Email not displaying correctly? View it in your browser. Issue #7 — Jan 26, 2011
AAPC BillingInsider eNewsletter

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F R O M   T H E   F I E L D

To Improve Revenue, Cross-train
Billers and Coders

It's no surprise, probably, that in successful practices billing and coding departments are adequately cross-trained. A biller, for example, cannot effectively manage denials without a working knowledge of the coding guidelines. Understanding bundling issues and having knowledge of proper documentation requirements are essential to ensure billing compliance. Communication is crucial between coders and billers to underwrite a healthy revenue cycle. Routine, consistent meetings facilitate the communication process.

Avoid this scenario: Chris works in the coding department. Dr. Fine provided services for long-time patient A. His documentation indicated that he did Level 4 Evaluation and Management (E/M) service along with a procedure. Chris coded the 99214 with a modifier 25 and then the procedure. The claim was submitted. Beth works in the billing department. When the payment came back on Patient A, the E/M was denied. Beth wrote off the office visit without asking anyone.

What happened? For some reason the carrier dropped the modifier when the claim was entered into the system. If Beth had communicated with Chris she would have understood that it was not bundled and that the appropriate modifier was used. A follow-up call to the insurance carrier questioning the denial would have paid this claim.

Billing and coding staff need to know what lays inside your practice contracts to assure services are coded correctly and that payer-specific guidelines are being followed. Contracts contain certain terms and guidelines that must be followed and knowing the intimate details of each and every contract allows for a well prepared team. The job functions both must have a solid understanding of federal and state requirements and applicable prompt payment laws.

G O O D   T I P S

Hire the Best!

Many of the articles published lately have dealt with policies and best practices of front end collections, maintaining patient satisfaction, and reducing the work effort involved with collecting small amounts of money after the service has been rendered. Experience has taught that it takes more than an office policy to accomplish the desired outcome of eliminating billing statements for co-pays and deductible that should have been collected on the date of service.

That "something more" is the employee that is the gem at the front desk/check-out window who remembers the patient's name and who is capable of asking for (and collecting!) the co-pay or amount due from the patient with a smile. Since this is the first and last contact a patient has with your practice it is critical to choose employees wisely.

Some hiring tips:

  • What is your first impression when meeting this applicant?
  • Is the applicant timid? Too aggressive? Indecisive?
  • Ask them to tell you about previous things they've done in life and determine their attitude towards people and work.
  • Ask the applicant open-ended questions — not yes or no questions!
    • How would you ask for money — What words would you choose?
    • How would you handle a patient refusing to pay?
    • Describe an experience you had with an angry/displeased patient (or customer).

Find out what scores or grades they got at their highest level of education to determine if they have the aptitude to understand the complexity of dealing with multiple carriers. Most importantly, do they have a desire to succeed and work hard? Good people skills, intelligence, and desire to work hard is a winning combination.

Pay them well. Employees that enjoy what they do and are rewarded for a job well done will stay the course, be productive, and manage the business at the front desk.

F E A T U R E D   S T O R Y

Handling Patient Complaints—Avoid Compliance Risk

Billers can be on the front line when it comes to patient complaints. "The insurance company was billed incorrectly," or "the statement was wrong." But did you know you can identify potential compliance concerns? Let's look at two examples:

  • Mr. X calls your office and complains that the wrong insurance company was billed. You fix the claim and resend the information. Over the course of the week, you receive several calls just like this and just like you are supposed to do, you make the needed corrections and resubmit the claims.
  • Mrs. J is angry. She is a Medicare patient and is getting a bill for services that were denied. She says no one told her she would be responsible to pay this amount and wants you to follow up with Medicare to see why the claim wasn't paid. You complete your research and find out Medicare denied the claim as not medically necessary.

In each of these cases, there is a potential compliance risk. In the first case, there seems to be a pattern where the incorrect insurance company is being billed. This is a compliance risk because it could appear that you are trying to receive improper payment from someone. Payers such as Medicare have very specific rules published about when it should be billed as the primary payer, and when it should be billed as the secondary payer. Failure to bill correctly can result in possible investigations.

In our second example, it does not appear the Advance Beneficiary Notice (ABN) was completed. For Medicare patients, if a service may not be covered, you can only bill the patient or the patient's secondary insurer if a properly executed ABN is obtained. If you do not get an ABN, you cannot bill the patient or the patient's other insurance. More information about ABNs can be found on the CMS website at

Taking the time to really listen to patients and identifying the true issue behind their complaints can help you protect your practice from compliance risk. Be alert to potential issues and if you identify any concerns, report them to the person responsible for compliance in your office.

FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies or just anecdotes please submit them to us for future editions.

In This Issue
Cross-train Your Team
Hire the Best!
Handling Complaints

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