I have always maintained that medical billers should know coding, and medical coders should understand medical billing. We become CPCs so that we can decipher medical records and code to the highest specificity, allowing billers to keypunch information into the system and transmit claims to insurance carriers. The problem is, what we learn in a coding course, and what payers want, often times conflict.
So, how does a medical biller or coder get paid on an initial claim submission if the rules vary from one payer to another? The answer is simple. You can review the explanation of benefits and see how various claims pay and you can also work on resolving problems with claim denials. Interestingly, you will discover that some denials reflect problems with the clearing house, the payer’s database, information lost in cyberspace, incorrect patient information, missing referrals and authorizations, unbundling of codes, missing digits on diagnosis codes, and a whole lot more.
Medical Billing: Posting Claim Payments and Problem Resolution
All claim problems I present are actual denials that have been appealed for payment. Hopefully this information will help all coders and billers, particularly those who work in a small office and do not have anyone to discuss denial issues with. The golden rule of payment posting: NEVER WRITE OFF A DENIED CLAIM UNLESS THERE IS JUSTIFIABLE REASON.
Case One: An insurance claim denied for four reasons. A) Payment is included in the allowance for another service/procedure. B) There is no separate payment for this service because it was included in the payment for the primary procedure. C) Duplicate claim/service. D) Separate reimbursement cannot be provided for this service because it is generally included in another service. There is no patient balance. Our patient had a physical exam along with a blood draw, pulse oximetry, and urinalysis. I know that only one denial message jumps out at me: DUPLICATE CLAIM/SERVICE. All other explanations indicate this payer bundles venipuncture (36415) and urinalysis (81002) in with the preventive exam (99396). If this was not a duplicate service, the pulse oximetry would have been paid with the office visit. As a biller, you cannot assume the reason for denial is accurate unless you verify information. If you do not know a payer’s rules regarding bundling of services, do not assume their denials are true. Once you verify coverage you will know in the future what codes are bundled into an office visit. EACH PAYER IS DIFFERENT so maintain a log. Upon research, this charge slip was given to our biller twice within a two week span. The first claim paid and the second submission denied. Our billing office wrote off the second charge that totaled $308.00 in services as a charge adjustment- not an insurance contractual adjustment as the first process. The second step our billers took was to run a report and analyze all claims transmitted on the day our duplicate claim was sent. As it turned out, the medical practice had sent 28 duplicate charges over to our billing department, totaling over $13,000.00 in charges erroneously increasing the accounts receivable balance, giving the physician and practice manager inaccurate financial information to plan office operations.
This type of information is invaluable to a Physician Practice Manager, a Medical Biller, and Medical Coder. RESOLUTION: The medical practice manager must implement a system using a log, to indicate what electronic medical records have been locked, the dates of service sent to the billing department, and when the billing department received the work.