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.”