Six Sigma Blogs

Any strong medical billing process and medical billing company must compare insurance payments to your contractual allowables and aggressively pursue underpayments. If this is not happening then most likely 5 to 10% of your practice’s revenue is being lost.

Medical billing services have a number of basic steps they should incorporate into their billing process. These steps should include using a claims scrubber, use of no-response calls, posting zero pays, pursuing underpayments, and using likelihood of payment scores for patient collections.

This article focuses on just one of the key elements you need from your medical billing service: pursuit of underpayments. Pursuit of underpayments starts with a critical step: comparison of EOBs to your contractual allowables (the payment your payers have agreed to make for each CPT code). You cannot count on payment posters to catch underpayments with their naked eye; the comparison must be automated and systematic. It goes without saying that if you do billing in-house the comparison still should be done.

The reason that comparison to allowables must be automated is because of the clever and systematic manner in which payers typically underpay claims. These underpayment patterns can be difficult to spot, but one of the advantages a Medical Insurance Billing Service has is that it sees payment information and patterns across many clients for many payers. This allows medical claims billing services that regularly and systematically compare payments to contractual allowables to spot patterns that a single practice might miss.

A pattern that is often seen by billing companies is one where a payer will underpay the same codes across multiple providers by the same dollar amount in month one. Then in month two, the payer will resume paying the code correctly and will begin to underpay a different code (or codes) across multiple clients.

These underpayments are not huge (5 to 10 percent) but they add up quickly to big dollars for a medical practice. The combination of switching the codes being underpaid from month-to-month and keeping the underpayment amount “under the radar” can make the underpayments difficult for an individual practice to spot.

Needless to say, it would be difficult for a payment poster to remember enough about the allowed amounts across a practice’s tens of payers and dozens of CPTs to spot the underpayment strategy described above. This is why it is critical that automated comparisons be performed by your medical billing service.

What does all of this mean to your top line? A medical insurance billing service that properly implements the pursuit of underpayments can increase your revenue by between 5 and 10 percent - and this is pure profit.

Spotting the underpayment is only part of the battle, of course, the billing service also needs to have a systemic process in place for pursuing the underpayments. It is critical to pursue event the small underpayment amounts. Once a payer sees that their resources are being tied up readjudicating claims because of a $5.00 underpayment, the underpayments will often cease to happen.

Copyright 2008 by Carl Mays II

If your are not aware and prepared for the 2009 cardiology billing and coding changes you may be leaving a lot of money uncollected.

Not since the mid 90’s has cardiology seen such significant coding and billing changes as have been put in place in 2009.

Cardiology practices were hit harder than the average physician by this year’s changes (with a 2% reduction in Medicare fees instead of the 1% increase seen by the average physician) driven in large part by changes that will impact imaging performed in the office.

As a result some cardiology practices will see revenue decreases far exceeding the average 2% (particularly the offices heavily dependent on echo services). Other cardiovascular services may experience increases if properly managed.

Some of the 2009 cardiology coding changes are:

- Sweeping changes in the codes for following up on implanted devices (sweeping as in all of the old codes are gone and the new ones have significant differences). The new codes include such things as specific codes or internet (remote) device checks, codes for devices with leads in 3 chambers, ICM device follow-up codes, and codes for periprocedural checks.

- 30 and 90 day global periods are now in place for follow-up for some devices. Also, the new codes are specific to either an interrogation evaluation or a programming evaluation. The codes are no longer dependent on whether reprogramming occurred.

- 2009 also brings codes specific to a wearable cardiac telemetry device such as a Cardionet type service. This is the end to billing with the unlisted procedure code; but there is a catch here too. These codes also have global days.

- Codes that bundle multiple echo services under a single code have been introduced. Examples include a single CPT for bundling an echo with both a Doppler and color flow and a stress echo CPT that bundles both the stress test and stress echo.

As the examples above demonstrate, the magnitude of this year’s cardiology billing changes are more significant that has been seen in recent years. Without proper education, cardiology billing training, software upgrades and billing resources cardiology practices may see marked reductions in collections and increases in AR.

Copyright 2009 by Carl Mays II