In our company, we deal with insurance companies across the nation. Working with a variety of payers gives us a wide range of experience but we also encounter our fair share of challenges in obtaining reimbursement. Here are three simple tips that make collecting from payers a little easier.
1. Know the Rules
The best way to cut down on difficult-to-collect claims is to make sure claims are filed correctly the first time.
Most insurance companies publish billing guides or provider manuals on their website. Billers should be familiar with the claim requirements of each payer and have a copy of the most current provider manuals for easy reference.
This is critical in renal billing, as the rules for dialysis and nephrology claims differ from other specialties; many insurance representatives are not familiar with the rules. It is up to the biller to be the expert on the payer’s billing requirements.
Even when a claim is filled correctly, the payer may still deny in error. Recently, we received several denials from a payer for dialysis facility claims. We spoke to the payer about the denials, and the customer service representative told us that the claims were denied because they were submitted on the wrong claim form. The biller explained to the customer service rep that the claims had been submitted using a UB-04 claim form, as instructed in the payer’s dialysis billing manual. Multiple customer service reps insisted that the claims would only be paid if they were submitted on the “correct” claim form: a CMS-1500.
After several fruitless phone calls with the payer’s customer service reps, our biller called the provider representative to resolve the denials. The provider rep reviewed the claims and denials and concluded that the claims had been submitted using the wrong claim form. The provider rep even went so far as to ask: “Who told you to bill on a UB-04 in the first place?.”
Our biller directed the provider rep to the page in online version of the payer’s dialysis billing manual, where the manual clearly calls for this claim to be submitted using a UB-04 claim form. The provider rep apologized for the erroneous denials and the claims were quickly reprocessed and paid.
2. Know the Payer
A payer may offer several insurance plans; each with slightly different billing requirements. With passage of the Affordable Care Act, more insurance companies offer commercial, Medicare Advantage, and Medicaid Managed care plans. Often each of these plan types has its own set of coverage and billing guidelines. The ability to easily differentiate between the different plan types allows the correct billing rules to be applied to claims
3. Stay Current
Take time to read payer updates.
Most payers will communicate changes in billing requirements, coverage, and policies well before the changes are made effective. Be sure to read the email updates, online bulletin reports, or monthly newsletters from your payers to stay up-to-date on regulations.
A proactive biller will be familiar with how, where, and when updates can be found from their major payers. Taking the time to read payer updates regularly allows a practice to prepare for any policy changes that will impact reimbursement.
Years ago, before dialysis was paid under the bundle, I did the billing for a dialysis program in which a large percentage of patients were covered by a local payer. As was common before the bundle, this local payer reimbursed separately for vitamin D, IV iron, and ESA medications commonly given during dialysis
The payer published a monthly newsletter for providers that detailed upcoming policy changes. Month after month, I read newsletters that had nothing to do with dialysis billing. But still, I continued to read through them—just in case.
Then the payer published a policy change that would have been disastrous to the program I billed for, had it gone unnoticed. The payer announced that in two months they would begin requiring prior authorization for Epogen as a condition of reimbursement. Since we knew about the policy change in advance, the dialysis program created a process for getting Epogen prior authorizations and put it into practice before the payer’s policy became effective. We averted disaster by keeping up-to-date on regulation changes.
Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD facilities, nephrology practices, and vascular access. Your questions are welcome and she can be reached at firstname.lastname@example.org, 801.775.8010, or via Sceptre’s website, www.sceptremanagement.com.