Prompt payment from insurers requires time, legwork by physicians

Miami Beach, Fla. - Getting payments from Medicare and other insurers promptly and accurately - and, for many Medicare physicians, continuing to receive payments - requires a strong detail orientation, says an expert who spoke at the annual meeting of the American Academy of Dermatology.

For starters, Alexander Miller, M.D., says that out of concerns for fraudulent billing, “Medicare is concentrating on charting requirements for laboratory orders. So if you’re ordering any labs, you must sign a requisition for the lab tests. The outside lab is required to have a signed requisition on file,” even from dermatologists who use the lab only to process slides that the dermatologists themselves will read. Dr. Miller is a dermatologist and dermatologic surgeon in private practice in Yorba Linda, Calif. He is also an American Medical Association Current Procedural Terminology (CPT) adviser.

He adds, “A copy of the signed request may be kept in the chart in hard or electronic form. Or you may sign a note requesting that the lab tests be done. Additionally, the signature should be legible. And if not, you must provide a record of the names, signatures or initials you used to identify that you actually signed the document. It doesn’t have to be an actual signature - you can use a symbol such as a star, as long as you identify in the master list that the star represents your name” as the requesting physician.

Another Medicare requirement that many physicians are unaware of involves documentation of test results, which requires a signature or initials and a date within the patient record, Dr. Miller says.

In this area, “If you are audited for the tests you ordered, Medicare wants to see that you received the tests, reviewed them, and took action based upon the results - even if that action is just telling the patient that the results are normal.”

Revalidation requirements

Regarding Medicare revalidation, which is required of all providers who enrolled before March 25, 2011, Dr. Miller says, “This doesn't happen automatically. You should wait for your Medicare Administrative Contractor (MAC) to send you a revalidation notice, and make your staff aware that if they get any mail from your MAC, put it on your desk. Then you can read and delegate it, but it must be done. You have 60 days after the postmark date - not the date you received the letter.”

If you miss this deadline, “Your MAC will call to remind you. From that point, you have 10 days to revalidate. If you still don’t follow the rules, you’ll be suspended from receiving payment for 30 days. However, you can still bill Medicare. And if you revalidate during this time, you’re fine.”

But if a physician fails to revalidate during the 30-day payment suspension, Dr. Miller says, “Then your billing privileges are revoked for 120 days, after which you are suspended from the Medicare program.”

Dr. Miller also suggests monitoring your practice’s insurer billings and payments to ensure accuracy on both sides.

“If you’re being rejected by Medicare repeatedly, eventually you’re going to get audited,” he says.

Furthermore, he asks, “Are you tracking what insurers are paying you - and the hassle factor? Because insurers are tracking you. If they don’t like you, they can fire you. But if they’re bad for your business, fire them.” In this regard, Dr. Miller reports that after quitting three large PPOs, “I got busier, and I got paid better.”

Coding questions

For general coding assistance, he suggests consulting American Academy of Dermatology resources including Dermatology World’s “Cracking the Code” column, which is searchable online, plus the quarterly Derm Coding Consult and the 2013Coding and Documentation for Dermatology manual.

Additionally, Dr. Miller suggests becoming familiar with the latest National Correct Coding Initiative (NCCI) edits. “This list specifies whether CPT codes may be bundled - billed and paid together. It also tells which procedural code needs to be billed first for a particular modifier, and which procedural codes get modifiers. It’s not always intuitive.”

For instance, he says, the NCCI specifies that complex repair codes are subservient to destruction codes (and should carry modifiers, if applicable), though the former procedures often have higher technical requirements and monetary value.

For benchmarking, Dr. Miller recommends consulting resources such as the Medicare Part B National Summary Data File (formerly called BESS). “It allows you to compare your code utilization patterns to regional and national patterns. Medicare is auditing people who are three standard deviations away from the norm. Anthem BlueCross BlueShield is doing the same thing.”

Disclosures: Dr. Miller is an AMA CPT adviser.