Practice Management Alert

If your billing department never considers appealing a Medicare claim even when you're sure the denial is inappropriate you could be missing out on deserved revenue. Although billers generally agree that Medicare is a responsive and fair payer, its carriers make mistakes.
 
"I hear people say that they don't bother to appeal Medicare claims, and I can't believe it, because that's money," says Terry Murillo, business office manager of the seven-physician Atlanta Pulmonary Group in Atlanta. "It may not be a lot of money, but a lot of little bits add up. If people don't bother to appeal when they think they've been wrongly denied, it's no wonder the rest of us have to fight harder because even Medicare is scrutinizing claims more and more."
 
When you get an explanation of benefits (EOB) from Medicare in which a claim you think should be paid is denied, don't roll over and play dead, agrees Cam McClellan Teems, senior consultant and billing and collection specialist with Gates, Moore & Co. in Atlanta. If your claim is denied because of an error, such as an incorrect modifier or diagnosis code, learn from your mistakes and make sure you file clean claims. Don't continue to file claims that have erroneous information on them, she says, because it needlessly costs you time and money to refile the claim, and delays receiving the correct payment. When your claim is denied for reasons other than mistakes, such as services determined to be "not medically necessary" or services deemed as "incident to" procedures, and you're confident that determination is incorrect, stand up for yourself and appeal, she advises.
 
The key to successfully appealing a Medicare Part B claim in which the denial is based on more than a simple mistake is understanding the appeals process and meeting the requirements of each step along the way. Medicare regulations allow providers and beneficiaries who are dissatisfied with a claim determination to have it re-examined. That re-examination can continue through five different levels, beginning with a review of the claim by the carrier and ending with a federal district court hearing, if certain criteria are met. (For more on the Medicare appeals process, see page 35.) Most practices, however, resolve their problems at the review or fair-hearing step.
Call for Explanation of Denial
If you believe a claim is error-free but not paid as it should have been, you should take a step before starting the Medicare appeals process, and ask the carrier why the claim was denied, Teems recommends. "Often, the descriptors on the remittance or EOB aren't clear, and you can understand it better when you hear it from the person on the other end of the phone," she says. If [...]