AAPC Requests Uniform Standards and Edits at Hearing

On Nov. 17 and 18, the National Committee for Vital Health Statistics (NCVHS) held hearings on the need for uniform standards and edits across the industry. AAPC’s Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, vice president of ICD-10 education, offered testimony on the daily frustrations currently encountered by members. Here is some of that testimony:

“Currently a sampling survey of AAPC  members indicated that on average most practices contract with no less than 18 health plans and some upwards of 80+. As we are all aware, no two plans are alike and even within each plan itself the different family of offerings make the frustration of not having consistent guidelines and edits an administrative burden most practices simply can’t afford. There are many items that go into setting up practice management systems to handle edits correctly, but simply transitioning to electronic does not solve all the burdens.

A screenshot of an average practice management system on the back end shows this concisely. Every field needs to be completed for each procedure or service provided. For a family practice provider, this can easily top well over 100. For each health plan contracted with, a line needs filled out in the fee schedule for each code (service or procedure). For those practices that contract with even 50 health plans, that means 5,000 line items. Each line contains price charged, expected amount from health plan, modifiers required, contractual obligations, bundling edits, special characteristics (such as for this plan it needs to be CPT® or for this one it needs to be a HCPCS Level II, etc.).

The time it takes to set up each individual health plan can take hours as detailed research is necessary to be sure to capture each different nuance required. Remember, if we get it wrong when doing the detail of all 5,000 lines it could be called fraud.

On average a biller/coder stays on the phone between 20 to 45 minutes trying to get an answer. Provider portals, while easy enough to maneuver, do not offer a realistic solution, especially to the old stand-by edit ‘Claim/service lacks information that is needed for adjudication.’ Exactly what information is missing? This results in an inquiry, online can take at least 24 to 48 hours to get a response (that usually does not provide any additional information or instructs you to contact a representative) forcing you to call; when you call your are consistently transferred multiple times, having to go through an automated system that, until you fail to respond a certain number of times, you can’t get an actual person. Most edits used by the health plans are vague in nature and can’t be interpreted by the average person without numerous attempts to manage it.

If a provider sees 30 patients a day, 5 days a week and if even 10 percent are rejected or have edits applied that equals 15 claims a week per physician; and if the average time spent is only 30 minutes, it takes 7-1/2 hours a week just for a one-provider practice. Most practices have multiple physicians; there are very few single physician practices.

Auto posting was a welcome relief for most practices; however, many have realized that they most often take just as much work as manual posting due to all the edits and inconsistencies. Many EOB’s linger unbalanced until an edit can be resolved by an administrator or the vendor. Certain health plans will alter the codes submitted to fit their own guidelines, making the claim not match what was billed and not allowing for automated posting. Again, this prompts an inquiry that can take several days to resolve before that remittance advice can be processed through the practice management system.

The time spent to train someone for this portion of work is time consuming to say the least. Many practices get frustrated and overwhelmed and the claims sit in the system unpaid due to staffing constraints, causing additional financial burdens on the practice.

Some sort of consistency is indeed necessary and can happen we believe in some uniform format. It would be helpful to providers if all health plans used a standard format for EOBs just as we are required to submit our claims in a standard format. Edits should be as uniform as possible for all health plans and contain language to a provider that is easily interpreted. Easier resolutions need to be made available to providers, such as having an actual person to speak to in order to get a claim issue resolved in a timely manner. We believe that these seemingly little fixes could save providers valuable time, effort and money.”

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11 Responses to “AAPC Requests Uniform Standards and Edits at Hearing”

  1. Deborah Osterberg CPC BS says:

    The testimony offered by Rhonda Buckholtz to the National Committee for Vital Health Statistics (NCVHS) during November 17 & 18 2011 hearings (addressing the need for uniform standards and edits among health plans) was well stated. I was absorbed within Rhonda’s very first paragraph by her accurate accounts and clear verbage. Inconsistent guidelines and edits are deeply imbedded in the industry. The result is that non-standardization has become the standard.
    As co-owner and operator of a practice management accounting system since 1993, involving coding/billing/reimbursement, time and again it has been disheartening to watch as eager and extremely capable new employees are swallowed by discouragement following their literal immersion into the tangled mess of multiple and differing standards for edits within each individual health plan. It is a labor-intensive process to sort through it all and it is a highly inefficient healthcare system that requires billing specialization specific to each of numerous health plans. This drives up the already high cost of health care.

  2. A. Schoenhofer says:

    AMEN! This was very WELL STATED, and epitomizes what we coding professionals go through every day. The task of figuring out even some of the more menial coding scenarios due to non-standardization of edits and rules can be a time consuming nightmare. New coders and billing staff do get disenchanted with the profession they chose very quickly. A big THANK YOU to Rhonda Buckholtz for taking it there!

  3. Brandi Tadlock says:

    Rhonda Buckholtz’s plea is long overdue – the commercial side of the industry simply has too many variables to consider, with regard to payer protocols. In addition to the complaints outlined above, many payers also implement custom coding edits, which are not recognized by CPT or CMS guidelines. The rationale is often inconsistent, (if not incoherent), and researching and appealing these edits requirires an exhaustive effort. There is often little recourse available to providers, when custom edits are based on flawed rationale.

    Also, although many health plans do make their coverage criteria accessible online, that’s certainly not always the case; of those who DO provide the information online, policy databases tend to be difficult to locate, and navigate. It’s rarely as simple, as just entering a code into a search field, and having the relevant policy populate.

    At the very least, health plans should be required to disclose the rationale behind their edits online, in a conspicuous location, and in a format that’s detailed, and user friendly. Additionally, providers should have the opportunity to proactively challenge the validity of payer edits and coverage policies, without having to tackle denials on a case-by-case basis. When an-erroneous claim edit is discovered, it can potentially lead to an epidemic of claim denials, which can take months to resolve ‘one-at-a-time’, even after the issue has been corrected.

    Many payers don’t take the initiative to retroactively review denials, which were previously based on an invalid edit – forcing providers to shoulder the burden of having claims reprocessed, that never should have been denied, to begin with. They need the option of being able to ‘nip-it-in-the-bud’, with respect to dealing with payer policies; and/or more opportunites for recourse, when payers are uncooperative, in addressing the very claims-processing issues, that THEY created.

    Just as a providers are required to immediately return any identified overpayments, caused by a systemic problem in their billing procedures; payers should be required to expediously reprocess claims that have been underpaid, due to a systemic problem identified in their own system(s). What’s good for the goose, is good for the gander.

  4. Diane says:

    Yes, we all seem to be in agreement. Sometimes I actually think there has been violation of clean claims that should be paid but are simply stalled.
    The mire we experience with on-hold phone time, transfers, and inconsistency with follow-through should be analized and reworked to say the least.
    I attended a workshop where the speaker was General Norman Schwarkopf (Desert Storm), who said, “find out what’s wrong with your organization — and fix it!”

  5. Donna Nelson says:

    All I have read is so true, and the problem seems to be getting worse by the day. If a claim is denied due to the payers fault, the provider has to file an appeal to get it payed, and some claims I am still fighting when the service provided was over 6 months ago medicare can also have different pay policies depending on who is your area payer, all insurances to include medicare and medicaid should be standardized, as we are force to be standerized with are coding, billing and even charting. I agree what is good for us is good for them….

  6. Patricia says:

    As a very new member of AAPC, I am fascinated by Rhonda Buckholtz’s testimony. I never truly appreciated the nuances of billing different insurance companies until I read Rhonda’s presentation. It seems to me that the insurance companies should bear the burden of THEIR idiosyncratic billing requirements. It galls me that the insurance companies make the rules and they also get to deny payment if the providers don’t jump through the hoops adequately enough. It’s no wonder health care is in the state it’s in! It seems to me that if the providers use generic coding conventions when submitting bills that the companies that make up their customized rules should have to figure out how CPT, ICD and HCPCS codes apply to the company’s rules.

  7. Kimberly Kieke, CPC says:

    I often say that medical coding is similar to being a trapeze artist jumping through hoops. Except the hoops are in constant motion and, if you miss any and you fall, your broken body may be scraped up off the ground, stuffed into an orange jumpsuit, and placed in a cold dark cell.

    I’ve trained many providers in the art of coding, and a few youngsters have been envious of their older peers “because they already know all of the rules”. My sad reply is that, while they do their best to keep up with the ever-changing rules, it’s sometimes more difficult for older providers because they long for days past, when they were actually able to focus on caring for their patients instead of paper-pushing and bean-counting to come up with and E&M level.

    Now, when provider reimbursement is lowered and many insurance companies are – in my opinion – in the business of denying claims and collecting premiums, providers must also support leagues of lawyers and coders (an entirely new industry spawned out of necessity). All that, just to stay in line with complicated coding regulations and “optional” compliance plans designed to prove their innocence before they are ever even charged with any wrongdoing.

    I have to admit that I do understand why Medicare regulations are so stringent. They are entrusted with a limited funding source, and those funds may soon be depleted because most beneficiaries and providers do not understand the original intent of Medicare, which was to be a safety net for the ill and elderly, not a comprehensive medical plan. Medicare has begun to pay for some limited preventive medicine because, in the end, it saves the program money to treat illnesses when they are detected earlier. Worse yet are those criminals that purposely set out to defraud the system, ultimately robbing the rest of us who have so diligently paid into the system for most of their lives.

    My professional life, my personal life, and the lives of my family, have been blessed with leagues of honest, caring medical professionals. I say work with them to create a single, constant and accessible set of national coding and claims-filing rules to follow, and let them “practice their love”, as President George W. Bush so eloquently put it.

  8. Robert Bartlett says:

    I see the problem of no single standard all the time. I code for an infectious disease group, so I have to know who accepts consultation codes and who doesn’t. None of the Medicare products accept them, but there are other non Medicare products that also will not accept them. Sometimes I don’t find out until I get a remit notice showing it’s not a payable code for that specific insurance product. By the same token soemone could have a different plan with the same insurer, and consult codes are accepted. There is an absolute need for uniformity.

  9. TONI DAVIS says:

    Thank-God it’s not just me! I agree to the 10x

  10. Candice Brazeale, CPC, CRHC says:

    Rhonda this could not have been presented more perfectly. It has been a long time coming. I just hope this comes to pass and sooner than later. Thank you for all your time and effort. Hopefully, we will see some changes soon.

  11. Marilyn Pratt CPC says:

    Thank you for sharing our voices and frustrations. This is an area of my responsibility that I have learned to simply dread.

    One thing I might add that happens time and again to my peers: The people that you are finally able to get through to are not able to comprehend the question, and are, therefore, of minimal assistance. The physicians hire experienced, knowledgable coders to get clean claims issued the first time.

    My single biggest issue is unlisted codes. If I had an accurate code to report, I would. Payers consistently pretend that an unlisted code wasn’t even submitted.

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