Public Policy

Revenue Essentials

Accounts Receivable

Physicians do not necessarily recognize the need for involvement in the accounts receivable (A/R) component of the revenue cycle. Physicians should be aware of denials, and the reasons for the denials. Some services are denied because of issues that can be easily corrected (e.g., truncated diagnoses, two physicians of the same specialty billing on the same date, missing modifiers). These denial types might require physician assistance in changing the codes originally submitted. If the denied services can be corrected with the appropriate information and resubmitted electronically, payment might be recovered quickly. Other types of denials require submission of the documentation to support the service billed.

Billers should know the difference between the types of denials and the required action for each denial type. Physicians should feel confident that such denials will be handled in the correct manner. Be mindful of billing staff that accepts denials and surrenders the reimbursement efforts without hesitation. As a physician, do not default to the idea that “no news is good news.” Do not assume the billing manager (physician employee or outsourced firm) will let the group know if there is a problem. Develop a standard that requires monthly feedback of denials.

Only a short window of time exists for the appeals process to occur. Do not lose the potential to recover monies because the information was not provided to the physician in a timely manner. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

  1. Centers for Medicare and Medicaid Services. Protecting Your Practice. CMS Web site. Available at: www.cms.hhs.gov/MLNProducts/downloads/Protectingpracbroch508-09.pdf. Accessed Aug. 2, 2009.
  2. Office of Inspector General. Work Plan Health Care Financing Administration Projects Fiscal Year 1999. Physicians: Billing Service Companies. Available at: http://oig.hhs.gov/publications/docs/workplan/1999/99hcfawp.pdf. Accessed Aug. 2, 2009.
  3. Office of Inspector General. OIG Compliance Program Guidance for Third-Party Medical Billing Companies in Federal Register, December 1998, Vol. 63; pages 70138-70152. Available at: http://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf. Accessed Aug. 2, 2009.

Physician Alert

Billing services can be an asset to physicians who have limited resources or support in claim submission. It is important for physicians to be aware of the focus that billing companies have received from the government. The Office of Inspector General (OIG) has been monitoring these companies, even adding “Billing Services” to its review list in the late 1990s.

OIG reviews attempt to determine whether Medicare claims prepared and submitted by billing service companies are properly coded in accordance with the physician services provided to beneficiaries, and the agreements between providers and billing service companies meet Medicare criteria.2 Previous investigations resulted in compliance plans for billing companies in an effort to prevent upcoding or unbundling procedure codes to maximize Medicare payments to physicians, particularly for companies who were paid a percentage of recovered monies. Some of the risk areas that have been identified are:3

  • Billing for undocumented items or services;
  • Unbundling;
  • Upcoding;
  • Inappropriate balance billing;
  • Inadequate resolution of overpayments;
  • Lack of integrity in computer systems;
  • Billing for discharge in lieu of transfer;
  • Failure to properly use modifiers;
  • Billing company incentives that violate the anti-kickback statute or other similar federal or state statute or regulation;
  • Joint ventures;
  • Routine waiver of copayments and billing third-party insurance only; and
  • Discounts, professional courtesy.

—CP

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