At ElectroMed, we keep a finger on the pulse of our outstanding claims daily and can usually tell you which insurances have been causing some slowdown in our revenue cycle due to unpaid claims. I know I'm not alone in saying that it sometimes feels like these payers have a strategy in place to keep us at bay.
We have been finding with the transition of Tricare to UHC, claims are not being processed correctly and part of it is because of how your providers info is loaded into their system.
The unfortunate consequence of this is now they have the power to delay the process of your claims indefinitely and it is requiring diligence on the part of the provider to get issues fixed.
Personally we have had quite a few claims where the problem was pointed out to UHC and they say they will fix it in their system "give it 30 days" and when you check on the progress of the claim, no one knows what you're talking about and the process has to begin all over again.
We have yet to gain any traction on a permanent resolution of this issue as it is one of MANY we experience with MDX who not only processes Tricare but UHC and Aetna among others.
BUT....they are not alone in the misbehaving....VA is experiencing their own challenges with continuous personnel changes and lack of follow through. This requires unfaltering commitment to follow through on the part of the provider.
With this said...we have our eye on Medicare who is now in the process of transitioning from Palmetto GBA to Noridian. With "Early On-Boarding" happening as we speak, we truly won't know the actual effects of this transition for another 45 days or so.
We'll keep you posted.....
EGD and Colonoscopy anesthesia options in the state of Hawaii are varied so know your options. Gastroenterologists have an obligation to educate their patients about the anesthesia options available to them and costs associated with each option. Proactive patient education has proven to be the most effective tool in a healthy doctor-patient relationship and a deterrent for negative outcomes. Let us help you educate your patients
We knew it was coming and it's time to plug into the ramp up to keep up to date on the changes. If you haven't already check out the new website to keep yourself in the know...... https://www.noridianmedicare.com/je/
There are no dead bodies...( not yet anyway...) but there is a crime scene.
Unpaid medical claims.
Efficient medical billing management REQUIRES the skill of a Forensic Medical Biller.
Forensic Medical Billers not only find the old and almost dead claims within your system but also find the reason why the claim is that way and provides a solution to prevent the problem from happening again.
The best tool to efficient medical billing management is a staff that stays on top of all claims that haven't been paid in a timely manner or at the correct payment amount.
In today’s economy, you have to make EVERY penny count. Do you know where your money is? Thirty, sixty, ninety days out? More? Have no idea? Let’s find out! It’s not going to be painless but you’ll feel so much better once it’s done and maybe even a few dollars richer with no additional effort.
· Step #1 Run your A/R report, it’s that easy….SCARY but EASY!!
· Step #2 Assess that report and your current medical billing efficiency. Numbers don’t lie.
· Step #3 Investigate the details of those numbers. Review claims, contemplate patterns, and learn the deeper meaning of your current state of efficiency.
· Step #4 Establish and incorporate corrective action processes if necessary, don’t forget to celebrate your achievements!
· Step # 5 Educate everyone involved, good and bad.
No time for this????
Call us to help make your Medical Billing Management more Efficient!!
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If you disagree with a Medicare payer’s audit findings, you may appeal (see Exclusions on Medicare and Limitations on Payment, 42 C. F. R. Part 405, Subpart I). This is important because if Medicare successfully prosecutes you for fraud, you may face civil monetary penalties of $10,000-$15,000 per occurrence; and, if fraud is proven you also lose any protection you may have had under the statute of limitations.
The five levels of Medicare Appeals are:
Level 1: Redetermination (no minimum monetary limit) – You must appeal and request a redetermination in writing within 120 days of notification. If you do not request a redetermination within 30 days, Medicare will begin withholding moneys from your current accounts receivable (A/R), and could begin notifying the beneficiary’s secondary and tertiary payers.
Level 2: Reconsideration (no minimum) – You must submit a request for reconsideration in writing within 180 days of the redetermination’s failure notification. Sixty days from notice of failure to succeed at the Level 1 redetermination, Medicare will begin withholding A/R to settle what is “owed” for the alleged overpayment, and will begin notification of secondary and tertiary insurers.
Level 2 appeals are conducted by a qualified independent contractor (QIC). In a QIC, a panel of physicians uses its clinical experience to consider the medical, technical, and scientific evidence on record to assist in a final determination.
You must provide a clear explanation of why you disagree with the audit findings and its supporting evidence and/or documentation. Failure to present the evidence now may make it inadmissible when needed during subsequent appeals.
Level 3: Administrative Law Judge (ALJ) (minimum amount is $130 for 2012) – If the provider fails the first two levels, an ALJ hearing is set that’s typically done via teleconference. Request for an ALJ hearing must occur in writing within 60 days from notification of a failed reconsideration. Sometimes, the ALJ will hear evidence on the case(s) in question more globally; sometimes he or she will want to go over each case, one by one.
Specific reasons why the defense disagrees with the Level 1 and 2 findings, cogent arguments, and expert witness testimony at this level is helpful because the ALJ will often seek clarification from the expert why the provider documented a certain way, or may ask the expert to explain why the defense disagrees with the first two levels of appeal. Medicare may not show up, and instead let the evidence from the redetermination panel and reconsideration QIC stand on Medicare’s behalf.
Level 4: Medicare Appeals Council (MAC) (no monetary minimum) – The MAC review occurs in the Departmental Appeals Board of the federal U.S. Department of Health & Human Services (HHS). To advance to this level, you must provide a written objection within 60 days of the ALJ decision.
Your objection must clearly outline and explain specifically what elements of the ALJ decision you oppose. The MAC limits appeals to those in writing (no teleconferences), unless the provider does not have legal counsel (which is ill-advised, especially at this level).
Level 5: Federal Court of Appeals ($1,350 minimum for 2012) – To proceed to this level, you must appeal in writing within 60 days of the MAC determination.
Fact findings, written interpretations, or rules are deemed conclusive if they are supported by substantial evidence. At this level, the argument must be clear and well documented. Legal counsel and representation are strongly encouraged.
See “The Medicare Appeals Process: Five Levels to Protect Providers, Physicians, and Other Suppliers” for more information.
Click here for story from AAPC.org
Wouldn’t it be great to have a knowledgeable employee or two that you could pull out of a hat, but only when you needed to? And more importantly, only pay them IF you made more money based on their performance?
If you’re like most medical practices, at least 10%, and in some cases 30% or more of your claims require follow-up of some kind to complete adjudication. Denials and short paid claims make for some of these claims, but sometimes the claim just never hits its mark.
BUT, maybe you already have that dedicated employee calling the insurance company to “check the status” of your outstanding claims, following up on a claim that didn’t quite pay what it should have or maybe they just can’t figure out why a claim is being denied since your claim looks correct from their point of view.
You know….. the employee that is sitting on hold or worse yet navigating through some technical nightmare they call an “intuitive phone system” only to be told that they have “no claim on file” or “it’s being reviewed” or some other excuse that doesn’t make any sense at all.
If not, then you either have the most perfectly run medical practice AND most patient employee OR your money is sitting in someone else’s pocket.
Here at ElectroMed, we understand what it takes to bring in that 10-30%, and it’s good old fashion perseverance. Our top notch staff understands what it takes to get the job done because we live it daily and would love to put our talents to work for you.
We’re not trying to replace your dedicated employee or sell you a new practice management system. Instead, we’d like you to consider giving us the opportunity to work that “10-30%” and see if we can add to your bottom line and you only pay us if you get paid.
We believe that providers should get paid for what is legally and rightfully theirs and encourage them to let us do what we do best so that they can do what they do best.