Page 39 - Deleware Medical Journal - September/October 2019

PRACTICE MANAGEMENT
FILING AFTER THE TIMELY- FILING DEADLINE HAS PASSED
Different insurers have different time limits, and if your practice doesn’t keep track of them, you could miss out. One of the factors that can trip up billers here is, once again, Medicare. “Medicare is 365 days from the date of service,” notes Groux. “But for an HMO or Advantage plan, you could have a 90-day window.”
FAILING TO PROVE MEDICAL NECESSITY
You may run into this issue if a payer’s local coverage determination states that a procedure or service is only covered if billed alongside a certain diagnosis, says Groux. If you bill with
a different diagnosis, you will be liable for the cost of the procedure — unless you can show you informed the patient that the service would not be covered. “The patient can sign an ABN [advance beneficiary notice] so they know we can bill them,” says Groux. “You can tell Medicare you have an ABN on file, so if the claim is denied, it’s a patient liability.”
MISTAKES RELATED TO CREDENTIALING
“You may have some providers who
are not yet credentialed with certain carriers, so you’re losing money that way,” says Groux. “I reviewed one practice’s accounts receivable. One of their surgeons was not credentialed, so they provided $500,000 in services for free.”
... AND ANOTHER THING ”
Physicians should monitor for sudden spikes in the use of certain codes, which could trigger an audit, warns D’Souza. There might be a perfectly legitimate reason, such as your practice adding a new service — but make sure you have the documentation to back it up.
“I had a practice that started billing chronic-care management codes, probably about 2,000 a month, up from none,” says D’Souza. “So they got audited by Medicare. They passed, because they were ready with the documentation.”
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