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Advice from Experts: Troubleshooting Claims Problems
By Miki Fairley You've done everything right - all the upfront work
is done and you've submitted a clean claim electronically - and now
you'll soon be paid, right? Well, maybe not. In this imperfect
world, problems will still arise despite your best
efforts.
So what to do?
 Management experts Eileen Levis and Joyce Perrone
share some of their experiences and insights to help you
troubleshoot difficult claims. Levis is president and CEO of
Orthologix, Philadelphia, Pennsylvania, and president of the
Pennsylvania Orthotic & Prosthetic Society (POPS), and Perrone
is a consulting partner for PROMISE Consulting, Pittsburgh,
Pennsylvania, and practice administrator for DeLaTorre Orthotics
& Prosthetics, Pittsburgh.
First, they recommend starting with your own mindset and that of
your staff: perceive the patient as your partner in the payment
process, and payers' representatives as people simply doing their
job. "It's not necessarily an adversarial relationship," says
Perrone.
"I have found, especially since the implementation of HIPAA,
insurers have refined their processes and software systems," says
Levis. "Their staffs seem more knowledgeable in O&P, and some
of their software programs cross reference ICD9 codes with HCPCS
codes. You often have the ability to provide additional clinical
information which can make the difference between an authorization
and a denial of services, getting paid or not. Ultimately, a real
problem claim will require a phone call and follow-up."
Perrone says that O&P providers may think insurance
companies are being deliberately devious and difficult when often
they are simply disorganized. "Often their systems are chaotic -
not functioning at the highest level. They lose a lot of things,
but it's not intentional."
Part of the answer lies in having a good software program
yourself. "You need a system that will track when a claim was sent
to an insurance company," says Perrone. "Try to get the person's
name it should go to and let them know you are sending it directly
to them."
When Claims Are Denied
When problems arise with denied claims, Perrone has found that
most insurers will give you the information you need to submit the
claim correctly. "Ask, What do I need to do to get this paid?" she
advises.
Establishing good working relationships with insurers helps.
Perrone points out that the Pareto Principle, also called the
"80-20 Rule," applies to your payers. Says Perrone, "About 80
percent of your money comes from about 20 percent of your payers.
Analyze who are your most important payers and ask, 'How can I get
into those companies?' Find out who the vice president is, who the
medical director is - who's the 'wizard behind the curtain' that
has the authority to get things resolved."
Often a large referral source, such as a big orthopedic
practice, can help you get your foot in the door, Perrone notes.
Inviting payers' representatives to come to your facility and see
for themselves what O&P is all about helps too. "It puts a face
to the brace," says Perrone. These efforts can lead to a better
working relationship with your most important payers.
What about Medicare? Levis, who sits on the Medicare Region A
Provider Communication Advisory Group (PCOM), says, "There really
shouldn't be as many problems with getting paid by Medicare these
days as in the past. If you submit clean claims, use valid codes
within the HCPCS system, and you've checked the patients
eligibility, you should be fine. If you submit electronically, you
will be paid within 18 days." She adds, "Of course, depending on
what region you are in, post-pay audits can offset those payments,
but that is a subject unto itself."
Factors that can cause denial of Medicare claims, according to
Levis, are omitted, missing, or misuse of modifiers; using the
generic "999" code, or submitting a duplicate claim. Sending
duplicate claims can also generate denials from private
insurers.
Why do providers submit a duplicate claim? Sometimes providers
think their claim has been lost. For instance, if they call to
check on the status of a claim and it hasn't shown up in the
carriers system, they conclude its lost and then resubmit it.
"However, some carriers track every 30 days, others track every 45
days, and some track every 15, so be very sure that your claim is
not in their system before you send another one." Also, check your
electronic transmission records/logs before resubmitting an
electronic claim. "You should have an acknowledgement that a claim
was received," advises Levis. "Nevertheless, sometimes we all have
a claims problem that seems just ridiculous and impossible to
resolve. With some exceptions, most can be resolved and paid, but
will require patience and a lot of supporting documentation and
follow-up."
Medicare Problems
Although Perrone has found private insurers generally
cooperative about giving providers the information they need to
send a correct claim, she has found the opposite with Medicare.
"Medicare will deny the claim, saying something vague such as lack
of medical necessity, or we need more information, but they wont
explain it and give you the information you need to do the claim
correctly," she says. "It's like, 'No, you just need to figure it
out.' I feel like saying, 'Can't you give me a hint?'" she
laughs.
Always being polite with Medicare representatives helps, Perrone
says. "If you get a rude one, just thank them courteously, hang up,
call back, and hope you get someone nicer." Going to a Medicare
ombudsman can often help resolve a problem, if you get one who
takes his job seriously and works at it, she notes.
As a last resort, you need to remember that Medicare is a
government agency and as such, is sensitive to congressional
representatives and senators. If problems with Medicare are
seriously impacting your cash flow, you can go to your
representative or senator and say, "I'm having a problem with
Medicare. Can you help?" she says.
Medicare has categorized some of the codes, Perrone notes,
agreeing that a certain code applies to a particular company's
brace. "But if you make it yourself in your own lab, and don't have
a part number or receipt, your claim may be denied." The answer
lies in having a discussion with your ombudsman and finding out why
they are looking for a part number when your own lab made it, says
Perrone. "Sometimes you may have to send it in writing that this is
what has occurred and that it was not purchased from a different
lab, and therefore there is no part number." This information can
be faxed to Medicare 48 hours before sending your electronic claim
transmission, so Medicare will have it upfront.
Collecting from Patients
Collecting from patients can be the hardest part of managing
accounts receivable. If you feel you are being jerked around by a
patient who has the means to pay, you may be able to enlist the
help of your referral source, says Perrone. "You can thank them for
their referrals and say how much you appreciate them, but tell them
you are having a problem with this particular patient, and wonder
if they can give you some advice."
Engaging the physician is very important, Perrone stresses.
Otherwise, the referring physician or the practice staff (physician
assistant, nurse, billing supervisor, or CEO) may not see your
viewpoint, and if the patient goes to him and says how mean and
greedy you are - "telling him you're threatening to take the leg
back and have him hop around on one foot" - you could lose hundreds
of thousands of dollars in referrals.
"It's walking a fine line," she adds. "You need to be
diplomatic, but not a doormat."
Perrone continues, "If the physician becomes upset at your rates
on an explanation of benefit the patient has waved in front of him,
the best defense is to remind the doctor that we are paid globally
for the item and NOT for any prior or follow-up visits. We have
also informed the physician that we also have hard goods costs
involved with our product as well as intellectual costs."
Also, always send a letter back to the doctor summarizing your
visits with the patient, Perrone advises. "Remain clinical and not
emotional, but be clear about noncompliance issues. If the patient
is a problem, you may want to talk to the doctor directly and
discuss the situation. Generally it is a bad idea to talk about
money with the doctor! But, if the patient complains to the doctor
about your bill, it may make more sense to the doctor as to what
led to it."
"I agree, that there are times when recruiting the assistance of
the patient's therapist or physician might assist in collecting an
overdue balance," adds Levis. "Of course, DIPLOMACY is the key."
Again, having done your homework thoroughly up front will keep
situations like this to a minimum.
Networks Can Help
Although many problems aren't caused by anyone acting in bad
faith, but are simply various types of errors and
misunderstandings, some may be more deliberate. If an independent
facility is part of a network, sometimes the network administrators
can help.
"Our members handle their own claims and billing, and each deals
with their individual collections issues in their own way,"
explains Cathie Griffith, president/CEO of the PrimeCare O&P
Network, based in Cordova, Tennessee. "However, in some cases
PrimeCare staff is called upon to help troubleshoot when an MCO or
other insurer is recalcitrant concerning reimbursement in the
amount mandated by the contract."
In most such cases, reason prevails, says Griffith. "Terms of
the contract are clear and unambiguous, of course, and it is
difficult to argue any different interpretation of those terms. As
soon as the insurers realize that the provider has someone else in
his court, prepared to enforce the terms of the agreement instead
of giving up the battle because its just too much trouble and takes
too much time to clear things up, then the insurers are usually
willing to resolve matters in our provider's favor."
This can take some time and may involve providing appropriate
evidence to substantiate that the terms of the contract were met by
the provider, says Griffith. Some of these reluctant reimbursers
save money by hoping that providers will just overlook an incorrect
payment, or just get tired of arguing about the problem and give it
up, she says, adding, "Persistence is the key."
In the current climate for O&P businesses, however, fewer
and fewer providers can afford to write off charges genuinely due
them, just for lack of persistent follow-up, she points out.
"Businesses are getting pressured from too many directions all at
once, with the price freeze, competitive bidding, rising costs,
poaching by uncertified fitters, a rash of inappropriate audits,
etc."
She warns, "It has reached the point where providers must be
prepared to fight for every nickel that is rightfully theirs, if
they want to stay in business for the long term." 
Table Of Contents - February 2005
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