Staff in the Health Care Finance Division (HCFD) of the Colorado Medical Society (CMS) began to assist practices with claims resolution through the Hassle Factor Project in 1997. In 2001 the project became part of the overall Medical Practice Advocacy strategy, encompassing Claims Resolution Assistance as well as Health Plan Complaint programs. Issues received by CMS such as claim denials, payment delays and appeals were escalated to payer attention. While the project was very successful, less than 2% of the CMS membership utilized it.
As a result, in 2006 CMS re-evaluated HCFD's activities to determine the best way to utilize our resources in support of the Practice Viability Banner Goal. The process included discussion with the general membership at the 2006 CMS Annual Meeting. The final recommendation was that the focus be switched from one-on-one claims advocacy to education and empowerment. CMS is to act as a clearinghouse of practice management information providing feedback of that information through educational programs and materials.
We are available to assist you in troubleshooting problems, understanding correct modifier usage/bundling edits and other payer processes, as well as provide advice on “next steps” to be taken through our Second Opinion process (see below). Although we will no longer handle individual claims, when you have followed all of the payer's directions for resolving a claims dispute without success we will continue to act as your Ombudsman to escalate your issue with the local payer.
Listed below are examples of some common claim denials with suggestions on the first steps toward resolution.
Appeals - My appeal was denied. Now what do I do? Remember to use all levels of appeal available. The health plan's instructions (even required forms) must be followed to the letter. Failure to follow these instructions may adversely affect a positive outcome. Click on the links below to access some of the health plans' appeal process.
NOTE: Health plans not listed require providers to access to their secure site to obtain the information.
The AMA has also developed a helpful brochure to assist you with submitting your appeals. How to Appeal Inappropriate Health Plan Claim Denials
Coding/Bundling/Modifier Denials - One of the services I reported was denied as “separate payment not allowed when reported with another more comprehensive service/procedure.” According to the National Correct Coding Initiative (NCCI) the codes should be paid separately. The first thing to do is obtain a copy of the information the health plan used to make the determination in order to prepare an effective appeal. The information may be a reimbursement policy, reference to proprietary bundling databases (ClaimCheck®), newsletters/bulletins, provider manuals, etc. Compare this information to “national standards”, e.g., National Correct Coding Initiative (NCCI) edits, American Medical Association (AMA), special society coding guidelines, etc. There may be information within these resources that will guide you in developing your appeal.
AMA CPT Information
E&M Documentation Coding Guidelines
ICD-9-CM Coding Guidelines
National Correct Coding Initiative (NCCI)
National Specialty Societies
Several of the health plans have developed coding tools for their providers. Resources include coverage and reimbursement policies, code editing tools, etc. Access to this information will usually require registration and logging in to a secure portion of their website.
Incorrect Payment Received - I think the health plan paid incorrectly. How can I know for sure? Understanding the contract agreement and knowing your fee schedule are vital to the proper processing of adjustments. The ability to properly read and interpret the information on the EOB/EOP is a vital step to the accurate reconciling of account. Each message must be reviewed and acted upon as necessary. It is imperative that you understand all messages the health plan is “communicating.” Contact the health plan for a complete explanation and/or clarification of the problem (remember to log the date, time, name of person you speak with and the reference number). Click on the links below to view a few representative examples of plan specific EOB/EOPs and processing messages.
Lost Claims - Does the health plan have the claim? The health plan cannot be held accountable for withholding payment if we are not totally confident that the health plan actually received the claim. Clearinghouse and health plan claim acceptance/rejection reports must be reviewed within 24 hours of claim submission. One suggestion for keeping track of outstanding claims is to program your practice management/billing system to generate a report every 45-50 days listing them by the health plan. Contact the health plan for status of these claims. If the health plan has no record of the claim, submit a new claim. Do not automatically resubmit claims without first contacting the health plan or checking online to verify that the claim is nowhere in their system. Many of the “lost claim” complaints we received reveal that the claim was not “lost”. The claim in fact was processed. However, the Explanation Of Benefits/Payments (EOB/EOP) that showed the processing was never received by the practice.
If the suggestions above do not apply or do not resolve the problem, please follow the instructions below to submit a request for a Second Opinion from HCFD.
Request a Second Opinion! - CMS Member Benefit Only
We are happy to provide assistance to our CMS Members and staff to help resolve their problematic claims or any other health plan issue through our Second Opinion process. Please register and/or login to our Practice Management Community to access this valuable FREE service.
Summary
In an ever-changing environment it is imperative that offices keep abreast of health plan policies and procedures and federal and state regulations to maintain a viable practice. Remember to…
