How to avoid reimbursement denials

To get paid, a practice needs to submit a clean claim

Some practices are reporting that their percentage of claims uncollected 60 days after submission is rising. Slow payment may be a business strategy of an insurer or health plan. In some states, legislatures are attempting to remedy that problem by enacting "prompt pay" laws. Sometimes, payments may be slow in coming, or denied, because the practice or facility did not complete all of the necessary steps to submit a clean claim. A clean claim is a billing form which has all of the necessary blanks filled in, and answers which conform to the insurer's requirements. Here is a checklist for determining whether a practice has completed all of the steps necessary for getting paid:

For Medicare, have you:

• Applied for and received a provider number for the site from which you are submitting the bill? (If billing "incident to" a physician, has the physician received a provider number for the site where services were rendered?) Note that as of May 23, 2007, all providers must have a National Provider Identifier (NPI).
• Submitted an appropriate CPT and ICD code?
• Ascertained that the ICD code you provided has 5 digits? (Or that the appropriate ICD codes is one for which 4- or 3-digit codes are appropriate)
• Made sure that you have chosen an ICD code that indicates that the service is medically necessary? (Example: EKG is not a medically necessary service if the ICD code submitted is for "dysuria")
• Determined that the service is covered by Medicare? (Example: Yearly physicals are not covered; however a once-in-a-lifetime physical -- when the patient is first enrolled in Medicare -- is covered.)
• Made sure that your lab is CLIA registered or that you have a waiver. If you have a waiver, the billed test must be one that is on the list of waived tests.
• Ascertained that the patient is covered by Medicare?
• Ascertained that your state law authorizes an NP to perform the service you are billing?
• If a procedure and an evaluation are provided that day, added a modifier -25 to the CPT code for the evaluation?
• Ascertained that the service has not been billed already?
• Provided all of the ICD codes applicable to the patient, including chronic illnesses which may have factored into the decision to order diagnostic tests or referrals that day?
• Billed Medicare electronically, using a HIPAA-compliant system, or, if on paper, used the appropriate form; i.e. the CMS 1500?

For Medicaid, have you:

• Applied for and received a provider number? (Note that some states' Medicaid will reimburse only family and pediatric nurse practitioners. Some states will reimburse all nurse practitioners.) As of May 23, 2007, all providers must have a National Provider Identifier (NPI).
• Submitted an appropriate CPT and ICD code?
• Determined that the patient's coverage is current as of the date of service?
• Determined that the service is covered by Medicaid?
• If billing for a lab test, made sure that your lab conforms to any state Medicaid requirements for billing that test?
• Determined whether the patient is covered by a Medicaid managed care plan? If the patient is covered by a managed care plan, an NP may need to be admitted to the health plan's provider panel.

For commercial indemnity insurers, such as Blue Cross have you:

• Been approved as a preferred provider, if the insurer requires such designation?
• Gotten a provider number with the insurer, if the insurer requires it? Or, as of May 23, 2007, have a National Provider Identifier (NPI).
• Been credentialed with the insurer, if so required? (Note that credentialing can take 120 days to complete.)
• Submitted a CMS 1500 to the insurer, with a CPT and ICD code which appropriately describes the services provided?
• Provided services which are medically necessary (or preventive services covered under the policy) and not excluded by the terms of the policy?
• Used a laboratory approved by the insurer?
• Ascertained that the patient's coverage is current?

For patients enrolled in a managed care plan (HMO or MCO) have you:

• Applied for and received approval as a network provider?
• Received approval from the patient's Primary Care Provider to provide the services (unless you are the patient's PCP)?
• Determined that the service is covered under the patient's plan?
• Adhered to the terms of the contract between you or the practice and the managed care plan?
• If the patient is capitated, determined that the service you are billing is not included in the capitated fee?
• Submitted the bill on the form the company wants used for such billings? (Usually, the CMS 1500 form.)
• If the service is a diagnostic test provided in-office, have you determined that your contract allows you to bill for the service?
• Determined that the patient's coverage is current?

What to do in the off hours to make things run more smoothly

1. Gather and read all contracts between the practice and insurers or managed care plans. Look for:
   1. Any requirements regarding billing of nurse practitioner services
   2. Any requirements for credentialing of clinicians (For example, if a contract says "All physicians providing services to XYZ Managed Care Plan's patients must be credentialed through XYZ's process" and nothing is stated regarding nurse practitioners, the practice manager must ask XYZ whether nurse practitioners must be credentialed, or whether a nurse practitioner's services may be billed under a collaborating physician's name, if the physician is credentialed.)
   3. Services excluded from coverage
   4. Requirements regarding prior approval; for example, from a Primary Care Provider or utilization manager
   
   
2. Make a chart or grid of insurer's requirements or limitations. For example:

   Billing of NP services
   	Bill NP services under physician's name	Bill NP service under NP's number
   Insurer's name
   XYZ	X
   ABC		X
   and so on...

   
   

   Coverage of procedures
   	Thin prep	Pap Smear only
   Insurer's name
   XYZ	X
   ABC		X
   and so on...

   
   
3. Periodically analyze the various insurers and managed care plans regarding a) how promptly they pay claims, b) the adequacy or inadequacy of fee schedules and c) how frequently they deny claims. Attempt to negotiate better terms with companies whose fees are inadequate or who do not make prompt payments. Make a business decision whether the practice will do better accepting or declining to accept a company's patients. Decline to deal with insurers or managed care plans that will not negotiate, will not improve and do not pay promptly.

Copyright 2006, Carolyn Buppert
This article is taken from The Green Sheet, published monthly from the Law Office of Carolyn Buppert. To order, click here. For more detail on billing nurse practitioner services, see "Billing Physician Services Provided by Nurse Practitioners is Specialists' Offices, Hospitals, Nursing Facilities, Homes and Hospice."To order, click here.

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