Medicare Compliance & Reimbursement

Learn how to use each payers tools to your practice’s advantage.

Although every practice prioritizes patient care, ultimately, everyone strives to ensure their services are reimbursed to the maximum extent. “We want to make money, but we also want to keep the money that we make,” said Corella Lumpkins, CHC, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, CPC-I, CEMC, CCS, CCS-P, in her HEALTHCON Regional 2025 presentation “Maximize Revenue: Post-Payment Compliance Practices.”

Read on to learn how to use the same tools as the payers in your own practice to stay compliant and to see your claims paid to the fullest.

Check Out the 13 Steps of the Revenue Cycle

Lumpkins referred to protecting your collected revenue as the 13^th step in the revenue cycle. The other 12 steps of the cycle appear below:

1. Patient scheduling and registration
2. Insurance verification
3. Patient co-pay collection
4. Documentation of visit
5. Medical coding
6. Demo and charge entry
7. Claims checking and error resolution
8. Claims submission
9. Payment processing and posting
10. Denial management
11. Accounts receivable (AR) follow-up and appeals
12. Patient statements

After all of these steps are completed, years later, the payers can still come back and ask for funds to be returned for any number of reasons; so you need to protect your practice as the final step, she stressed.

“Payers perform post-payment compliance — why aren’t you?” she asked the audience.

Be Aware of Reasons Payers Can Ask for a Return of Funds

With the Department of Justice cracking down on “widespread schemes including upcoding, phantom billing, kickbacks and fraud, waste, and abuse, more and more offices are coming under scrutiny and having to return funds,” said Lumpkins.

Administrative waste related to insurance pricing, provider payment processes, and price transparency are all necessary to tighten up operations, she mentioned.

Know the Tools of the Payer

“I’ve worked on the payer side, and I know how savvy they are. We have to know what our payer plans have the ability to do so we can combat it,” said Lumpkins. She went on to explain that every time a practice calls a payer representative to check on a claim, a dashboard comes up on their computer screen showing them the following for every practice or provider:

• Average age of the claim
• Number of claims submitted, rejected, and denied daily, monthly, annually
• Number of requests for documentation or medical records
• Number of requests for documentation or medical records received
• Number of records received that resulted in payment
• Number of appeals or corrected claims received
• Total dollar amounts of paid and partially paid claims
• Total dollar amounts of plan recovery revenue

She asked the audience, “How many appeals or corrected claims are you completing? If you aren’t fighting, if you’re just taking what the payer plan is giving you back, guess what that means? They aren’t going to give you anything additional.” If they are asking for documentation, be sure to send it back. Once the payer finds that weakness in your team, it will chip away at it.

Always have your medical records up-to-date and ready for scrutiny for those times they are being requested.

Understand RVUs

Maximize your reimbursement by listing your relative value units (RVUs) correctly. Payers aren’t going to optimize those for you. “You can’t always go by the price,” said Lumpkins. “Sometimes you need to go back and look at the RVUs, because some of our prices may be adjusted due to one payer that pays a tremendous amount of money for one code while another does not.”

You want to list your most resource intensive procedure first (highest RVU value) For example:

Usual payment per claim item:

• First procedure pays at 100 percent
• Second procedure pays at 50 percent
• Third procedure pays at 25 percent

For Medicare, you will want to list these a little differently:

• First procedure pays at 100 percent
• Second through fifth procedure(s) pays at 50 percent
• Six or more procedures are priced manually

Use Modifier 59 Sparingly  

In lieu of using modifier 59 (Distinct procedural service) on most claims, Lumpkins stressed that more specific X modifiers are often more appropriate instead. For example, modifiers XE (Separate encounter), XS (Separate organ/structure), XP (Separate practitioner), or XU (Unusual separate service) will give the payer much more information than the less-detailed modifier 59. Using more specific modifiers will help prevent claim denials and shorten the processing time from the patient’s date of service to the date of payment.

Learn From Your Mistakes

When you receive denials, it’s important to learn from them. If you are finding common denial reasons among certain coders in your office, it may be useful to put together a training course or manual to keep the same mistakes from continuing. Lumpkins pointed out that reworking denied claims can be a manual, time-consuming process that costs a practice between $25-$181 per claim. When you start learning from those past denials, you can reduce costly ones in the future. “Every time we touch a claim over and over again, we lose money,” she said.

These teaching moments apply to the providers as well. Lumpkins gave the example of an operative report that would result in a $20,000 claim, but the notes were terrible and only half a page long. She tried to explain to the practitioner, “Now if something happens, and the payer is only going to pay three of your seven codes and I’m working to fight for those other four codes, but you only have two words in for those other codes? I’m not going to be able to win that for you.” Whether the procedure is extensive or a few minutes long, the detailed notes can save the claim payment later.

Timely information can be just as concerning, she added. If the payer is asking for more information months later, and suddenly the practitioner “remembers” everything about the procedure, that can be very suspicious. It’s very important to educate your staff on detailed operative reports created on the same date of service to prevent these situations from occurring.

Perform Post-Payment Audits

Lumpkins provided some helpful tips to keep your office running smoothly and to keep fewer claim denials from crossing your desk:

• Select random claim samples to audit
• Perform a detailed line-by-line view of the claim
• Use comparative analysis along with medical records and remittance reconciliation
• Give post-audit recommendations where necessary to your staff

Set clear objectives with your staff members as you go over these claims. What is your reason for the audit? Do you need billing experts, coders, and auditors involved? Choose a time frame of claims to audit and a sample size before you begin so the project doesn’t feel overwhelming.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC