For a large multi-specialty practice, that included both clinical and ASC services, we were required to add additional staffing, which required us to add coders to our team. We successfully trained and hired additional staff, while simultaneously working their account and helping them to clean up back issues. As we began digging into the old AR that was sitting out there, it became very clear to us that there were some coding and billing issues that were never addressed by the previous billing department personnel.
We made the joint decision to go back and audit all charges for a year to make sure that they were correctly coded and billed out to the insurance carriers. While this is time-consuming project, that requires multiple staff and expertise levels, we were able to audit all of the claims in question and generate some additional revenue on those charges for the client.
Because of the expertise of our staff, and the results of the audit, the claims that we submitted for this client were much cleaner than the ones that had previously been submitted. This of course helped the Aging side of the work, reducing our AR issues and therefore the amount of work needed on that end.
With 2000+ visits per month, we routinely billed out their charges within 3 business days of receipt, while at the same time keeping up on their Insurance Aging so that it didn’t get backlogged. Oftentimes were called on to educate providers on documentation and dictation requirements to ensure their coding was accurate and able to support all facets of billing.
Bottom Line: MBP’s expertise in coding & billing paid off big for this client. Their claims went out cleaner, within 3 dates of receipt in our office. Those same claims then paid cleaner, thus reducing their Insurance Aging steadily. In 6 months we reduced their inherited Insurance Aging volume by $350k and increased their monthly receivables between $15k-$22k per month.
Case Study: WC & MVA Claims
MBP has extensive knowledge in WC and MVA claims ~ and how to get them paid!
Because our team members have attended training to get a behind-the-scenes look on what a claim adjuster does and why they pay the way they do, we understand:
- the MN liability payments for MVA
- that there is a cap on the overall payable amount and know what’s covered and what’s not
- that there are Independent Medical Exams (IME’s), that they affect how claims are paid, as well as what will and won’t be covered
- that both types of insurance have their own fee schedules and treatment parameters that must be followed to get the claims paid
With our Urgent Care client the concern was that because they are an urgent care, oftentimes their MVA or WC patients came straight from the accident, so they wouldn’t have their claim numbers or insurance information yet. Oftentimes we had to contact the employer directly, (while still working within HIPAA guidelines, to obtain the employees accident information, the first report of injury and WC carrier info.
We have done research into other states regulations for various specialties, as well as within governmental agencies to understand and acknowledge that every state has different rules and regulations for WC and MVA.
Bottom Line: MBP’s knowledgeable team knows how to research to find the specific rules and regulations that apply to your MVA and WC claims in order to get them paid.
Case Study: Specialty Billing Expertise
We took over billing for a family practice clinic in a rural community. This particular clinic bills out general family practice codes, as well as OMT's, labs, DRX some PT codes, and a variety of other services due to their rural location and the one-stop-medical-shop mentality of their clinic in servicing their small local communities.
This clinic came to us from two different referral sources: one through a mutual professional contact and the other one was through a patient at the clinic. The clinic was using a small-sized billing center at the time and not seeing maximum reimbursements. The other billing center specialized in one type of billing, and this clinics’ billing was not that specialty. Therefore, this clinic suffered in service and receivables.
When the referral came to us, it was very clear that we were familiar with many of the facets of their billing already, leaving us just one or two of their areas that we had to research in order to bill successfully.
We were very familiar with the clinic’s billing characteristics and requirements from our experience in working with similar clinics. There were only one or two issues that required some research before we were ready to begin successfully billing.
We put a specialized billing team together for this clinic that resulted in dramatic reductions of A/R and increases in revenue. Within the first 6 months we reduced their inherited Insurance Aging volume by $100k and increased their monthly receivables between $5-$10k per month. Based on those numbers, it’s pretty clear that month-to-month receivable numbers from the year prior to MBP taking over versus the first year that we did do their billing are amazing! The clinic was obviously very appreciative and happy with our work.
Bottom Line: when choosing a billing center they must be able to accommodate the needs of each individual clinic. MBP has proven time and again they can meet, and exceed provider expectations!
Case Study: Lab Charges & CLIA Numbers
This has affected a few of our clients over the years. MBP has done extensive research into CLIA’s, how they work and what gets the labs paid. This includes coding with the correct modifiers and understanding how the modifiers themselves work with the CPT codes.
- One client is a General Practice and had issues because they didn’t have the right type of CLIA for the advanced labs he was charging out. We educated the clinic about using the QW and 90 modifiers at the same time because they had some that they were able to bill in house and some that they had to bill out to a lab.
- Another client is an Urgent Care and has a limited CLIA and only did “rapid” lab tests in-house, having send the rest out.
- Another client is a Specialty Clinic. They are able to bill out all their labs as in-house even though they send them out to get processed because of the contract they have in place with the lab and the provisions their CLIA allows.
- Medicare patients’ labs fall under a special standard and always have to be sent out to a lab, so they need to be tracked in a different way than all the other labs.
Bottom Line: MBP’s attention to detail and knowledge of insurance and CLIAS has proven to be an asset ~ in all of these situations ~ for all of these clients. We’ve educated them and streamlined their coding processes with them, in order to appropriately bill out the types of lab services they’re providing, and get reimbursed correctly for them.
Case Study: Bilateral Procedures
For a few of our clients, when we first took them on, they were routinely being denied on their bilateral procedures. Our auditing of old claims, and research performed for new claims, confirmed that individual carriers had different requirements for this billing scenario. When each carrier has a different standard for codling and paying of charges, it’s up to the billing office to understand which carrier does what.
For example, if you are billing multiple bilateral injections on one date of service (DOS), then you have to know that:
- Preferred One & United Healthcare – want them split into individual lines, each charged at one unit, and including the -50 modifier on the second line (which indicates it was a bilateral injection)
- Medicare – also wants it on two lines, only they want modifiers –RT and –LT indicating that it was done bilaterally.
- BCBS, Medica & Health Partners – are less picky than other carriers and they will take one line with 2 units and a -50 modifier
- It is important to note that a few of the carriers that follow the Medicare Fee Schedule (MFS) also follow Medicare’s standards for coding and modifiers.
MBP is adeptly aware that the -50 modifier is a considered a “flagged” modifier, that has the potential of being over used by clinics, and as such could trigger the request for additional information on a certain charge, patient chart or group of them. This is why thorough dictation and documentation on services rendered is important.
Note: the above example should be used as a resource only, and not be taken as actual coding advice. If you have questions on how to code/bill a specific procedure or situation, please contact MBP for further assistance.
Bottom Line: MBP knows the carriers doctor’s work with, their requirements and has the resources to research the information needed to get claims paid correctly.
Case Study: Diagnosis Limitations
For several years we have billed specialties that use the office visit (OV) & osteopathic manipulation therapy (OMT) CPT coding combination on a single date of service (DOS), which at times can create denials for inexperienced billers. However, with MBP, we’ve implemented solutions that prevent these types of denials:
Several Diagnosis Codes – a standard HCFA claim accepts only up to 4 diagnosis codes, regardless of how many procedure codes are used. When more than a total of 4 diagnosis codes are used, in-house billing software systems will automatically split out the claim into as many individual claims as needed, in order to tie diagnosis codes to the appropriate procedure codes. In the case of the coding combination in this scenario, that often means that the OV becomes one claim and the OMT becomes another claim.
This causes problems at the insurance carrier level because now in our in-house billing system we show a single DOS as a single claim. But because of how the claim is split out due to the excessive number of diagnosis claims, the carriers show these charges as two separate claims in their system.
Often times we'll receive payment on one code, followed by the other codes payment a few days later. If one of the codes is not paid, insurance follow-up is then needed.
Our AR staff knows of this issue and deals with it extremely well. They know that when calling the insurance carriers they need to automatically check on each code individually, rather than a DOS as a whole.
Bottom Line: MBP’s attention to detail ensures that split claim coding situations still result in maximum reimbursement for the client!
Case Study: Fee Schedules
MBP has done extensive research into fee schedules for both in-state and out-of-state. We understand how contracts with insurance companies are specified to the individual clinic, while at the same time insurance companies may still pay according to a broad fee schedule and/or patient specific contract.
We understand how insurance payments and adjustment differ from plan-to-plan, but also know what to look for in irregularities when entering payments.
Bottom Line: MBP’s inquisitive staff pays very close attention to payments and denials ~ and the details that go along with them. We never take a zero payment at “face value”!
