Incorrect Reimbursements—Is This Your Practice?

Imagine you have received a remittance for patient John Doe for charge 99214 in the amount of $69.89. Your billing staff reconciles the money and updates the account. Would you consider this a successful reimbursement? If so, it may surprise you to know you have just been underpaid by $20 because the correct fee schedule was $89.89.

In 2008, the American Medical Association reported that claims were reimbursed incorrectly at least 29% of the time for private carriers and 2% of the time from Medicare. Adding this amount to the 14% of fees physicians spend trying to collect the reimbursement in the first place could financially devastate a practice.

A well-run practice should include supporting staff who have full knowledge of what your top payers are contracted to pay. In today’s world it is no longer good enough to just know the rules and regulations of coding and reimbursement. It is now extremely important to quickly verify that reimbursements are correct because some carriers have deadlines regarding claim appeals—even if there are errors.

Another example of an incorrect reimbursement from a payer is incorrect bundling of charges (e.g., bundling an office visit with a procedure or combining the reimbursement for drugs with a procedure). In addition, some carriers down-code evaluations and management codes automatically, and it is left up to the practice’s billing staff to appeal the change. To ensure you are being correctly reimbursed, your billing staff should:

• Keep contracts of your largest carriers readily available to your billing manager;
• Run scheduled audits of accounts receivable;
• Closely review all explanations of benefits;
• When dealing with coordination of benefits, be aware for what each carrier is liable;
• Identify the payer’s responsibility and member’s liability for each contract; and
• Know your payer’s timely filing guidelines in case a charge has to be appealed.

A rheumatology practice should never rely on outside entities to make sure it is correctly reimbursed. This is not only your practice, but also your business and livelihood. Ensuring correct reimbursements will contribute to a financially healthy practice.

If you have any questions or concerns on this matter, you may contact Melesia Tillman, CCP, CPC, at (404) 633-3777, ext. 820, or [email protected].

Are Your HR Files in Order?

Do you know if your practice is in legal compliance with the many employment rules and regulations business owners must follow? Protecting your business from human resources (HR) liability can be overwhelming—particularly when the physician, as practice owner or partner, must act as an HR manager. However every practice, regardless of its size and location, must deal with HR issues in one way or another, and understanding what is expected of you is half the battle.