Appeal rejected claims immediately or count on being denied proper reimbursement. (Practice Management Clinic).

Immediately appeal all claims that are rejected inappropriately. For example, if a payer has inappropriately bundled services together, you need a system that will identify such a bundling and that will quickly activate a process to appeal the denial before time runs out (Medicare usually requires that requests for appeals be filed within 6 months). Let's examine how we attacked this problem in my office last year.

First, you must track all rejections. If your software or your billing service doesn't do this, you are losing revenue. You can, of course, track rejections by hand and create a file, but this is time consuming. We discovered that from Jan. 1 to July 1, 2001, 68 CPT 92511 claims were inappropriately rejected, even though they had been appropriately modified (-25) to the E&M code. This could have resulted in the loss of $5,088. Another 154 claims were inappropriately denied, which could have resulted in the loss of an additional $14,597. Our experience with the 92511 edits illustrates how vigilant we must be.

This is rocket science 

Medicare publishes the Correct Coding Initiative (CCI) four times a year. On Oct. 30, 2000, CCI version 6.2 edited E&M services with 92511 (and several audiology services). On Jan. 16, 2001, the CCI version 6.3 edits were suspended retroactive to Oct. 30, 2000, thanks to the efforts of the American Academy of Otolaryngology--Head and Neck Surgery. However, Medicare and other carriers did not "auto" adjudicate these claims, and many other carriers continued to apply these edits (92511) after Jan. 16, 2001. Therefore, if you had followed the CCI guidelines, you would have realized that you had the right to appeal these denials.

We appealed them by writing a letter to the carrier and copying it to the patient and to the Indiana Department of Insurance. Such actions, when taken before the appeal deadline, can dramatically improve reimbursement.

In today's marketplace, you must be sure that all claims are clean and that no clean claim is denied--not a single legitimate one!

Reimbursement 101

Start with the basics:

* Collect the copays.

* File all claims promptly and cleanly.

* Monitor each claim from copay to primary to secondary to patient payment.

* Post all payments via line item.

* Monitor each payer.

* Appeal all inappropriate denials immediately.

* Post payments on the day of receipt.

If you are not doing this efficiently, you have a problem with the processes in your office, your billing software, or both. Also remember that all outsourced billing companies are only as good as their software and processes.

Generally, if your cost of collecting is low and performance is high, there is no need to change. However, if the cost is high and the performance is low, it is time to change. If both cost and performance are low, consider a change. If both cost and performance are high, consider a change only if you are confident that you can continue your excellent collection while reducing your overhead.

In all cases, focus on your accounts-receivables management. Introduce quality technology where you can, reduce your reliance on high-cost personnel and complicated software, and look at the big picture.

When faced with business problems like these, there is a tendency to trip over dollars while trying to pick up nickels. Work with the people who have earned your trust.

Dr. Isenberg is an otolaryngologist in private practice in Indianapolis.; [e-mail]