CMS RAC Scenarios For Full and Partial Denials Plus Tips to Tell the Difference

As the nationwide Medicare RAC roll out continues, you need to be keeping an eye out for "full denial" occurrences - cases where your practice will be required to return the full amount of the claim paid, even when the services performed were legitimate.

It's obvious that your RAC auditor will be more aggressive with any audits compared to your Medicare Part B Carrier when it comes down to identifying overpayments due to the fact they are paid on a contingency fee. This means there will be more full-denial situations in which you could potentially lose all payments for a claim.

CMS has hinted at the fact that the deciding factor that you need to be aware of is the place of service in which the services were rendered. When a RAC auditor determines you rendered a service in a setting more acute than what was medically necessary, your claim becomes questionable and the RAC has the right to completely deny the entire claim, leaving you without the opportunity to rebill the claim.

The most common overpayment situation RACs will identify wil result in a partial denial. This happens when you submit a claim with some overpayments and some services properly billed. Rather than loose everything, RAC auditors only ask for the amount of the overpayments to be returned.

For example, if a physician bills a 99214 (E&M code for office visit, established patient) and the RAC determines that a lower level E&M code is more appropriate, the claim will be partially denied. This type of denial is called a partial denial. In this scenario, the overpayment amount is the difference between the payment amount the provider originally received and what should have been paid. The RAC will be paid a contingency fee based on the denied amount.
If you get hit with extensive overpayment demands when your local recovery audit contractor (RAC) shows up in your state, CMS has some advice: appeal immediately.
During the RAC three year demonstration, the majority of appeals were won using two strategies:

New Information/Documentation: Providing new documentation or information will persuade the RAC's thought process by giving them something tangible to focus on. If you think you have additional pertinent information, "present it to the RACs and bring it to the attention of the medical director". It may become apparent that they didn't even receive the original evidence you sent.

Local Coverage Determinations (LCDs): Some RACs failed with LCDs because they change so quickly. You could potentially win an appeal by checking to see if the RAC used an incorrect LCD or if a new LCD exists that the RAC failed to consider.
The key it to save yourself headache by making sure you send all of your documentation you have in support of your claim during the discussion period, before you formally appeal. Entering the discussion period doesn't do anything to your 120 day deadline to file a RAC appeal. That deadline exists no matter how long you spend with your RAC in the discussion period.

Full denials leave you with nothing
If you are paid for services never covered, you obviously should not have received any payment. What happens when you bill the correct services but in the wrong place of service? Unfortunately if the place of service category leads to a change in benefit category, you get hit with a full denial and neither the RAC or CMS can do anything to lessen the burden of the financial loss to your practice.

For example, if an in patient rehabilitation facility claim is billed and the Medicare carrier or RAC reviews the claim and comes to the conclusion that although some of the therapy services were warranted and necessary, such services could have been performed in a less acute setting (i.e. home health agency, outpatient setting, etc.), the claim will be denied in full. In this situation, the rehab facility cannot re-bill the claim and the overpayment is for the entire amount of the original claim billed. The RAC would then receive a contingency payment based on the denied amount.

It's imperative that you monitor these types of denials if your organization is audited by a RAC contractor so that you can determine which ones have the most likely hood of winning an appeal.
Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, and other general medical practice consulting services.

How to Reduce Expensive Medical Costs

The cost of health and health related services are increasing day by day. One of the smarter ways to cover such medical costs or medical expenses is to buy Health insurance. Many of us prefer to purchase health insurance, popularly known as Mediclaim to avoid financial risk and ensure medical care for the future. The importance of health insurance is growing steadily across India.

The insurance companies in India are learning their lessons from the global insurers to make sure that they bring innovative plans to foster health and well-being of patients. The new private players in the insurance industry have widened their health insurance coverage package due to the modifications in the law. The health insurance industry has benefited immensely due to the rise of the new players. These companies offer reliable medical insurance that takes care of medical expenses, which may bother you each time you visit your doctor or a hospital for a medical check-up.

Most of the companies offer a health insurance that includes cashless facility at a variety of hospitals. In this case, those who have tied up with the insurer do not have to bear a large portion of the amount from his own pocket, which is directly managed by the Third Party Administrator (TPA). A comprehensive Medical insurance covers costs and expenses on blood, oxygen, Operation Theater, appliances, anesthesia, X-rays, dialysis, chemotherapy, medicines and drugs, pacemaker, artificial limbs and cost of organs. The above mentioned medical expenses are bound to happen, especially when a patient is hospitalized. A reliable medical insurance provides much more than a usual hospitalization cover. You get a health check-up coupon on every purchase, absolutely free of cost, which can help you save your other medical costs.

In India, some health insurance plans also offer you tax benefits under Section 80 D of the Income Tax Act, 1961. Make maximum out of the tax season to enhance your savings. You can smartly plan your expenses with the help of a medical insurance policy. We suggest you to go for an online purchase of your chosen medical insurance. Buying Mediclaim insurance online is not only affordable, but also ensures complete confidentiality of personal details. You will have access to your document and form throughout the day. You can take as many print outs you want and the hardcopy is sent to you on the provided address. You get instant insurance without any paperwork. Thus, we advise you to secure your future with a health insurance policy and reduce the medical expenses.

Conquer Your Urgent Care Coding & Billing Challenges

Urgent care centers dole out medical services with no prior appointment and offer extended hours to patients seeking care for a wide array of non-life-threatening issues. The first urgent care centers opened in the the 1970s. Since then this sector of the health care industry has expanded to over 8,000 centers nationwide, and expected to continue to increase.

Change is coming and the success of your urgent care business may eventually depend more and more on quality performance rather than on quantity of service.

However, urgent care coding can be quite complex and thus throws open a lot of challenges.
Why are most of your claims not reimbursed? It is essential to follow a proper billing and coding process so that all claims are reimbursed and no claim gets lost. However billing mistakes commonly do happen in urgent cares billing services and claims can get rejected for various reasons, like:

Using incorrect diagnostic codes

Non-specificity of codes

Indirect linking of codes

Inexperienced coders

The coder is not certified

The coder is not trained specifically for urgent care

Don't let your claims fail to materialize. Learn how to code for your urgents care center and do away with these coding and billing problems by attending quick and convenient audio conferences where you get the low down on the latest in CPT, ICD-9 and CMS rules. Anyone responsible for coding, billing and collections, including physicians, education specialists, coders, office managers and billing coordinators stand to benefit from such audio conferences. So stay on top of the latest urgent care techniques and keep the cash flowing.

Learn Electronic Medical Billing

Medical billing is the process of submitting the claims to insurance companies in order to receive money for the service rendered by a healthcare professional. Before treating and billing a patient, healthcare providers check the eligibility of the intended service with the insurance company electronically. The insurance company has medical directors, who review the claim to check the validity of the payment based on the credentials of the care provider and the necessity of the treatment. A response to the eligibility request is returned by the insurance company through electronic means or more commonly from their website. Proved claims are reimbursed up to certain percentage of the billed amount. Failed claims will be rejected and the healthcare provider will be notified.

Since 1997, all practices which involve patient interaction should pass HIPAA, the Health Insurance Portability and Accountability Act. Under HIPAA, most of the billing claims for the service are required to file via electronic means. HIPAA was enforced in order to prevent fraud and abuse in healthcare delivery and health insurance. While manual filing is time consuming, electronic billing is fast and accurate. With the usage of electronic billing, the rejection and denial has reduced drastically and the percentage of reimbursement has improved.

Electronic medical billing is nothing but the combination of IT and health care sector. Medical practices have been using software to manage their finances for several years. However, the present electronic medical billing programs are well known as medical management practice software. Electronic medical billing software covers a wide range of functions including tracking patient demographics, scheduling appointment, tracking billing information and insurance payments, patient's visits, diagnosis and generating records.

Electronic billing is easy to use, thus helps the staff to improve their productivity. They have also made entire billing much faster .With the electronic billing, any error in the claims are notified to the billing center in minutes, so corrections can be made immediately. Healthcare providers are also satisfied with this system, because electronic billing makes the reimbursement very quick. This software is very friendly to the patients and customers as they give flexibility in scheduling appointment and easy access to the personal information. The cost of electronic claiming is less when compared to the claim submitted on paper. So, insurance carriers encourage electronic medical billing. Electronic billing also helps to eliminate the hassle of posting, printing and sorting the mail.

So, in total, electronic medical billing was a result of combined effort of software companies and healthcare departments to invent a new technology to simplify the process of medical billing.

Electronic medical billing has made the billing procedure much easier and more efficient. The software helps in fast and accurate billing while reduci

Medical billing is a complex procedure of billing and collecting payments for the health care service provided to the patient. To run a profitable medical business, hospitals and other health care facilities should follow an effective way of collecting reimbursement. Electronic medical billing is vital to run a successful practice.

The cash flow in any health care facility depends on fast and accurate billing. This is a tedious process which requires attention to minute details. Accuracy and efficiency are very essential for medical billing. Any error occurred in the data entry will finally end up in denial of the claim. This not only causes loss but also waste of time and energy of the health care professionals. In paper claiming denial is as high as 30%. Electronic medical billing has reduced denials to a greater extent. However electronic billing cannot prevent rejections if not performed by a skilled professional.

HIPAA, health Insurance Portability and Accountability Act requires most of the claims to be done via electronic filing. As soon as a patient enters a health care facility, office personnel takes the personal details such as name, age, sex, address and insurance company of the patient. Before giving any service, the health care processional checks the eligibility of the patient electronically for the planned treatment with the insurance company. This is known as "health care eligibility and benefit response" transaction. Upon treating the patient, medical billers submit a claim form that is customized for each patient to the insurance company and insurance company acknowledges that the claim has been received and will be processed. Once the claim is processed, the payer responds which all claims can be reimbursed or denied with reasoning. With the help of electronic billing, all these procedures are done very fast. So, the doctors will be reimbursed in 10-15 days, where as paper claiming takes months together to get the payment. Electronic medical billing has made the back office job almost paperless and also helps to reduce the number of employees needed in the non-clinical department.

Paper filing requires inventory, postage, phone calls and employee expenses. Since electronic billing is much faster and efficient, the staff requirement is greatly reduced. Electronic billing needs software and computer. When the advantages are considered, spending on computer and software is really worth.

One of the drawbacks of electronic claiming is technical problems. Medical office personnel may not be able to fix the glitches in the software. Electronic medical billing is a good option for those who have already established and have a great number of patients, so that they can afford the electronic medical billing software. Otherwise, the cost of the software itself can make this an unprofitable business.

Medical Billing Made Easier

Electronic medical billing has made the billing procedure much easier and more efficient. The software helps in fast and accurate billing while reducing denials or rejection. It is a cost effective way of increasing cash flow in the medical office.

The improved productivity is directly related to the software used in electronic filing. That means, if well programmed software is used to process the billing, the cash flow is more in the medical facility. As per the government all the electronic medical billing should comply with HIPAA, health insurance portability and accountability act.

Some of the software may provide only partial HIPAA compliance. Any flaw in following HIPAA could lead to complications and penalty. In built compliance prevents any fraud in coding and billing. So before buying any electronic medical billing software, it is better to evaluate the complete HIPAA compliance and other security measures.

This type of software provides a wide range of benefits. While paper claims take around 1-2 months to get paid, electronic claims are paid in 10-15 days. This is possible because any error in the claim can be fixed in few hours, unlike paper claims; where it takes days to notify the error in the claiming.

Patient and customer satisfaction is guaranteed in electronic medical billing. The software is well designed so that it is more user friendly, yet very secure. This gives the flexibility in scheduling appointment and updating any personal information.

With the usage of electronic medical billing, the staff productivity is highly increased. When compared to paper filing, E-billing doesn't require much of man power as it is automated. This software is so easy to use; it helps to process the billing very fast and accurate. E-Billing saves time and money for health care professional by eliminating printing, folding, sealing and mailing the statements. Since electronic medical billing software produces reports and statements by automation, it saves a great deal of time.

One of the disadvantages of electronic medical billing is the cost involved in purchasing the software. Software is available in two forms. First one is completely installed in the health care facility's computer and the other one is a part of the software is in Software Company's data base. Productivity wise both work the same. Technology becomes outdated every few years. So physicians are compelled to buy the new ones in the market.

However, when the advantages of the electronic medical billing are considered, every penny spent on the software makes it really worth.

Best Medical Transcription Courses

Even though formal training is not mandatory to be a medical transcriptionist, having a certified degree or associate degree is very ideal to get a job. There are plenty of courses available to train people in medical transcription. They are available in both the forms; web based training and classroom based courses. However online training courses are more popular because of the convenience and flexibility. It is ideal for those who already have another job, because online training institutes let them learn transcription in their own pace.

Medical transcriptionists convert the verbal medical record dictated by the doctor into text document, which will be included in the patient's permanent medical record. So a thorough understanding of the medical terms, procedures, human anatomy, physiology and abbreviations are very essential. Lack of knowledge in these subjects will interfere with accuracy and interpretation.

Medical transcription courses help students to be fast and accurate. They provide the students with 'real life situations', which helps to work them in a stressful, noisy and busy environment. As learning medical terminology is very important, it is equally important to learn to listen regardless of what is happening in the surroundings, because accuracy and efficiency mainly depends on the importance given to the details.

Medical transcriptionists have to deal with the doctors, surgeons or any other health care professional from all over the world. Hence, it is very essential to understand their dictation no matter what accent and tone they talk. Training courses train the students in this regard, so that they can transcribe in the real life very accurately.

A good knowledge of English grammar, punctuation and spelling is required for a successful transcriptionist. Along with these fast typing, data entry, word processing and computer knowledge are prerequisite for a transcriptionist. Medical transcription courses train these linguistic skills to their students. Transcriptionists should also know about legal and ethical issues surrounding the medical records. Since transcriptionists handle patient's personal and medical records, maintaining patient confidentiality is very essential. Even though medical transcription is a stressful job, it helps to earn a lucrative income.

In the current economy, people are losing job and worrying about how the economy will affect their present job. But economy does not affect health care sector as it affects the other jobs. As far as people need medical support, all the health care department careers are stable. Having a second job is very ideal in this unstable economy. Medical transcription is one among the best careers a person can think of.