Practice Management Alert

Physicians must get up to speed before Jan. 1

If a biller puts the wrong date on a superbill and the carrier takes issue with the claim, what should she do?
 
In 2006, the biller will have the option of fixing the problem without appealing the claim.

There are several new rules regarding appeals taking effect next year, and billers would be wise to bone up on the new regulations because the process will be governed by different time frames and submission rules in 2006.

The basics: Carriers will still perform the first level of appeals--which will now be known as a redetermination--and physicians will have 120 days to request this level of appeal. Physicians will have 180 days to file a request for the next level of appeal, also known as a reconsideration, which will be performed by the qualified independent contractor (QIC).

After that, you have 60 days to request the third level of appeals, the administrative law judge (ALJ). If the ALJ doesn't go your way, you have 60 days to appeal to the Department Appeals Board. (And after that, you have 60 days to appeal in federal court, as long as you have at least $1,050 at stake.)
 
No New Info Without -Good Cause-

An important change in the appeals process for billers is that you must submit your complete case, including all documentation, to the carrier at the first level. After that, you can only add more information to the appeal for -good cause- or to correct minor errors, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, coordinator of HIM Certificate Programs at Clarkson College in Omaha.

So just what would a carrier consider -good cause- for submitting information at the second or third level?
 
-I don't know if there are any official rules regarding -good cause,- but generally this means that there was an issue out of the appellant's control,- Bucknam says. Consider these examples of -good cause- that may allow a medical office to submit information after the first level of appeal:

Example 1: If the medical office requests a ruling from Medicare, and it arrives after the office submits its appeal, the office may be able to add the ruling to the appeal documentation.
 
Example 2: If the medical office needs information from the patient, but the patient does not provide it until after the appeal deadline, it may be cause for submission of additional information.

Know What Constitutes Minor Errors

One new appeals rule that could favor medical offices is -minor errors- on a claim. If a biller makes a mistake on a claim deemed minor, she may not need to appeal the denial, according to CMS.

Instead, the biller can ask the carrier to reopen the claim so she can correct the problem, entirely avoiding the appeal process.
 
What are -minor- errors? A biller should be able to rectify any kind of typographical error without appealing,  Bucknam says. Most carriers allow billers to correct information like incorrect dates, typos in codes, and transposed ID numbers on a claim without appealing.

Example: Anne the Biller is preparing to send a claim off for Patient M, who came into the office for treatment of his heartburn. On the claim, Anne mistakenly lists the place of service as a hospital. Errors like noting the incorrect place of service can be repaired without appealing, Bucknam says.

-Generally these are factual errors that only require the correction of information, but no judgment or consideration--simple-to-correct problems,- she says.

Get proof: If you are trying to avoid an appeal by correcting a minor error on a claim, make sure you have documentation to back up your correction, says Quinten A. Buechner, MDiv, ACS-FP/GI/PEDS, CPC, president of ProActive Consultants LLC in Cumberland, Wis.

Before a carrier accepts a correction, the biller may have to prove her case by -producing a charge sheet/superbill with the right [patient] data,- he says.

For more information on dealing with small errors on claims, see -Clip and Save: 3 Steps That May Prevent an Appeal- later in this issue.