In our years in business handling over 100,000 O&P claims per year in 22 states, CBS Medical Billing and Consulting has acquired some important resources and strategies that help us successfully navigate the insurance and reimbursement maze. I will share a few that we find invaluable that you can add to your list.
On a daily basis, our O&P billers use many Medicare web pages. Medicare web pages are not limited to the local coverage determinations (LCDs), which anyone in O&P should already have downloaded to their desktops. For example, a unique feature on the Noridian website under Education and Outreach is the Tools section (https://med.noridianmedicare.com/web/jddme/education/calculators-tools).
You will find tools including:
- Appeals Decision Tree to help you determine if a claim can be appealed.
- Documentation Checklists created to help suppliers ensure all necessary documentation is ready and on file.
- Appeals Calculator to identify submission deadlines.
- Medically Unlikely Edit (MUE) Lookup, a new interactive tool that helps you determine the allowed quantity for Healthcare Common Procedure Coding System (HCPCS) codes.
Other useful online resources we utilize are online insurance policy and procedure manuals. Just like Medicare, most insurance carriers have their policy manuals available on the web. The manuals contain information from item-specific coverage policy to billing guidelines. Knowing the policies and procedures for all your carriers is essential when it comes to reimbursement.
Let’s use the example of a 16-year-old patient with an Aetna plan who needs a new microprocessor knee.
Upon verification of benefits, you receive generic information such as “covered if meets medical necessity,” but what does Aetna consider to be medically necessary? This is where the policy comes in.
By reading the policy, you will find out that the payer will consider a microprocessor if the patient is a healthy, active community ambulator over 18 years old.
Without reviewing Aetna’s complete policy, you may have delivered a prosthesis that would not been covered (www.aetna.com/cpb/medical/data/500_ 599/0578.html).
Here’s a great CBS secret. Are you tired of phone trees and ridiculously long wait times to get a live person on the phone to ask a simple question? We found an online tool called GetHuman (www.gethuman.com) that provides current wait times along with a phone number or keys to press to speak to a live agent. It also identifies the best times to call to speak to a representative faster and often has the equivalent of a Rolodex with phone numbers to call for various departments. It’s not perfect, but it does save time.
If you find yourself speaking with an insurance representative who is in another country and you are having a difficult time understanding them or being understood by them, you can request to speak to an on-shore agent. There is currently a bill in Congress that would require U.S. companies with call centers outside the country to transfer a call to an agent in the United States upon request. But even without it, we have never been denied a request to speak to an on-shore agent.