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Tip: Four ways to dodge Medicare claim denials

Patient Financial Services Weekly Advisor, August 27, 2004

Ambulatory surgery center reimbursement claims are often refused or reduced.

Sandy Pearson, BSN, MBA, administrator at Tuckahoe Surgery Center in Richmond, VA, and Cynthia Ross, billing service representative for Idaho Vision Care in Boise, share four strategies to make your Medicare reimbursement submissions a success.

1. Keep tabs on your patients: Encourage registrars to ask for your patients' Medicare cards every time they come in, says Ross. Insurance plans change all the time, so don't bank on a patient's coverage being the same today as it was four months ago. "Communicate with your patients," Ross says. "Keep their information current."

2. Confirm services ahead of time: Determine whether the surgeon is eligible to be paid on the scheduled date of a procedure. If he or she is not eligible, refer the patient to a hospital. Also, confirm effective coverage dates. If you can't confirm the information, call the patient 48 hours before the scheduled procedure with this information. "We want to clear up issues before patients rearrange their lives, their families' lives, and their work schedules," Pearson says.

3. Be on the forefront of coding changes: Medicare billing codes change every year, and coder(s) should be aware. Coders and billers must understand modifiers and use them appropriately. For example, if a patient has a bilateral procedure such as a bunionectomy, you need to bill with the correct modifier; otherwise, Medicare will deny the second procedure as a duplicate claim.

Tip: An audit may include a review of your coding processes. Pearson says the audit may look at the following elements:

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