Reimbursement Errors from a CPA’s View

Sep 11, 2015 at 09:12 am by steve

Jerry Callahan

Jerry Callahan, a CPA with Kassouf & Company, finds that every practice he consults has a problem wasting time verifying insurance coverage before a patient crosses the threshold.

At many practices, the staff looks up a patient’s coverage on the payer’s website. “Some staffers still spend time calling to verify insurance,” Callahan says. “But all they need to do is use the auto-verification feature on their practice management software. The problem lies in poor training on the software.”

Practices today miss quite a few easy opportunities to increase their reimbursements or save on billing expenses. Family Practice Management magazine estimates that losing only five percent of revenue results in a 13 percent loss of income for the physicians. “The savings are in the details,” Callahan says.

For instance, secondary insurance is no longer just for those on Medicare, says Justin Berry, a CPA with Pearce Bevill. “I’m experiencing this often with the solo Blues and government coverage.” Front office staff now needs to ask everyone, even parents, if the patient has secondary insurance.

Even when the practice gets the information, the billing staff are missing out on this potentially easy source of revenue. “The back office is not billing the secondaries in a timely manner, if at all,” Berry says.

After a family member’s stay at an area hospital, Berry received multiple bills for something covered by his secondary policy. When he called the hospital, they recited all the information for the secondary coverage but had, for unknown reasons, not bothered to bill them. “They told us ‘OK, we’ll file it.’ So the back office may have been hoping the primaries — that allow electronic filing—would cover it, because secondaries are mostly paper clients,” Berry says.

Besides the expense of recouping the payments from patients rather than insurance, Berry says this oversight can result in unhappy patients, which could mean lower reimbursements. “The move toward value-based reimbursement models means this situation could result in the provider getting poor patient-satisfaction scores,” he says. That will trigger lower reimbursement fees.

The back office also needs to ensure physicians stay credentialed with all insurers. “I can’t tell you how many times we have found offices where everyone is responsible for this, so no one’s being responsible for it,” Callahan says.

In the last six months, Callahan has seen Medicare suspend the billing privileges of eight providers until they revalidated. “That meant they couldn’t see a Medicare patient for two to three weeks,” he says. “The best practice would be to schedule on your calendar when revalidation is due for each provider, because the reminder letters can get lost.”

Once the patient enters the building, Callahan advises that practices utilizing nurse practitioners and physician assistants adapt their office visit protocol to suit the patient’s insurance coverage. “Some payer contracts do not pay for extenders at all,” he says. “So if only the extender sees the patient without any physician input, the practice will receive no reimbursement for that visit.”

During the visit, providers can also lose large amounts of reimbursements from slightly incorrect documentation. Berry had a client practice in pain management who was audited by Medicare. Though they had regularly billed for two coding components — one related to procedure and one related to evaluation and management — the notes were for both aspects of the procedure were written as one large paragraph. “So the payer saw it as one procedure, and we had to write checks back to CMS for almost $20,000,” he says.

More reimbursement monies get lost when practices fail to load each payer’s fee schedule into their billing software. This annually updated data states how much to expect for each CPT code. With this information in place, the practice can produce a variance report to reveal where expected claim payments fall short. “About 60 percent of practices don’t do this,” Callahan says.


Without that report, the difference in payment gets written off as a loss and noted as a contractual adjustment. But discovering why a reimbursement is underpaid on a procedure or service can lead to notable revenue. “Because most things you’re doing, you’re doing a lot of, so it’s all volume driven,” Callahan says. “A small difference multiplied by a large number of occurrences over time means you’re going to end up with a significant amount.”

The same reasoning applies to billing chart audits. Berry says they took over the administration of a practice where “everybody thought the previous administrator, who had been there for a long time, had done a great job. Like collecting receivables within 25 days.”

But when they brought in a billing specialist to audit the charts, they found that the use of some modifiers had been overlooked. “We refiled and collected $80,000 for the previous six months,” Berry says. Since they could only refile so far back, the prior 10 years of that earned revenue was simply lost. “Even though you want to trust that people are doing their job properly, it’s just good practice to have an outside set of eyes look at your reimbursements.”

May 2024

May 21, 2024 at 01:33 pm by kbarrettalley

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