I.
PROVIDER PART
(Coding, billing and claim submission)
Ø Get to know your most commons insurers.
Ø Make sure you know the pre-authorization process and the
insurance policies.
Ø If the facility is a participant or in network
provider, make sure you know contract specifics regarding billing and coding.
Example if the contract has an extender language clause you need to bill the
correct specialty.
Ø Remember every code must be supported in the record.
Ø If you have any question about the notes don’t
hesitate to ask the provider for help.
Ø If the provider codes their own procedures always look
at it and make sure is accurate. Comply with filing time frames. (This change
by insurance company)
Ø Get to know which documentation is needed for the
procedure billed (this will decrease the possibility of a denial).
* We will write about specific documentation for procedures later on another post*
II.
INSURANCE PART
A.
Claim Analysis
Insurance analyze
claims for systematic denials and for information to start investigations.
System Analysis
|
Data Mining Analysis
|
Incomplete
information
|
Billing
patterns
|
Non-covered
services
|
Peer
to Peer coding comparison
|
Pre
authorization needed
|
Out
of scope billing
|
Code
edits/ Coding errors
|
Duplicate
billing
|
Past
timely filing limits
|
Unbundling
|
**Only the
most used systematic analysis are listed. May vary by insurance **
B.
Claim Denial
If you claim is
systematically denied you will received an EOB without payment. If after the
data mining process your case is selected for investigation you will receive a
request for records letter along with the EOB.
Please note: Not
all of the investigation are initiated by the data mining process. Many other
resources are part of the decision. Third party private, government and member’s
referrals are part of the investigation decision.
C.
Claim Review
After the records
are received the insurance may start a clinical review even a medical director
review depending on the initial allegation and the type of procedure billed.
After the review is done and everything is ok the claim continue the process
for adjudication and payment. If it doesn’t pass the clinical review and is
deny you may need to start an appeal process based on the denial reason.
Common denial
reasons are;
1)
Coding not
supported
2)
Not medically
necessary
3)
Services not
rendered
4)
Services not
covered under plan
III. Why insurance
start an investigation?
- Billing for services not rendered
- Incorrect use of Codes (CPT, HCPCS etc.)
- Billing for non-covered services by submitting similar covered codes within a claim in order to have the non covered service reimbursed.
- Up coding and/or billing for services at a higher level of complexity than the services actually provided
- Modifier misuse and/or the use of modifiers to override system edits.
- Unbundling services/codes
- Billing within the global surgery period
- Billing for more units that the ones actually rendered
- Billing for services performed by other providers
- Submitting false and/or duplicate claims
- DME claims for services and supplies not provided
- Billing for appointments the member missed (missed visits)
- Billing for services above the scope of practice
- Billing for Non FDA approved equipment (Investigational & experimental usually non-covered)
- Billing for services/items not ordered by a physician
- Documentation does not support the services billed
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