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Stop living in Medicare denial

Ambulatory Safety Monitor, September 23, 2004

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A report that analyzed claims denials in 2003 from Medicare carrier HGSAdministrators  outlined the top six reasons for refusal and reduction of ambulatory surgery center reimbursement claims. Those reasons include everything from healthcare providers not being certified or eligible for payment on the date the service was administered, to Medicare claims being entered as duplicates, to expenses being billed before coverage begins.

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

1. Keep tabs on your patients: Ask to see your patients' Medicare cards every time you see them, 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.

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 the effective coverage dates.

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

4. Arm your coders with the knowledge they need to do their job correctly: Plenty of technology exists to assist coders in billing Medicare claims, such as encoder software, which checks for duplicated or inclusive codes. There are also online courses, nationally coordinated Web casts and conference calls, reference books, and help lines. Try Web sites such as http://www.ompro.org or http://www.medical-coding.net for coding tools.

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