Tag Archives | Beneficiary

Worried about Delayed Pay? Verify Your State’s Prompt Pay Laws

How many times has it happened with you that you submit a clean claim but still don’t get paid even three months later? Do you have any recourse? Yes, thanks to the prompt pay laws that each payer must follow when paying your medical claims.

Verify Which Laws Apply to Your Practice

Each state requires private insurers to pay all clean claims within a certain time frame. If the insurer does not pay the claim in a timely manner, then the payer is subject to paying interest on the charges owed to the practice (or directly to the beneficiary). Most time frames range from 15 to 45 working days, with 30 days about the average.

“If you are a little adventurous, you could search for your state law on the Internet,” says Joseph Lamm, office manager with Stark County Surgeons, Inc. in Massillon, Ohio. Lamm warns, however, that “reading through state laws and their multiple exceptions, references to other sections of state law, and ‘legalese’ can make this a very frustrating exercise.”

“Take advantage of your local or state medical society and the experts they employ to see if your state has a prompt pay law, and to which insurance companies it applies,” Lamm suggests. “The medical societies are on your side and will give you the correct information.”

State prompt pay laws do not apply to federal insurers, because the Federal Government dictates that clean claims must be paid in 30 days for Medicare Part B.

“If a state wants a prompt pay rule that’s longer or shorter, they certainly can do that with reference to other payer services,” says Connie A. Raffa, Esq., partner with Arent Fox, LLP in New York, NY. “But Medicare rules are federal and span across the country.”

If your private payer…

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Per New CMS Transmittal Modifier, All Claims With Modifier GZ Will Be Denied Immediately

As per the latest CMS regulation, all claims with modifier GZ appended will be denied straight away. It is not unusual even in the best-run medical practices that the physician performs a noncovered service and doesn’t get an ABN signed.
If you shoul…

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CPT 99406, 99407 Coverage Extended to All Smokers

CMS announcement is triumph for physicians who haven’t collected in the past.
If you’ve been writing off tobacco cessation counseling as non-payable, it’s time to change your tune.
In the past, CMS only covered 99406-99407 (Smoking and tobacco us…

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92541 + 92544 Will Soon Be OK

AMA corrects vestibular test codes to allow partial reporting.

The Correct Coding Initiative (CCI) came down hard on practitioners who perform vestibular testing earlier this year, but a new correction, effective Oct. 1, should ease the restrictions and help the otolaryngology, neurology, and audiology practices that report these services.

The problem: CCI edits currently restrict practices from reporting 92541, 92542, 92544, and 92545 individually if three or less of the tests are performed, notes Debbie Abel, Au.D., director of reimbursement and practice compliance with the American Academy of Audiology.

The solution: Starting October 1, 2010, “if two or three of these codes are reported for the same date of service by the same provider for the same beneficiary, an NCCI-associated modifier may be utilized to bypass the NCCI edits,” CMS wrote in a decision to alter the edits.

The American Speech-Language-Hearing Association (ASHA) has requested “clarification regarding the correct NCCI-modifier to use when reporting the codes to Medicare,” noted Lemmietta G. McNeilly, PhD, CCC-SLP, CAE, chief staff officer of Speech-Language Pathology with ASHA, in a July 29 announcement.

Look for Changes to Vestibular Testing Descriptors

The root of the CCI problem began when the 2010 CPT manual was published, including new code 92540 (Basic vestibular evaluation …) and the subsequent codes following it, which make up the individual components of 92540. “The clarification that resulted in the NCCI edits being lifted should be included in upcoming versions of the manual,” Abel tells Part B Insider.

According to the AMA’s Errata page, code descriptors should read as follows, effective Oct. 1:

  • 92540 — Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and

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Watch for Denials If You Take Shortcuts on Form 5010

Say goodbye to form 4010A1 for ICD codes as well, starting in 2012.

Dig into your claim forms now to ensure that the beneficiary’s information is accurate to the letter, or you’ll face scores of denied claims on the new HIPAA 5010 forms.

Why it matters: CMS will deny claims on which the beneficiary’s name doesn’t perfectly match how it’s listed on his Medicare I.D. card when you begin using HIPAA 5010 form — the new Medicare universal claim form starting in 2012.

Include Jr. or Sr. Suffixes

“Whenever there is a name suffix, such as ‘Jr.’ or ‘Sr.’ abbreviations, etc., it must be included with the last name,” said Veronica Harshman of CMS’s Division of Medicare Billing Procedures during an April 28 Open Door Forum regarding the eligibility component of the HIPAA 5010 form.

You can include the suffix either with the patient’s last name or in the suffix field, specified CMS’s Chris Stahlecker during the call.

“The date of birth must also match exactly to what the Social Security Administration has on file,” Harshman said. CMS will use several new error codes on claims once the 5010 form goes into effect. “If you communicate with CMS through a third-party vendor (clearinghouse), it is strongly recommended that you discuss with them how these errors will be communicated to you and how these changes will impact you and your business,” Harshman advised.

Look for Production Systems Next Year

According to the HIPAA 5010 Final Rule, CMS will have a production 5010 system available as of Jan. 1, 2011, Harshman said.

The last day CMS will accept a 4010A1 form will be Dec. 31, 2011. As of Jan. 1, 2012, if you aren’t using the 5010 form, you’ll “lose the ability to receive eligibility data from Medicare,” Harshman said. In…

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CMS Clarifies How to Report Audiology Services

Look for a physician order for diagnostic audiology tests.
If you thought CMS’s May transmittal on coding for audiology services was the last word on the subject, think again. On July 23, the agency rescinded the May directive and issued new guidance…

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CMS Changes Conversion Factor Yet Again

Plus: Look for an increase in your DEXA scan reimbursement.

The bad news: Your carrier won’t be paying your claims using the conversion factor of $36.0846 anymore.

The good news: CMS is only changing the conversion factor by less than a penny, making it $36.0791, according to CMS Transmittal 700, issued on May 10. MACs will use this 2010 conversion factor to calculate your payments, but keep in mind that after May 31, you’re still due to face a 21 percent pay cut unless Congress intervenes. Keep an eye on the Insider for more information on whether Congress steps in…

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Recognize a Write-Off in 6 Steps

Save this option for when other collection methods have failed.

You’ve offered discounts, payment plans, and more,but you still haven’t received payment from a patient. You may be forced to do a write-off at this point, says Steve Verno, CMMC,…

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Correct Coding Initiative: ‘Mutually Exclusive’ and ‘Bundled’ Defined

Decipher what column 1/column 2 means in this neurosurgery bundle example.

Question: Would you explain what the differences are between mutually exclusive and “column 1/column 2″ edits that come from the Correct Coding Initiative (CCI)?

Florida Subscriber

Answer: Mutually exclusive…

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Want to Bill the Patient? Make Sure You Use Two ABN Modifiers

A revised GA and new GX hope to clarify some of Medicare’s non-coverage policies.

At least one aspect of dealing with Advance Beneficiary Notice of Non-Coverage (ABN) forms is about to get a little simpler, thanks to two modifiers.


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ICD-9 Coding: Stop Asking ‘Which Diagnosis Code Will Get My Claim Paid?’

Assigning an ICD-9 code merely to get your claim paid could land you in legal hot water.
Medical coders face a lot of questions each day in the course of their work, but one question you should not be asking is “which diagnosis code should I put on this claim if I want to collect?”
When […]

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