Part B Insider (Multispecialty) Coding Alert

Published on Sat Aug 27, 2005 PDF

System snags cause improper denials, delays

If you’ve been losing reimbursement to computer hiccups at your carrier, you’re not alone.

The Part B carriers have been moving over to new software, known as the Multi-Carrier System (MCS), and the transition has created billing nightmares. If you’ve received some mysterious denials or delayed claims, you could be suffering from MCS-related gremlins.

While some carriers moved to the MCS a year or two ago, others, such as Blue Cross and Blue Shield of Kansas, just transitioned on Sept. 6. Even carriers that have been running the MCS for half a year may still be struggling. Problems include:

• Freaky denials. Some carriers started applying bundling edits improperly when they switched over to the MCS, says Holly Louie, compliance officer with Practice Management Inc. in Boise, ID. In many cases, the carrier will recoup payments improperly.

Also, Part B carrier AdminaStar Federal has been denying claims because of old insurance coverage, says Sarah Myers with Family Practice Associates of Lexington, KY. For example, if the patient had a worker’s comp claim in 1993, the carrier will suddenly start denying claims because it thinks the 12-year-old worker’s comp coverage should pay instead. “Their records were going kind of wacky,” says Myers.

• Missed updates. The updated computer systems sometimes won’t recognize when you use newer codes. For example, since the start of the year you’ve been using 36415 to bill for venipuncture, instead of G0001. But AdminaStar has had trouble recognizing the new code, says Myers. The carrier has solved most problems, but still rejects one out of 10 veni-puncture claims.

When new ICD-9 Codes took effect, some carriers weren’t able to recognize them because of the MCS, says Louie.

• Frustrating delays. “So many claims have been held up for so long” because carriers were trying to fix multiple problems, says Louie. “The systems weren’t able to talk to each other.”

• Lost crossovers claims. The Kansas Blues hasn’t been processing crossover claims, including private insurers and Medicaid, properly, says Sheryl Torres, business manager with the Nevada Medical Clinic in Nevada, MO. These claims should cross over from Medicare automatically, but they’ve been held up. The carrier claims it has corrected the problem, but the claims haven’t gone through yet.

• Weird downcoding. Admina-Star was downcoding some evaluation and management claims automatically, says Myers. She believes the problem has been resolved at AdminaStar, but watch out for similar mishaps if your carrier transitioned recently.

The bottom line: Be sure to scrutinize denials and stay on top of delays that may be caused by system snags. For more on navigating billing nightmares, turn to “Avoid Computer Claim Casualties With These 9 Tips” on the following page.