Surviving a Payer Claims Review Audit


Patient Copays: To Bill or Not to Bill?

BlogMay 12, 2013By 

L.A. jury sides with doctor in Anthem Blue Cross case


Jury awards $3.8 million in damages to a Porter Ranch doctor who contends insurer Anthem Blue Cross retaliated against him for being a strong patient advocate.

By Chad Terhune, Los Angeles Times
5:00 AM PDT, April 10, 2013

In a rare case, a Los Angeles jury awarded $3.8 million in compensatory damages to a Porter Ranch doctor who contended insurance giant Anthem Blue Cross retaliated against him for being a strong patient advocate.

The jury ruled late Monday in favor of Jeffrey Nordella, 58, an urgent-care and family-practice doctor who alleged that Anthem barred him from its network in 2010, when he applied to be a preferred provider.The damages could climb higher Friday, when the 12-person panel reconvenes and considers punitive damages against Anthem, a unit of insurance giant WellPoint Inc.

The jury found that Anthem, the state's largest for-profit health insurer, violated Nordella's right to "fair procedure," and the company did so with "malice, oppression or fraud." That latter finding prompted the hearing Friday in Los Angeles County Superior Court to determine punitive damages.

Anthem denies Nordella's allegations and is considering an appeal.

Nordella said he was turned away because he had challenged the denial of hundreds of patient claims over the years when he was previously included in Anthem's network. He said he often protested Anthem's conclusion that care wasn't medically necessary and would not be covered. Nordella went so far as to meet with top Anthem officials in 2001.

Anthem "held this grudge and continued to lie and deceive," Nordella said in an interview.

Doctors and health insurers have battled over reimbursements and the denial of claims in court for years. But legal experts said cases like Nordella's usually never reach trial or result in multimillion-dollar verdicts.

"I was surprised by the size of the verdict, and it's really the first case I'm aware of in years," said Carol Lucas, a healthcare lawyer in Los Angeles who represents doctors and medical groups. "Insurance companies will likely look at what happened here to Anthem, and they will make sure they can justify any exclusions from their networks."

This case comes as health insurers, in a bid to hold down costs, are increasingly dropping doctors and hospitals and promoting smaller networks. Insurers typically try to negotiate lower rates with the fewer providers left in the network, who get higher patient volume in return.

Last fall, Anthem persuaded the city of Los Angeles to adopt a lower-priced "narrow network" that excluded certain doctors affiliated with UCLA and Cedars-Sinai Medical Center. That decision prompted loud protests from some city workers.

Nordella said many doctors are unwilling to challenge powerful insurance companies because their incomes are so dependent on being in these provider networks. "Physicians are so afraid to come forward," he said, "and I hope this changes that."

Anthem Blue Cross "is disappointed in the outcome and will examine our options in filing an appeal," said spokesman Darrel Ng.

The company rejected Nordella's application for its PPO network because he wasn't board certified in family medicine and because Anthem already had a sufficient number of primary-care physicians, Ng said. At the time, Nordella was medical director at Porter Ranch Quality Care, a walk-in clinic that offers urgent care and family medicine.

Theresa Barta, a Newport Beach attorney who represents Nordella, said the insurance company contended it had 137 primary-care physicians in its network within 10 miles of Porter Ranch. At trial, Anthem could name only seven of those doctors, Barta said.

Because of frequent changes in its list of physicians since 2010, Anthem said, it could not retrieve all of the requested information. The company maintains that its doctor network was adequate when Nordella applied.

In California, the most influential case on this issue has been a state Supreme Court ruling in 2000 in favor of a doctor who challenged his termination from another insurer's network. That ruling, experts say, established the precedent that health insurers must grant doctors due process when they bar them from their networks if the insurer's members represent a significant part of the physician's income.

"The insurance company's decision can't be arbitrary or for reasons beyond the ability of the physician to practice medicine," said Thomas Jeffry, a healthcare attorney in Los Angeles who represents medical providers.

Barta said that at the hearing Friday over punitive damages, she will tell jurors that Anthem Blue Cross in California generated $525 million in profit in 2010 for the parent company, WellPoint, which also runs Blue Cross plans in 13 other states.

During closing arguments at trial, Barta said Anthem intentionally limits its physician roster to make it more difficult for PPO patients to get care, which reduces Anthem's medical costs and boosts its profits.

Nordella's wife was murdered and two of his children were assaulted in 2005. He said that gave him a deep appreciation for what patients face. He received the news of the verdict while riding his John Deere tractor and planting grass seed for his daughter's outdoor wedding this summer.

"It puts life in different perspective," he said, "when you are sitting on that side, as a patient."

chad.terhune@latimes.com
Copyright © 2013, Los Angeles Times

Better Technology, Fewer Denials


Could investing in new technology to help reduce claim denials actually help you collect as much as $85,000 from a single payer?
That's the experience Reginald King, director of billing and credentialing for Centennial Pediatrics, says his multi-location practice had shortly after it purchased its data clearinghouse technology two years ago.
King says his clearinghouse software, which uses a "claims scrubbing" technology to unearth coordination of benefits mistakes and eligibility issues that trigger denials, helped the practice collect its rightful reimbursements, boost upfront claims collection payments by 8 percent, and get paid up to 20 days faster by payers.
"When I came here almost two years ago, our claims-collection percentage was average," King recalls. "It was okay."
At a time when patients are expected to pay more for medical procedures and copays, and payers are cutting back on services, lowering denials has become a top priority at practices that want to stay in business. And fortunately, King's experience is a testament to the new breed of technology that can help practices reduce such denials.
Rooted in denial
Before the era of electronic transmission, when practices would submit paper claims to insurers, they would have to wait days or even weeks to find out if the claims were rejected — by manually going through remittances to find denials.
"Practices would get a denial, and basically then, you see why it was denied and what you need to fix it and resubmit that claim, and hope it goes through that time," says Sabrina Burnett, vice president of Austin-based consulting practice Health Directions, LLC, noting that the process would take 45 days or longer. "Sometimes even on that second submission, it wouldn't process fully. It would get rejected again."
Today, thanks partially to the Electronic Remittance (835) transaction rules, plus the increase in electronic communications between payers and healthcare organizations, practices are no longer shuffling through paper. But many are still wading through electronic PDFs, says Salil Shetty, founder of RemitZEN, a manufacturer of healthcare claims reimbursement technology. In fact, some practices still update 50 percent to 80 percent of data sent by payers into practice management systems manually, which take hours to sort.
"[Practices] often needed to go through hundreds of claims to find the ones that are denied," says Shetty.
Even though denial-management technology — a category that includes data clearinghouses, which allow practices to store and send claims to multiple payers, and claims "scrubbing" software, which scours claims for denial-triggering codes and errors — exists, not all practices use the most up-to-date, sophisticated offerings on the market.
"Traditional scrubbing technologies tend to be more limited," says Michael Gladson, director with Chicago-based consultancy Huron Healthcare, noting that older technology often relied on simple "yes or no" criteria.
The need for new technology
The timing for the new, improved denial-management technology couldn't be more fortuitous, as claim denials are an increasing complaint by physician practices.
"Everybody is under both additional cost and reimbursement pressure," says Gladson. "A lot of practices are getting by, trying to perform even better with fewer staff. I can't confirm that there is a sea of more denials coming through, but it is taking longer and it is harder to resolve them."
Because of the added stress, practices need to be savvier when it comes to collecting money.
"What is happening now is providers are getting pinched and pinched, so they have to find every way to get money that's owed to them," says Charlotte Martin, president and CEO of Gateway EDI, a manufacturer of revenue cycle management technology.
Time to upgrade?
Today's denial-management technology, sometimes referred to as revenue cycle management technology, possesses "a greater level of sophistication, with more frequent edits and greater accuracy," says Gladson.
But what if you already own technology to manage and edit your claims, such as a data clearinghouse system? Is what you have enough, or is it time to trade up?
Here are a few questions experts say practices should consider when trying to decide what to do:
• How many bad claims are you catching in advance? If the answer is "not enough," consider that today's advanced billing software allows physicians to get real-time claim updates, says Gladson. At Centennial Pediatrics, headquartered in Nashville, claims that don't meet a payer's litmus test get kicked back right away. "It's like a pre-rejection report that you can clean up," says King.

• Are you collecting what you should from patients? Once that patient is out of your office, it's more difficult to collect a payment, notes Burnett. "Where we were a decade ago, what these front-end software systems would do, is they would make sure you had the right number in the right place," says Burnett. "But where we are today is that you have this technology that while the patient is still in your office, you know what the patient's upfront responsibility is, so you have the opportunity for upfront collection. If you know right then what the physician is going to bill for, you can immediately put this information through the scrubbing technology and it will give you information based on payer, provider, and contracted fee."

• Do you know your most common denials? The latest offerings in the denial-management arena don't just flag denials. They are also able to generate reports so a practice can be aware of trends or major payer policy changes that are triggering rejections. Gladson advises practices to seek out technology that allows them to group denial codes so they can know who to hold accountable. "There may be 10 or 15 reasons for not being eligible," he says. "Then you can group them and prioritize them to address them." Doing this is an easy way to catch common "low-hanging fruit" denials that could be affecting your practice's bottom line, he adds.

• How much of staff is dedicated to denial management? If you have more than a couple of dedicated staff who deal with claims processing, and you'd like to cut down in that department, new denial-management technology may be the answer. "Two years ago, I had three additional people here working on claims," says King. "We don't require that anymore."
Getting your money's worth
In determining whether their existing technology is up to par, Burnett suggests practices ask themselves whether they are using all of the features provided by their current data clearinghouse or other denial-management technology.
By doing this, they may be able to lessen the strain on billing and coding staff.
Burnett offers the example of the practice whose in-house coder could use a little helping hand.
"Certified coders are extremely important and by no means should they ever be excluded from a practice," says Burnett. "However, some of these solutions allow you to pinpoint and correct coding errors online prior to the claims submission. So even if it's coded correctly, maybe for [a certain payer's] guidelines, maybe you need to take [a code] that's [a tertiary diagnosis] and make it primary."
And if your current data clearinghouse or other revenue management system doesn't have these kinds of features, that's a good signal to start shopping around.
"It's truly amazing that every provider out there does not have some of this [new] technology," says Burnett. "Ten percent to 40 percent of claims are denied. The ROI speaks for itself."

Marisa Torrieri is an associate editor at Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

Preventing Claims Denials


The physicians in your practice put patients first. They're eager to serve and dedicated to the task of providing quality care, but that doesn't mean they're willing to work for free. Each time your insurance carriers deny claims for reimbursement, however, they do just that. Says Cheris Craig, chief administrative officer at Urology of Greater Atlanta, it's a loss of revenue that her practice can ill afford. "We have a very small [profit] margin," she says. "Some of the injectable medications we use cost $2,000 to $3,000 a dose. If you're making 2 percent on each and you're forced to eat one out of 100 [due to a denied claim], then you're losing money each time you give an injection."
Thus the importance of developing a denial management plan. "Too many denials create a cash flow problem," says Mary Jean Sage, president of The Sage Associates, a practice management consulting firm in Pismo Beach, Calif. "From a policy and procedures standpoint, you need to establish some benchmark policies regarding what percentage of claims you're willing to write off as denied." Depending on the size of your practice, she notes, that amount should be no more than 4 percent.
Be proactive
The best way to minimize delays and denials is to monitor your claims submission reports regularly, or designate someone on staff to do it for you, says Sage. These days, most practices either submit claims electronically, or use a clearinghouse to do it for them. In either case, practices should track which claims were accepted and which were not. "This is something that practices don't always do well," says Sage. "You should get a report when you send the claim from your practice management system to the clearinghouse, but there's a second report that gets generated when it goes to the health plan and you have to make sure you review both immediately." The reports provide an explanation of benefits, or EOB, which identifies the reason for any denial, including incorrect demographic information, or lack of eligibility. "There you'll find out if you have an incorrect patient ID number, for instance, so you can resubmit the same day," says Sage, noting your turnaround on resubmission should be no longer than 48 hours.
Craig says she also reviews the expected payment report each quarter. "That's important even if you are getting paid because it tells you whether they're paying you correctly," she says. "Sometimes they under or overpay." For that reason, she suggests all practice managers keep a fee schedule for each carrier in their computer.
According to the Medical Group Management Association, some 5 percent of claims submitted for reimbursement ultimately get denied. The most common reasons for denials include errors committed by the front desk during registration (such as incorrect patient demographic information or identification numbers), lack of medical necessity, and lack of preauthorization. Incorrect or invalid ICD-9 and CPT codes - especially where bundled services are concerned - and inadequate documentation from your providers will also cause your claim to boomerang. Getting it right, and maximizing the reimbursement to which you're entitled, means getting everyone on staff educated on proper registration procedure and the importance of accuracy, says Dannelle McDermott, office manager at Wilkes Family Medicine in Newbury Park, Calif. "It's a collective task that the whole office is involved in," she says. "It starts from the minute your patient walks in the door and making sure your clerks enter insurance information correctly, to making sure your doctors are using proper diagnostic codes. It goes through several steps before it even gets to the billing department." McDermott says she uses mistakes as a learning opportunity to reduce the incidence of denials going forward - flagging manual errors as they occur and discussing them with the staff.
Denials in McDermott's office, she says, are down significantly since they implemented an electronic health record several years ago, which verifies eligibility in real time. Eligibility is confirmed well before the patient's appointment, giving her office a chance to get coverage questions cleared up. McDermott notes practices should not be afraid to involve the patients. "If a claim gets denied, I look at the reason and decide whether it needs to be appealed or call the insurance company to reprocess it," she says. "But I'll also call the patient at times to find out if their insurance has been terminated and get them to take responsibility for themselves. We already did our part and filed the claim."
Start a claims denial log
According to Sage, all administrators should maintain a claims denial log, enabling them to spot trends early and react in a timely manner. Such logs, which can be kept either on paper or electronically as part of a practice management system, should include written documentation from the insurance company, dates of service, dollar amounts, individual claim numbers, the specific code denied, and how it was handled by your team - resubmitted, charge adjusted, or appealed. "Usually, denials come back in the form of correspondence from the insurance plan," says Sage. "You need to work your correspondence. If I get a denial in the mail today, for example, it needs to be resolved and back out the door again within 48 hours."
That may require a little digging. "You need to understand why a claim was rejected and that's where I sometimes see practices not doing such a good job," says Sage. "You need to know why so you can either correct the mistake and resubmit or file an appeal - and if you're going to appeal you need to be sure it's being appealed for the right reason."
Likewise, each practice should establish a policy for how it intends to handle appeals, says Sage. Some practices appeal based on a monetary threshold, while others focus on the specific service provided. For example, Craig says her practice typically doesn't appeal a denial if the dollar amount is small, since she estimates it costs roughly $50 in human resources to process, but it does make exceptions if it's a procedure or test that's done routinely. "We perform a urinalysis on almost every patient who comes into the practice so we have to get reimbursed for that," says Craig.
Make them experts
If you've got the manpower, it helps, too, to assign your billers to one or two individual health plans, since reimbursement contracts differ greatly by company. Each has their own restrictions for what constitutes medical necessity, what is considered a bundled service, and the process for filing an appeal. All, of course, require that appeals be handled in a timely manner - but some allow you to appeal by phone, while others may want it in writing. If a written appeal is required, you'll improve your chance for reimbursement by submitting supporting documentation, including labor and test results, progress notes, and operative reports. Craig says her practice, with eight physicians and 65 staff members, has enough billing staff to train and assign each biller to a single carrier, which gives them an added layer of expertise. "My Blue Cross biller does Blue Cross claims all day long so she would know, for example, that there's no need to appeal that denial because they bundle it," she says, noting larger carriers are particularly complex since their rules differ for members of their HMOs and PPOs.
Given the complexity of insurance contracts, and the trend toward shrinking reimbursement, claims denials are a harsh reality for most practices. But you don't have to take it lying down. By tracking your denials and educating your staff on best practices for filing a clean claim, you can help your physicians collect their fair share for services rendered. In a market where every penny counts, says Sage, it's time well spent.

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.
This article originally appeared in the September 2011 issue of Physicians Practice.

Healthcare Providers Fight Back vs. Recoupment Audits, Slow Payments


As dollars became scarcer in the 1990s, health insurance companies increasingly employed “post-claims underwriting” as a basis for denying claims or rescinding policies. Some relief is expected from the Affordable Care Act's elimination of “pre-existing conditions” as a basis for denial of claims.
But the reform law does not put an end to denials based upon medical necessity, or a refusal to pay because the service or DME is “experimental.” Equally alarming is the practice of “pay-then-pull-back” recoupment audits, which can devastate the finances of providers of all sizes. Now, providers are fighting back.
In Tri3 Enterprises v. Aetna, the U.S. Department of Labor (DOL) has filed a November 30, 2012, amicus brief in the Third Circuit Court of Appeals in the appeal of a New Jersey federal district court ruling against a provider who filed a federal case against Aetna. In cases where only a provider agreement governs, (the policy is not an employee benefit) it is easier for insurers to cease payments and demand overpayment refunds, because such actions are often sanctioned by state anti-fraud laws. But when an ERISA plan also exists, (the plan is an employee benefit) adopting such an aggressive stance might not be so simple. In this case, Aetna authorized and paid Tri3 for non-segmented pneumatic compressors, i.e., medical devices, but then retroactively sought to recoup the payments after and audit by the ominously named Special Investigations Unit (SIU) determined the equipment to be “experimental.”
Aetna allegedly refused to treat its decision as a “claims denial” and refused to provide the procedural protections accorded under ERISA and its regulations to such decisions. Tri3 argues that under authority of ERISA, the DOL adopted rules protecting both insured individuals as well as providers who have accepted assignment of the claim from the insured. Tri3 claims in addition to the fact that the medical devices had been previously approved in other cases, and approved for payment in the instant case, it has a right to challenge the reversal and demand for recoupment under ERISA’s administrative claims review process. The trial court disagreed, dismissing the case for failure to state a claim ruling, “it is clear from the complaint that the central issue of the dispute is Aetna's allegation that Tri3 had misrepresented to Aetna the nature of the medical device that had been supplied to insureds.” The DOL has filed a brief on appeal favoring the provider’s position and arguing for a reversal of the trial court. The outcome will likely hinge upon whether the Third Circuit views Aetna’s action as an attempt to recover from fraud and abuse, (i.e., Tri3 misrepresented the nature or use of the devices) or whether the matter is more accurately characterized as a coverage dispute which might fall within ERISA appeals process.
As to slow payments, medical providers are using technology to fight back in a different way: enlisting the aid of former foes in the plaintiff’s bar to go after carriers who delay payments for covered treatment. Texas powerhouse lawyer Mikal Watts of Watts Guerra Craft LLP says his firm has “built up a solid docket of over 500 medical providers, representing hospitals, large doctor groups, and pharmacies seeking to enforce Texas’ Medical Provider Prompt Pay laws.” According to Watts, “the problem in the past for medical providers is that there was no efficient way to enforce prompt pay laws for small claims.” Watts uses sophisticated computer models from medically knowledgeable data analysis companies to identify patterns and initiate legal proceedings on a cost-effective contingency fee basis. “In total, we have identified hundreds of millions of dollars due our clients,” says Watts.
Historically, ERISA had been an impediment for individuals whose claims have been denied. ERISA preempts state law remedies, including an award of attorney’s fees to the successful party. Most employees could not afford to pay out of pocket for an attorney to pursue the claim under their group plan. Watts points out that Texas, and many other states, carefully drafted “slow pay” statutes with an eye toward avoiding ERISA’s limiting provisions.
As with any legal issue, you should consult an experienced health attorney if you have specific questions about your rights under assignment of benefits agreements or “slow pay” laws in your state or jurisdiction.

Martin Merritt, JD, is a Dallas-based attorney, representing physicians, practices, and others in cases involving Stark Law, state and federal regulations, Medicare fraud and abuse compliance, as well as transactions and contracts.

Five Common Coding Errors in Medical Practices

Medical practices are concentrating on critical practice changes in 2013, but it is important not to lose focus on the basics of coding. Don't be guilty of these common errors:
1. Randomly using modifiers. Modifiers are two-digit codes added to a service that tell the payer of special circumstances. The AMA develops CPT modifiers, which are numeric, and CMS develops HCPCS modifiers, which are alphanumeric or alphabetic. Both types of modifiers can be used on CPT or HCPCS codes. Why would someone randomly apply a modifier? Misunderstanding, incorrect information, or a desire to get a claim paid. But for both compliance and revenue reasons, correct use of modifiers is critical. Using modifiers requires an understanding of the global surgical package and National Correct Coding Initiative (NCCI) edits. There are several good coding books on the market that exhaustively explain modifiers.
2. Selecting the wrong procedure code. With more than 75,000 CPT codes, it is easy to imagine selecting an incorrect procedure code. However, the source of this error is usually not confusion about the procedure performed. Incomplete or inaccurate code descriptions on encounter forms, cheat sheets, and electronic charge systems are a significant source of error. Failing to read the editorial comments at the start of the section in the CPT book or the notes near the code is another source for this type of error.
3. Failing to link diagnosis codes. A CPT or HCPCS code tells the payer what service was performed. The diagnosis code tells the payer the reason for the service. Some patients present for more than one condition and may require unrelated services. Other patients may receive a service that is only covered for a specific indication. For example, a patient presents to a family physician for hypertension, but has a wart destroyed at the same visit. The code for the office visit must be linked to hypertension, and the code for the wart destruction must be linked to the diagnosis code for warts.
4. Using a nurse visit in place of another service. Some practices still believe that they can charge a nurse visit with an injection or for a venipuncture "because our nurse takes the patient's vital signs." Or they ask, "Can we bill a nurse visit with a flu shot?" Nurse visits are bundled into injection codes, and will not be paid separately by a payer using NCCI edits, or any payer using proprietary edits. As for the venipuncture, the practice motivation is that a nurse visit pays more than a venipuncture. But, it does not accurately describe the reason for the visit or the service performed. If the reason for the visit and the service performed was venipuncture: bill venipuncture. If the patient presented for an allergy shot, bill for the administration of the allergen. Assessing the patient pre- and post-shot is part of the payment for the administration.
5. Not keeping up to date. Medical practices and hospitals are understandably cautious about budgets. But failing to keep up to date on new coding rules and initiatives is an expensive mistake. It results in lost revenue and potential compliance risk for practices.
If you can avoid only one error this year, avoid not keeping up to date on coding. By doing that, you will avoid many of the other errors mentioned in this article.

Betsy Nicoletti is the founder of Codapedia.com. She is the author of "A Field Guide to Physician Coding." She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at betsy.nicoletti@gmail.com or 802 885 5641.

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