Author: PractiSynergy Team

Medical Billing Guide Medical Claim Adjustments

Top Three Reasons Your Claim Has Been Denied

Post author By PractiSynergy Team
Post date September 12, 2022
No Comments on Top Three Reasons Your Claim Has Been Denied

When it comes to medical billing, the coding network can get quite tricky. There are many reasons your claim may be denied. This fault could fall on the provider or the payer. The more informed you are, the easier the claim process will operate. It’s important to cooperate with your medical coding professionals and give them the most accurate information possible to avoid a denied claim. The best way to avoid errors is to communicate efficiently.

Having a claim error can negatively impact your practice and harm revenue cycles. To achieve an optimum experience with patients, it’s important to make this process seamless and smooth. We’ve all heard the “a bad foundation builds a weak house…” analogy. Think of your medical billing system in such a way. The well-being of your business is one of your main priorities. It’s essential to maintain a strong base of medical coding to keep everything on the front lines running as it should. At PractiSynergy, our highly trained staff works closely with you to build that foundation. This way you can get back to what’s important, rather than stressing about coding errors.

Furthermore, we’re here to divulge common errors leading to claim denials. Using our years of experience, we’ve gathered our knowledge to reveal the top three reasons we see claims get denied – and how to avoid them.

Claims not filed on time
- Provider contracts with Insurance companies dictate how long from the date of service a claim can be filed
- Traditional Medicare is 1 year
- Many insurers have drastically shortened time to 90-180 days
- You can appeal denials with proof you filed on time – these appeals also must be filed timely
No Authorization or Exceeded Authorization Denials
- Providers must know which procedures require prior authorization from the insurance company
- Most insurers allow providers to submit for emergency authorization when procedures must be done – or allow for post-service review and authorization
- Most insurers DO NOT allow providers to bill patients if the provider neglected to get a prior authorization
- The authorization typically states a time frame when the procedure must be completed as well as the number of procedures or visits allowed
- Appeals may be done if there is documentation that information received from the insurance company stated an authorization was not required.
Claim errors and patient demographic errors
- Coding errors happen – but there are ways to minimize these errors by building edits or macros into a practice management system
- Patient intake forms – these forms are typically filled out by patients. As these forms have become electronic they tend to feed directly into the practice management system. This causes an immense amount of error since most patients do not know exactly what information they need off an insurance card or they may put a nickname that does not match the insurance database
- All demographics need to match what insurance companies have on file or there is a high probability of claims being rejected or denied

By making sure your claims are authorized, reported on time, and fully reviewed before submission, you’re able to avoid the most common faults we see as medical billing professionals. Taking these proper precautions can help the well-being of your practice and its backend process.

Using this data, we’ve formulated our business in a manner to avoid such errors. We ensure our clients get none of the stress and all of the cash flow. When we work together we’re able to take the stress of coding errors off your back. Get back to what you do best. It’s our passion to help you, so you can help others. To get informed about our medical coding and billing services, Call Katie at PractiSynergy or reach out via Email.

Tags Denied Insurance Claims, insurance claims, medical billing, medical billing guide, medical coding, medical coding services, practisynergy, Type of Claims

Medical Claim Adjustments Medical Coding Guide

Deductible Season For All Medical Insurances

Post author By PractiSynergy Team
Post date January 22, 2022
No Comments on Deductible Season For All Medical Insurances

Doctor with health insurance healthcare graphic.

It’s here. Deductible Season. The time of year when most insurance plans re-set deductibles back to $0.

So, what exactly does that mean to your practice? Its not all doom and gloom, its not too late to make a few changes to help you maintain your cash flow.

1. Eligibility Check

Always check insurance eligibility. This includes MEDICARE! Medicare beneficiaries had open enrollment late fall allowing them to choose Medicare advantage plans as well as supplemental
plans. What do you want to look for when checking eligibility and verifying benefits?

a. Does the patient have an active policy? What is the effective date of that policy?

b. Does the patient have a co-pay, deductible, coinsurance, or an out-of-pocket maximum?

c. Does the service you provide require a prior authorization or a referral?

d. Does the patient have any secondary insurance?

2. Payment Collection

Collect payments from patients at the time of service. Unless an insurer bars you from billing a patient (such as Medicaid), it is wise to collect money up front. Always collect a co-pay at the time of service. If a patient has a deductible or co-insurance that applies to your service, collect a set amount of money at the time of service. Depending on your patient population and service provided anywhere between $50-$150 might be appropriate for your practice.

3. Don’t Make It Difficult To Pay For Patients

Always take a payment if a patient offers, and do not make it difficult for your patients to pay.

Technology is spanning all the generations. Patients regardless of age expect the ability to pay their bills online. Identity theft has increase and few patients want to send a check or credit card through the mail for fear it will be stolen. Secure email and text is a great way to remind your patients they still have a bill outstanding.

Finally, remind patients (verbally, in writing, or both) of their financial responsibility. Whether it is keeping insurance updated, patient contact information updated, and a friendly reminder that most insurers require the patient to pay the provider some portion of their bill – even Medicare (Medicare’s deductible for 2022 is $233).

These strategies will help medical practices keep a better cash flow during this deductible season. PractiSynergy can help providers set up these processes. Please contact Katie Fergus, call 515.412.2800 or email katie@wordpress-799426-3758877.cloudwaysapps.com.

Tags deductible, insurance claims, medical billing guide, medical billing resources, medical insurance, practisynergy, practisynergy blog

Medical Billing Guide Medical Claim Adjustments

Claim Adjustments In Medical Billing

Post author By PractiSynergy Team
Post date December 6, 2021

Claim Adjustments In Medical Billing - PractiSynergy

What are the adjustments codes do on the payers’ explanations of benefits and what do they mean? These codes tell the provider why all the money charged was not paid.

I have three categories for these adjustments: Contract Related, Process Related, and Patient Liability. From these categories, you should examine whether there is a payer error (not abiding by contracted rates or agreements), a billing error (something on the claim was not correct), or if the amount is owed by the patient

Payer Error and Contractual Adjustments:

The maximum amount was paid by the insurance company based on the contract the provider holds with the insurance company – This means what the amount charged by the clinic was more than the allowed reimbursement in the provider’s contract.
No prior Authorization – Provider contracts spell out the responsibility of the provider to acquire any prior authorization required by a policy or their payment may be reduced or denied
Billing Guidelines – claims may be denied due to the provider not following the proper rules to bill a particular medical procedure. For instance, providers may not be paid for cosmetic procedures. The definition of “cosmetic” is usually determined by a patient’s diagnosis coded and is spelled out in coverage documents for the plan. Providers are expected to review these and submit claims appropriately.

Billing Error and Process Related Adjustments:

Non-covered benefit – Providers are expected to check benefits for patients before they perform a procedure on a patient. Even a simple sick visit may be denied, or the payment may be reduced if an out of network provider give these services and the patient does not have out of network benefits. Another example may be when the insurance company expects a certain type of provider to perform a service (a physical therapist should not submit a claim for a throat culture for strep)
Patient does not have active coverage – Providers must verify a patient is eligible for their insurance as of the date the service will be provided. If the service happens before, after, or during a gap in coverage, the provider is not eligible for reimbursement from the insurance company. The beginning of the year is most common for these adjustments.
Incorrect coding – medical codes on a claim are critical to payment. Providers are ultimately responsible for which codes go on a claim. They may delegate this duty to certified coders to do a thorough job. Providers should always use current codes and not rely on Google to find the right code since there are many codes which are expired that swirl around cyberspace. For reliable codes please visit PractiSynergy.

Patient Responsibility:

Insurance companies may not pay a claim or only partially pay a claim if the patient has some cost-share responsibility. This may be in the form of co-pays, deductibles, or co-insurance. These amounts are deducted from the amount owed by insurance companies. Providers collecting these amounts up front would be best practice.
An insurance company may designate a patient owes the full amount charged if a provider is out of network or if the patient is not eligible for coverage on a particular date of service.

Providers should review these adjustment reasons on a regular basis to evaluate a payers’ performance (or the billing company performance). A quick check monthly on your most utilized procedure codes is also an easy way to make sure you are capturing all the revenue owed to you. PractiSynergy helps its clients with this analysis. Please contact Katie Fergus Call or Email to assist your practice review your payments and adjustments to make sure you are not missing any cash.

Tags Adjustment Codes, Insurance Claim Adjustments, medical billing, medical billing guide, medical coding, medical coding services, practisynergy, Type of Claims

Medical Billing Guide

Payer Credentialing and Contracts In Medical Billing

Post author By PractiSynergy Team
Post date October 21, 2021

Payer Credentialing And Contracts

Payer credentialing and contracting process – Yawn! The most boring topic – Yet one of the most important for medical providers. The process is laborious and tedious.

Gathering paperwork, filling out forms, and negotiating is not how most professionals want to spend their time, unless of course they are attorneys or accountants 😉

The process is meant for the payers to “vet” medical providers and make sure they are legit. (Wiki: Credentialing)

The process also allows the provider, to align themselves with different employer groups or accountable health organizations for exposure and marketing of their practice.

Why are some networks so narrow? These networks are aiming for a truly patient centered experience. The primary care provider and the patient would make decisions together for the best course of treatment. Specialists need to decide what groups might have the biggest impact on your bottom line.

That is where the negotiating comes in. In a narrow network, the specialists need to prove their worth and may have to jump through extra hoops or make certain concessions in contract negotiations to become an in-network provider.

Is it so bad to be out of network? If you are out of network, most commercial insurance plans have an entirely separate set of benefits. Patients typically have separate (and large) deductibles and out-of-pocket maximums for out of network providers.

While the insurance company may “allow” the full fee of your service instead of a negotiated discount that an in-network provider might receive – this balance typically falls on the patient.

The patient becomes responsible for the entire balance. Large medical bills are extremely scary for patients.

Scary may not even be the correct term – if they don’t know it is coming, they can be outright mad. Collecting money from patients is typically much more difficult than collecting from an insurance company.

Why aren’t there set fee schedules which all insurance companies just pay the same [Pay transparency]? That is a discussion we all need to continuously be asking our legislators. Until the “system” changes this is the game – if you don’t play, other will. PractiSynergy understands and knows how to play this game. We guide providers in revenue cycle management to maximize their profits. This all starts with contracts and credentialing.

Want to get in the game and learn more about credentialing and contract negotiations?

Call Katie at PractiSynergy or reach out via Email to receive a FREE CONSULTATION on how PractiSynergy might help your practice maximize revenues through payer contracting and credentialing strategies.

Tags Des Moines, Iowa, medica practice billing, medical billing, medical billing guide, medical payer contract guide, medical payer credentialing, payer contracts, payer credentialing, payer credentials, practisynergy

Medical Coding Guide

Medical Coding Commodity : Why Medical Coding Is Essential?

Post author By PractiSynergy Team
Post date October 8, 2021

Medical Code Commodity

The Merriam-Webster dictionary defines commodity as “something useful or valued.” In healthcare, coding is the most important yet silent commodity in the revenue cycle. So, what is Medical Coding Commodity and why is it essential? Let’s understand it…

With over 68,000 ICD-10-CM medical diagnosis codes and over 87,000 ICD-10-PCS procedure codes for providers to comb through, selecting the right combination of diagnosis and procedure codes can be a daunting task.

Medicare and other major insurance companies have their own “billing guidelines” which must be followed to get paid. Certified coders know where to look for the information to find what diagnoses may be used to determine medical necessity for various procedures.

For instance, Botox®, this drug is covered by Medicare and most insurance companies for Migraines, but they will not pay for it if you want to smooth out your facial wrinkles.

Most providers do not have the time to look up if a specific diagnosis is payable for each appointment, certified coders are essential to getting providers paid.

Electronic Medical Records (EMR) and Practice Management systems are supposed to assist with coding however, the EMR does not have the experience working with insurance companies who may have different policies on how to code a single procedure. Some insurers may require a modifier – while some may not.

Some may only pay when a procedure is paired with a certain diagnosis – while some may be flexible. Each insurer is different, and each state may also have different guidelines.

Certified professional coders added into a revenue cycle allows a critical view on a patient encounter prior to being sent to payers.

Coders can focus on certain specialties such as orthopedics, podiatry, optometry, etc. garnering experience from the different insurance companies and maximize payment for the providers on the first pass of a claim.

When a provider is searching for the right code that is time they are not spending with their patient. Any process improvement program would tell you wasted time/wasted resources is inefficient. Inefficiency can cause a debilitating effect on a medical practice.

Investing in an experienced coder will more than pay for itself by maximizing reimbursement and decreasing claim denials.

PractiSynergy has Certified Professional Coders (CPC) on our team reviewing procedure notes and providing education on documentation to providers to ensure compliance.

The combination of a CPC and experienced biller will improve compliance and increase cash flow, maximizing a clinic’s profits.

To tap into this “Coding Commodity”:

Call Katie at PractiSynergy 515.635.5531 or email katie@wordpress-799426-3758877.cloudwaysapps.com

Receive a Free Consultation on how PractiSynergy might help your practice maximize revenues and boost your cash flow.

Tags coding commodity, how medical coding can help medical practices?, importance of clinical coder services, medical billing, medical coding, medical coding services, practisynergy, why medical coding is important?