How do I know if I am in network with my patient’s insurance plan? Simple question with a not so simple answer…
Picking a billing service can be difficult. There are many options...some of which are less than great. Choosing the wrong team can unfortunately have costly consequences as well...literally.
Worried you might have a problem with your coding or your coding staff? Just curious about how you can improve? We have four simple steps so you can take to feel more confident that you are staying on top of you coding accuracy.
1) Use Your Resources
Sounds simple and should probably go without saying, but be sure to use resources beyond your AMA coding book. NCCI edits are often overlooked in the coding process, but they are a great way to see if your coding selection is allowed as payable on the same date of service. The CMS Physician Fee Schedule Search Tool is a great resource as well for finding global periods, assistant/co-surgeon and beyond. The AAPC coding forums are an excellent resource to find colleagues with similar issues. Don't forget to check the societies associated with your specialty as well; the AAD and the ASPS both have excellent resources. There are also a great number of other free online tools from CPT search engines, global period lookup calculators, ICD-10 search engines and more so don't be afraid to use them.
2) Question Your Sources
On the flip side, there are a great number of bad or misinformed resources out there. Just because someone wrote it, on the internet or otherwise, does not make it right. Coding is hard and you need to keep in mind that minimizing physician care to a series of five digit codes is not a perfect science. People will have conflicting opinions. In general, the validated and verified resources will tend to be a bit more conservative. Likewise, there are many over-aggressive resources out there that may not have as steady a foundation. Keep in mind where you are reading what you are reading and when in doubt, don't stop just because you read something that agrees with you.
You should also be careful where you get your coding books from. Keep in mind that your Ingenix book is backed by the same money that keeps your friends at the UHC corporate office paid so well. Call me a skeptic, but it just seems like there's a bit of an inherent conflict of business ethics in being a company that processes/pays codes and the company that helps doctors get paid. Doesn't pass the sniff test to me and any coding book is going to contain extrapolation/interpretation beyond the AMA guide books...not sure I want the company paying my doctors to be the ones lending me advice on how best to be paid properly.
3) Get Audited...No Really
Have an impartial third party run your records/coding to offer their opinion. Not only will you get expert advice through this process, but it also documents an important step towards self-governance as well as a focus on compliancy and improvement. In the unfortunate event you actually do need to suffer a true audit, having a track record of third party review of your own accord can be a powerful tool in characterizing your approach to the entire process as prioritized towards accuracy over revenue generation. Audits can run from $150/hour to $300/hour and may carry costs per record so they aren't cheap, but you don't need to have your entire case load audited. Pick 5-10 major cases at random and delve deeper if you discover you have an issue.
Like your resources, you need to chose your auditors wisely as there are good and bad here as well. Another benefit of a true audit will be commentary on your documentation as well, which is the foundation of what any coders process. This could really be it's own bullet point, but the more clear you make your documentation, the better. You'll be hard pressed to find a coding expert (there are some out there, that's why they are experts, but not many), nonetheless a coder, that has ever picked up a scalpel and done what you've done, which is a good rule of thumb to consider while documenting.
4) Credentials Don't Make the Coder
Obtaining billing and coding credentials is no breeze. It requires studying and a mastery of the subject matter as with anything else. I certainly don't want to disparage credentialed coders, because again, the credentials represent well earned titles. That said, not every great bartender went to bar tending school so to speak. The same can be said of most any vocation where one earns that acronym after their name. There are bad certified coders out there too (there are also those that maybe just need a bit more training). Keep this in mind, especially if you are leaning heavily on one single coding resource. Experience can be just as invaluable as the credentials so take the coding advice with a grain of salt. Again, good coders are hard to come by and it is not easy to obtain credentials, but a little cautious skepticism won't hurt if something doesn't sound right.
If you have questions about your coding practices or your coders please don't hesitate to contact us! We offer confidential billing and coding audits. We also offer free advice so...seriously, if you just have a one off question, give us a ring.
Big changes to Acellular Dermal Matrix (ADM) Medical Policies!
As an aside - we are not affiliated with, making any recommendations regarding, or suggesting superiority of brands in any way.
For a long time, Alloderm has been the only allowed ADM. Other venders and brands have been considered "experimental." Dermacell, another prevalent brand in the marketplace, has recently broken through the med pol end here and gotten approved as medically necessary with the majority of the major payers.
Why does this matter?
Many providers often use non-approved or "experimental" brands in surgery. These brands may be equivalent or beyond in terms of real world efficacy, but medical policy updates move slow. If a surgeon utilizes an "experimental" substance, it may be paid because the reviewers don't catch it or don't even ask for records. The risk here is massive. Hospitals are often unforgiving in their billing of patients and that is exactly where the bill tends to land so be careful!
What if the brand I like isn't approved?
Our stock response is don't risk it without backing from the vender to cover the cost. The medical policy being dated or wrong isn't going to change things. Feel free to work with the vender on pushing for approval if you would like to help, but until the substance is approved, don't risk it.
We have a few other tips and tricks too so feel free to reach out for further info! Feel free to call me directly!
Which insurance companies are covering Dermacell?
Aetna – Medical Policy: Breast Reconstructive Surgery, Policy # 0185: http://www.aetna.com/cpb/medical/data/100_199/0185.html
Cigna – Medical Coverage Policy: Breast Reconstruction Following Mastectomy and Lumpectomy, Policy # 0178: https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0178_coveragepositioncriteria_breast_reconstruction_follow_mast_lump.pdf
UnitedHealthcare – Medical Policy: Breast Reconstruction Post Mastectomy, Policy #CDG.003.09: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/breast-reconstruction-post-mastectomy.pdf
Anthem – Medical Policy: Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting. Policy # SURG.00011:https://www.anthem.com/medicalpolicies/policies/mp_pw_a053309.htm
LifeNet Health Press Release regarding Dermacell coverage, Anthem: https://www.prnewswire.com/news-releases/lifenet-healths-dermacell-acellular-dermal-matrix-receives-anthem-coverage-300603527.html
LifeNet Health Press Release regarding Dermacell coverage, Cigna: http://www.prnewswire.com/news-releases/dermacell-receives-coverage-from-cigna-300411026.html
How can we help grow your practice?
A very significant step in the pushback against the trend of slicing into physician revenue by insurance carriers was taken this month as Anthem rescinded its January 1, 2018 policy for same day services. Previously the policy intended to reduce E/M reimbursement by 50% when rendered on the same day as qualifying procedures. After a push by physicians, this policy has been rolled back to March 1, 2018 and from 50% to 25%. Continued efforts by physicians and the AMA will hopefully put a complete stop to the policy altogether, but that is left to be seen.
AMA Article link below here...
Some pretty major changes to pre-auth requirements for BCBSIL. This means that authorization staff will have to submit every time for approval. Please keep in mind how this will impact booking timelines.
19318 - Breast Reduction - Best practice has been to submit for pre-determination regardless so not a massive impact here.
211XX - CMF - Many craniomaxillofacial midface reconstruction codes now require authorization, which will be a bit of a change. Given most of these cases may be rendered in emergency situations, hopefully not a huge process change for most of us.
30520 - Septoplasy - probably the most notable change as no review was previously required. This will push back booking time frames for septorhinos. For those practices booking prior to obtaining authorization please be sure to keep a close eye on this change.