Practice Management Alert

Your reimbursement horror stories get some expert attention

Billing and coding is insurance company-specific, so you've got to know the rules to collect the payments you deserve.
 
There's nothing that says a carrier can't create its own bundling rules, says Wanda L. Adams, president of Wanda L. Adams and Associates Inc., a consulting firm in Festus, Mo. And some carriers seem to insist on bundling the most outrageous things! Medical Office Billing & Collections Alert recently heard from several readers who are about to pull their hair out as they struggle with carriers that perpetrate what they see as unfair bundling.

Complaint #1

Dealing with Aetna's rules for global packaging is "almost more trouble than they're worth," exclaims Barbara Ashley, collection coordinator at North Phoenix Heart Center in Phoenix. For example, Aetna bundles any E/M code with a stress test, Ashley says. This means that the doctor's interpretation and report go unpaid - a significant loss of revenue in her 12-physician cardiology practice, she says. She has  appealed some things all the way up to the medical director and it's still been denied, Ashley says.

And the experts say ...

1. Beef up your appeals with evidence to back your case. Remember that citing Medicare guidelines will not work, Adams says. Independent carriers don't have to follow those rules.

For success, cite the intent of the codes you're using from the CPT manual. You should also reference the AMA's CPT Assistant, the ICD-9, and the Coding Clinic Guidelines for the ICD-9 when appropriate. Copy whole pages and include them with your own written explanation of why you deserve payment. It's highly probable that you'll win your appeal if your "argument is based on national standards [and] your case is presented using the accepted guidelines and rules," Adams says.

2. You need to know your payers inside and out, says Erica Schwalm, reimbursement specialist and compliance officer at Pioneer Spine & Sports Physicians in W. Springfield, Mass.

One way to do this: "You need to build what I call an insurance knowledge notebook for your contract agreements," Adams says. List the questions pertinent to your practice and gather all the answers for each carrier. Things to include: filing limits, appeals process, referral requirements, fee schedule, submission guidelines, covered/noncovered codes, whether they take modifiers, whether they take Medicare HCPCS level II codes, whether they use internal codes. The notebook will serve as a quick review/reference for your experienced billers and as a great training guide for new staff.

Complaint #2

"United Health Care bundles everything," says Terese Pherigo, billing manager for Michael L. Kyle, MDSC, in Oak Park, Ill. They won't pay for an E/M visit on the same day as any minor procedure, and they do crazy things like extend a global period to include three whole months of re-evaluations and treatment, she says. Their policy doesn't say anything about bundling to this extent. Even the president of the company has denied appeals backed by proper evidence, Pherigo says. "It's like a full-time job to fight with them. Please help me!"

And the experts say ...

Yikes! It may be time to report an insurance company if you've done your appeals correctly and get repeated denials. Such actions may indicate blatant disregard for the rules.

- If it's a managed-care plan you're dealing with, "The plan has its own grievance process that [you] should follow," says Lester Perling, an attorney with Broad & Cassel in Ft. Lauderdale, Fla.

- If it's indemnity insurance, there's no formal complaint process to go through. You should report persistent problems with a carrier to your state insurance commissioner or even the attorney general.

- Of course you also have the right to sue, but this action is best reserved for extreme situations when lots of money is at stake, Perling says.

- Small-claims court can be an option if there's not a lot of money at stake but you feel that you're being denied your payments unjustly.

Remember: Being difficult with payments in little ways that don't merit legal action can allow carriers to save a lot of money on a national level, Perling says. Reporting problems to your state insurance commissioner is important because it's likely that other practices are having similar trouble. Enough complaints can spark an investigation and punitive or corrective action.