Reimbursement: The Ball Is in Your Court

The days of physicians rendering care and patients simply paying for medical services are long gone. Likewise, so are the days of patients simply being patients and expecting the physician and his staff to handle all the reimbursement details. Few physicians remain in private practice; instead, they work for corporations that require them to see a large number of patients every day. They are paid based on productivity and must work within an established set of boundaries to ensure optimum reimbursement for medical charges.

What's the best defense for physicians on the front lines of reimbursement? A compassionate, well-trained, and educated staff that can work with ease around the distractions and overwhelming workloads that lead to coding errors, unclean claims, and other problems that decrease reimbursement.

A few helpful steps

We recommend the following steps to increase receivables and reduce patient confusion and frustration when claims are returned unpaid. Share this list with your staff and make sure they are following through consistently.

• Receptionists should ask patients at every appointment to verify vital insurance and demographic information.
• Provide new patients with a list of office policies and keep a copy that they've signed in the chart.
• Have a staff member provide the patient with a copy of the superbill or check-out record, briefly explain the charges from that visit, and encourage the patient to reconcile and attach it to the insurer's explanation of benefit (EOB) summary when they receive it.
• If a patient's claim is denied, have a staff member available to help them understand the reason for the denial and to advise them of their right to appeal the insurer's decision.
• Make sure that your office has healthcare and advocacy contact information available for patients who have coverage or billing questions.

Key to correcting errors

Finally, and equally important, be sure your office manager or coding and billing representative looks closely at each provider remittance statement -- this is where errors can be most easily spotted and corrected.

These statements come with every payer's reimbursement check, and are often issued two or three weeks prior to the patient's EOB statement. The provider remittance statement will include fields such as claim number, patient name, date of service, contract amount, disallowed amount, and amount paid. If an action code is shown on the account, it is a red flag that the insurer is asking for some form of communication on that account, such as patient medical records, a different code on the procedure, a bill from the primary surgeon --  or they may simply be communicating the fact that payment is pending.

There is one definitive factor in this equation: if your practice fails to respond to the action code, reimbursement will not be forthcoming, and the patient will be made responsible for charges that should have been covered by the payer.

With the glut of health plans on the market today, proper use of the ICD-9, CPT, and HCPCS coding criteria plays a crucial role in ensuring uniform and accurate claim submissions. Often patients are the ones who suffer the ill effects of billing errors. When a claim is denied, patients are placed in the position of trying to reconstruct a medical event that may have occurred months prior, in payer language that is foreign to them.

Ultimately, patients and their healthcare providers should equally share in the reimbursement process. The rules may have changed for both parties, but there are ways to stay ahead of the system, namely educating your patients and making sure your staff follows through with its collective eye on the ball.

Beth Darnley is director of patient services for the Patient Advocate Foundation, and Sandra Shook, LPN, is case manager for the same organization, which serves as a liaison between patients, insurers, employers, and creditors.They can be reached at editor@physicianspractice.com.

This article originally appeared in the July/August 2002 issue of Physicians Practice.