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Appreciating Normative Comparisons
[By Patricia A. Trites; MPA, CHBC, CPC, CHCC, CHCO ]
Deviation in medical billing can be detected through utilization data that insurance companies produce on all providers that submit a claim for payment of services.
Insurance companies track utilization through a variety of parameters, including CPT codes, ICD-9-CM, or number of referrals. Different programs utilize certain benchmarks to trigger a review.
Example
For example, a physician who sees patients in the office from 8:00 a.m. until 8:00 p.m., seven days a week and has the highest billing amounts in the region can be subjected to a review. This doctor’s activities would be scrutinized. The utilization review department would probably flag this doctor’s provider number and request more information on a sampling of his or her claims, based on the volume.
Utilization Review
Some utilization review activities may occur due to the type of services that a doctor may offer. For example, if a cardiologist should suddenly start billing for a large number of incision and drainages of abscesses, this might trigger a review, since that might not be a typical scope of service for this doctor in this locality. The same could be said for a pathologist, triggering a review due to the high volume of wound care or ulcer debridement.
Audit Trigger Thresholds Vary
Thresholds vary from locale to locale regarding what triggers an audit. There are consultants who have suggested querying the local carrier for provider specific information regarding utilization activity to compare against community performance. Some Carrier Advisory Committee (CAC) representatives have indicated that this may bring undesirable attention from the Medicare program and trigger an audit. Consult professional associations. and, if possible; local CAC representatives to obtain most current information in your area.
Conclusion
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Filed under: Health Insurance, Managed Care, Practice Management, Risk Management | Tagged: billing compliance, Carrier Advisory Committee, CPT codes, fraud and aubuse, ICD-9-CM, medical audit triggers, medical billing, medical utilization review, Medicare audits, Medicare Carrier Advisory Committee, Medicare compliance, Patricia Trites |
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Dear Patricia,
Thanks for the wonderful information you shared through this article. I understand the issues that have come up regarding medical billing from time to time and there needs to be some strict follow ups to resolve such errors on part of the doctor’s activities. A constant check is required to evaluate these billing issues.
Debona
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Medical Billing Software
[Is It Helping?]
Sometimes when technology becomes so well-adopted, we tend to overlook the very reason we began to use it in the first place: To save time, to save physical energy, or to save brain power! Several times a week one can probably hear a co-worker or employee say something along the lines of “technology… such a wonderful thing”, in an irritated, sarcastic manner, as they stare at a Blue Screen of Death. Being the technology fanatic that I am, I tend to remind the person that experiencing these little errors and connectivity problems is a cakewalk in comparison to doing things the “old way”… so quit whining (in nicer words, of course). In this article, we are going to take a look at medical billing software. Is it doing its job?
In the United States, around 6 billion insurance claims are filed every year. Out of these, only 40% are filed electronically. Of the 60% of claims still filed on paper, nearly a third are rejected by insurance companies. [4] These rejections are devastating to small practices, especially to their medical billing staff. “Most rejections are due to small simple mistakes such as modifier errors or omissions, and typos that occur due to limited time, staff, and experience. Many practices simply don’t have the resources to consistently review the claims they submit,” said James Veccie, a revenue cycle management expert at NueMD, a company that develops medical billing software.
In an attempt to eliminate claim denial problems, medical software companies, along with legislation mandated by Congress, have created universal electronic claim filing software. This software can compare a practice’s claims to over 10 million edits before submitting any of them. If anything suspicious stands out, it will help the medical billing staff identify the problem and fix it, before they finally submit the claim. This has led to an enormous 95% acceptance rate of all filed claims. [3]
These electronically filed claims have also been found to reduce payment turnaround time. Small practices using such software tend to enjoy a shortened payment cycle, which on average decreases from 120 days to 14 days. [4] Furthermore, software user experience is getting increasingly more intuitive, which can cut down on training costs. It also helps to reduce the amount of hours allocated to billing by office staff. Ultimately, studies have shown that it costs anywhere from 6-12 dollars to file each medical claim using a traditional paper filing system, and only 3-6 dollars to file each claim using an electronic medical billing software. [4] All of this translates into providers spending more hours with patients and performing health services instead of drowning in the paperwork needed to get paid for their services.
Medical billing software does seem to be doing its job. By using it, providers have improved a 50% claims approval rate to a 95% approval rate with a 14 day payment turnaround. This allows them to decrease overhead and more importantly, give the proper amount of medical attention to patients. [4] If only we could stop cuts in reimbursements, or of course, find a better solution than fee-for-service.
William Rusnak MD
(@RusnakMD)
References
1. http://www.clearinghouses.org/
2. http://medicaloffice.about.com/od/medicalbilling/tp/Top-5-Most-Common-Billing-Mistakes.htm
3. http://www.forbes.com/sites/stephenbrozak/2013/10/26/the-5-things-you-should-know-when-your-healthcare-claim-is-denied/
4. http://www.camedicalbilling.com/Electronic_Claims_Facts.html
5. http://www.dentrix.com/articles/content.aspx?id=469
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