim, but that you understand that this is the only way to get the claim paid.

If the payer denied your claim due to issues with medical necessity, improperly quoted benefits, etc., you will have to appeal. "Most appeals are won at the second level, and this takes time," Nash warns. However, they can still be won -- and paid. "I just got one [paid] that was 1½ years old," he says.