Delivering a prosthesis or orthosis is anything but easy. To get to the point where you are good at it takes years of formal training. A master’s program, residencies, board exams, and years of experience are required to achieve the skills and expertise you have acquired.
Once the patient is out the door and begins to enjoy the benefits of all your services comes the next step: delivering a clean, compliant claim to the insurance company that will pay you for your efforts and not result in a denial. That requires you to be good at another specialty and develop a different type of skill and expertise.
Completing an accurate claim is not as easy as adding a modifier and pressing a button. It requires extensive additional education, understanding of complex regulations and policy, communication, interpretation, and deliberation, and it can increase your revenue.
This article will touch on strategies to avoid denials and associated additional days spent on resubmitting claims. The best way to avoid a denial is to do the appropriate work up front. That will save you time, decrease your working hours, and decrease your days until first payment.
Eligibility and Verifications
Ah, yes, it seems so obvious that these two things should be completed before the delivery, but we find time and again that this is not always the case. The verification must be completed correctly, and checking a patient’s eligibility is not the same as a verification.
Eligibility can be done online and supplies you with the data that states if the patient is an active member and the date the patient’s coverage became active. Verification, however, requires a call to the insurance company and verifies the L-Codes you are submitting for payment as well as any restrictions and limitations. Making the phone call to the insurance company is beneficial in so many ways; one of those ways is getting a reference number. Once the patient’s benefits are quoted, ask for a reference number. That number from the representative is a quote of the information provided on the call. The reference number can be used in the future to help fight for a claim that gets denied or paid incorrectly.
When completing the verification, always ask if there are any limitations or restrictions to the benefits. If the representative is quoting benefits, ask where you can locate those benefits and/or policies.
Be sure the device is delivered in a timely manner as eligibility can change. All too often the patient begins the process and his or her benefits are verified, but then appointments are cancelled or the delivery gets pushed out, and the benefits are never reverified. Reverification is strongly recommended if the verification date is long before the delivery date.
Again, this seems basic, but too many claims get denied because a hyphen was missing or the patient’s insurance information was updated on the claim but not in the software system. The good news is that this is an easy to prevent. During office visits, ask the patient to verify that the information that is in the system is correct. Get a copy of the patient’s insurance card and have that information scanned into the computer.
To prevent incorrect coding, it is imperative that your billers are trained on proper coding, edits, and LCDs. Claims should be reviewed prior to submission, and in addition to checking everything above, you should also be checking to ensure the coding and documentation is compliant and will not get flagged or denied.
Create a standard in your practice. You can make it a simple checklist and ensure all items are confirmed. The list can include:
- Diagnosis codes
- MUE edits
Learn From Your Mistakes
Surgeons have regular meetings to discuss and learn from their errors, which may result in a patient’s death, with the intent to avoid future failures. It’s a severe analogy but hey, we take getting paid seriously, so we should have similar meetings. Previous denials will teach you what to look for, learn, and teach your staff to avoid repeat denials. O&P EDGE
Erin Cammarata is president and owner of CBS Medical Billing and Consulting. She can be contacted at [email protected]