Back to Basics Physician Billing — The Very First Step


Q: A
biller had contacted me saying that: “I
can’t seem to get my first claim transmitted without some type of denial coming back. I
am checking the CPT and ICD-10-CM codes and it all links together. What is going on?” A: The first thing is, there is an initial
step that medical billers must take before they review the coding for a claim submission. Unfortunately,
it’s the reality of the billing world where they have to focus on the competency of the
practice’s front desk, and you need to monitor the denial trends because a lot of them point
to the front desk. Billers don’t have time to appeal every denied claim, which can take
anywhere from 5 minutes to over 2 hours. If you happen to work for a practice where
the front desk is horrendous and they haven’t made any changes, then what I say is that
every medical biller’s first step should be to review the registrations prior to reviewing
the coding or anything else. That would be the first step in the process. Over 56% of claims denied due to the front
desk. That is an average based on, I own a billing service which my family runs, but
I look at the stats and stuff so that I can share it with my students, and some practices
may have 30% denial rate and other practices have 70% all based on bogus information because
the front desk is not doing their job. What you need to do as a biller is look: Is
the front desk a qualified professional who is focused on the job? Medical billers, they
require the front desk to understand the insurance, to verify the insurance and all the patient
information before they’re seen by the doctor or healthcare provider. When the biller gets
the information, the service has already been provided. So, if there is no insurance or
any patient information is wrong, it’s very hard and it’s an extra step for the biller
to take in order to get the claim paid. Even though working a front desk is not really
difficult, if you do not work well in a chaotic environment, it’s not the place for you,
so even if you are confident or your front desk person presents well, if they don’t
work… you know, with folks coming in, patient is coming and going and people milling around
and copayment is being collected, then you need to make some changes. The next slide, when I asked: Do the billers
actually know what the insurance is about? This is an actual insurance card that I’ve
taken from a billing company and just whited out important information. If you look at
the bottom where it’s highlighted, it says United Healthcare Group Medicare Advantage
(PPO). Medicare patient comes in, they have a Medicare
card and they have this new Medicare Part C card, they hand it to the front desk. The
front desk registers Medicare primary and this is secondary. When the biller gets an
EOB (Explanation of Benefit) with all these denial codes, CO109, saying the patient has
other insurance. It’s usually because they have a Medicare Part C. So, you focus on the
United Healthcare, you look at the bottom where it says Medicare Advantage, and that’s
your hint. The other thing to keep in mind is that billers
have a year to bill Medicare. United Healthcare PPO, you have 90 days. If you don’t act
on that Medicare denial within the 90 days, you put the right information in, you won’t
get paid. So now, the biller not only has to go in and make the correction to the registration,
now they have to appeal the claim because it was billed wrong, they have to send it
to the right insurance carrier. This next slide is just a very clean example
of a scanned card of what it should look like in the medical record whether it’s scanned
in the EMR or if it’s in a patient chart. Everything should be clear and it has everything
in it from the member name and ID number and all the information, co-payments. The only
thing missing in this particular back of the card, you don’t have the mail paper claims
but you also don’t have the EDI of the payer, transmitter ID number, which is very important
if you’re billing electronically. But this is what an insurance claim should look like. Let me show you legitimate bad claims that
have come from my office from one practice where a biller actually went – you can go
to the next slide – and these two particular claims got denied. She went into the medical
record and this is what was scanned. Now, you should be able to read the patient’s
name as well as the ID number, and you don’t see it. That means now that the biller has
to contact the patient to get the information because the front desk didn’t check to see
– 1) they registered it wrong; 2) they didn’t scan the cards properly or make copies to
put in the chart. These are real life pictures of what billers deal with. This is what you
get. If your front desk is doing this, you need to do something quick. Next slide has to do with the front desk educating
the patient. This is just maybe a sign that’s out there: “Copays are due prior to services
rendered.” What does that have to do with the biller? Well, the patients and doctors
are contracted with the HMOs or PPOs that they have to collect the copayment at the
time of service. If they don’t, once the claim is paid, the biller now has to send
a bill for $20 to the patient to get paid so that’s not only the biller is telling
the doctor is paid for, it’s all the stationery, the postage or whatever. If the patient doesn’t
pay the first time, they have to pay for postage again; so a lot of extra work that the biller
has to do when by right when they get the encounter form and there’s a copayment that
was paid, it should be on there already. This next slide is really interesting; I actually
did this up because obviously I can’t use the real patient’s name. We had a patient,
Joey Serino, that came in, filled out a registration form, he wrote down on the registration form
his ID number… When the patient filled in the registration, he wrote Joey Serino. What
happened was, the biller transmitted the claims and this is an example of an electronic acceptance
and rejection report. Let’s say that two of the claims went through and we got the
accepted report, but the bottom one says: Joey Serino rejected. Reason for rejection:
Name and member ID do not match. When we looked up the card, it happened to
be legible and it says Joseph R. Serino. He wrote down his last four digits of his Blue
Shield as 9989, when in fact it ended in 98; he transposed the last two numbers. The front
desk, if they’re the ones registering, is supposed to take that information from the
card and make sure it’s accurate. In this case, when you get an electronic denial, you’re
not going to get a paper explanation of benefit. This is your denial and you can go in and
make the corrections and refile it right away. But unfortunately again, the biller has to
go in and correct the registration, correct the ID number, and then refile the claim.
These incidences has happened so much that it’s ridiculous, and it’s very frustrating
because there’s enough to do as a medical biller without having to go back and call
patients or make corrections for something as simple as this type of information. The next one is just simple again; I had to
type it out to change information. But if you look at the bill, it’s for $210.00.
They allowed zero, paid zero. The paid code in this particular instance is T, which means
member not eligible on date of service, which means the front desk did not verify eligibility,
which means again the biller has to contact the patient, get the correct information in
order to bill and you have to do it as soon as you get the denial because you’re dealing
with anything from 60 days to a year, but usually 60 to 90 days is the limit you have
to bill a claim, so you want to act on these denials right away. Basically, the very last part here, this is
a little chart of all the roles of a medical biller, and I just covered 01 –patient registration
– and I will touch on everything else in other webinars and pretty soon we’ll be
having weekly student question and answers and I’ll be touching this as well. Patient registration, like I said that’s
the most important aspect of the billing. If you don’t get that right, it doesn’t
matter if the doctor charged a thousand dollars in surgical procedures in the office, he won’t
get paid unless that’s done. So, you need to have to re-educate the front desk person
or bring someone else in that can handle the job because as you can see there is a lot
that a biller has to do and to be doing this very first step. It is being proactive but
it’s unnecessary. That’s it, thank you.

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