A claim is submitted but is not paid. No follow-up is done for three weeks. After a certain point, there’s a deadline to arrive at court. All that revenue is lost. This occurs in training sessions around the USA, every month. Thousands of dollars are still owed. Assumes someone else is going to be working on unpaid claims. The area where things go awry in your revenue cycle is AR management and medical billing.
What Active AR Management Actually Looks Like
When good medical billing for AR is done, claims will be sent for review daily without being on the bill. They are sorted by payer deadline. Their method of working is to work the oldest claim with the least filing window first. They will follow up within 24-48 hours of the denial. They are resubmitting claims promptly, as soon as they are corrected, and not waiting in a queue. No one cares to pursue anything in a way that will affect its longevity.
The majority of practices audit AR on a monthly basis. That’s too late for the claims that were due 2 weeks ago. By the time that a monthly report pops up, some of those appeals appear to be shut down.
Denial Patterns and What They Signal
If the same reason for denial appears in 10 claims submitted in one week, then it wasn’t a coincidence. It simply is a process issue. This AR Management Medical Billing system provides the capability to monitor AR dollars and denial analysis code by code and by payer for these patterns. The root cause of the pattern is addressed once the pattern is discovered. By addressing the underlying cause, the denial will not be reaccumulated in future claims. Workout work on the single denial each time and don’t see the pattern, you will be dealing with the same issue for eternity!
Patient Balances Are Part of AR Management
As the structure of high-deductible plans has demanded increased financial costs from the patients and their out-of-pocket expenses, it has propagated the patient payment burden to an unprecedented level. Most practices now have a large percentage of balances due to patients making up the majority of their outstanding accounts. To neglect that portion by restricting AR management medical billing to only work with claims from insurance companies would be a colossal mistake. It is imperative to send patient statements out promptly following a claim is processed. Rechecks should be done for 30 days and 60 days post. Well-stated and timely statements are paid by patients at a much higher rate than are poorly stated or late statements.
Why DME Billing Service Claims Get Audited More Than Other Claim Types
There is a long history of fraud and abuse in the DME industry. This is common knowledge to both payers and CMS. They examine these claims with great consideration compared to others. CLTs that do not carefully adhere to the documentation rules risk denials but could also cause many issues. There is a risk of audits retroactively that will go over a period of months. An audit can cause problems with the consistency of documentation or coding that can result in an overpayment demand of more than anyone denied claim.
The Three Documents Every DME Claim Require
The DME billing service claim must have a comprehensive prescription written order by the prescribing provider. Requires a certificate of medical necessity that will outline the need for the equipment. It requires clinical notes that relate the diagnosis to the functional problem, which necessitates the use of the equipment. You are required to have all three documents, and they must agree. If there are any contradictions or if one is missing, then the claim is immediately in doubt.
HCPCS Codes Are Far More Specific Than Most Teams Realize
HCPCS Level II codes are used by DME. These codes are not omniscient. A standard manual wheelchair’s code is different than a power wheelchair. Codes of a stationary oxygen concentrator are different than codes of a portable oxygen concentrator. Team DME Billing Service is not familiar with the differentiations; enter code numbers near them but not the ones that should be. The related instructions have been included in the DME email message. An error code will cause an automatic rejection.
Modifier Accuracy and Rental Tracking
On a DME claim, modifiers are used to indicate whether the equipment is being rented vs. purchased and whether it is a first claim vs. a continued rental. The claims with incorrect and missing modifiers are being processed at an inappropriate rate in the DME billing service. If a modifier is missing from a rent claim, the amount repaid for all claims in that rental cycle will be calculated without the modifier. Once it is known that the equipment is at a patient’s bedside and the appropriate modifier is used each time, it can be avoided.
