Tools of the Trade for Billing

Use them or lose them.

By Alecia Johnson, CPB

Whether your practice treats 150 patients per month or 2,000 patients per month, it is no secret that poor billing practices will lead your practice into muddy waters. It takes a special kind of person to enjoy the repeated rejection of working in billing, from submitting claims that are often denied to the piles of record requests to determine medical necessity. How do you begin to wade through the denials and determine what it is that is actually required to receive payment for the services provided? Getting your billers and other administrative staff set up with the proper tools for success will lead your practice to long-term success and an increased cash flow. In this article, I will review the information that can be collected from the patient, information you’ve got hidden in your file drawers, and information that can be found online.

1. Dual Coverage. Whether it is a married couple or the child of divorced parents, patients with two insurances can cause a nightmare in the billing department. When the patient shows up and hands over two cards, they often have an assumption of which insurance is primary. Here are a few basic guidelines for how to tell which payer is primary:

1. If the patient has insurance through his/her employer, that insurance will be the primary insurance. This fact applies even if the patient has coverage under their spouse or through Medicare.
2. When it comes to minor dependents, the Birthday Rule never fails. The Birthday Rule states that the policy subscriber with the birthday that falls earliest in the year becomes the primary policy. If Mom’s birthday is in January and Dad’s is in June, Mom’s policy comes first. Remember, however, that the Birthday Rule only considers the month and day, not the year.

2. Medical Policies and Insurance Contracts. While reading a 52-page contract might not be the highlight of your day, the patient’s insurance contract will enlighten you to many things regarding your reimbursement. If you read even one portion of that document you sign, review the fee schedule. Insurance companies love to sneak in hidden discounts and sign you up for additional networks. And how about those “one-time claim reductions” that show up on your fax machine and promise you faster reimbursement? Those reductions will not only pay you less and slower but they will often enroll you in networks that pile the discounts onto services you would have never agreed to take a reduction on normally. Medical policies are available on the provider portion of a payer website and will usually give specialty-specific guidelines. Wondering if a payer allows locum tenens billing for physical therapists? Wondering if a payer follows the Centers for Medicare & Medicaid Services (CMS) guidelines? Give the medical policies a peek and you’ll find the answers you are looking for.

3. Coding Books. Believe it or not, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT) manuals that are shoved in a corner of your office are more than just 1,000-page paperweights. Within the pages of these manuals you will find code descriptions, coding rules, and guidelines for each section. The tiny symbols that appear next to the codes will give you indications if the codes are add-on codes (they can’t be billed alone), if another diagnosis needs to be billed as primary, or if there is a set of codes that cannot be billed together. The guidelines section, which appears before the first code in a code set, will give you instructions on if you need to code an underlying condition, or even if the CPT codes within a particular set are inclusive codes (meaning you can’t bill for an x-ray and an evaluation, as the x-ray should be standard practice in the evaluation process).

4. Appeals. Having a good grasp of the appeals process for an insurance company will give you the upper hand in any denial situation. On average, it costs $25-$30 to file an appeal with an insurance company, according to the Medical Group Management Association (MGMA). If you’re dealing with a complex appeal, the cost only continues to rise. There are typically three steps to an appeals process:

1. First-level internal appeal
2. Second-level internal appeal (there might be one or two levels of internal appeal depending on the plan)
3. A third-level external appeal. The third-level external appeal is an appeal that is reviewed by an external organization, or someone who works outside of the health plan.

When filing an appeal, ensure you’ve got the following information:

• Patient name
• Patient date of birth
• Patient policy number
• Original claim number

In addition to this information, be sure that the argument you’ve drafted is clear and concise. If needed, back up your appeal with compliance, clinical, or legal documentation. The final step in filing an appeal is to be sure that you are filing well within the timely filing limits. While an insurance company might allow a full year to file an original claim, appeals filing can be as short as 30–90 days from the original submission of the claim.

There is no one-size-fits-all answer for dealing with insurance companies, but having a basic understanding of the revenue cycle process is a necessary foundation. With a toolbox full of ways to ensure claims payment, there should be very few claims that slip through the cracks.

Alecia Johnson, CPB, is the billing and contract manager for RET Physical Therapy Group in Bellevue, Washington. She also currently holds a board position on the Washington State Physical Therapy Managers Association as well as the Kirkland, Washington, AAPC chapter. She can be reached at ajohnson@retpt.com.