Part 1- Blue Cross Blue Shield of NC
BCBS Guidelines for Global Maternity Reimbursement
Global maternity care includes pregnancy-related antepartum care (4 or more), admission to labor and delivery, management of labor including fetal monitoring, delivery, and uncomplicated postpartum care. Typically, a global charge should be billed for maternity claims when all maternity-related services are provided by the same physician.
There are several circumstances that may require you to bill delivery, antepartum, and postpartum separate:
Antepartum services below are not considered apart of global maternity services and should be billed separately as services are rendered.
59410 - Vaginal delivery only (w/ or w/o episiotomy and/or forceps); including postpartum
59515 - C/section only; including postpartum
59614 - Vaginal delivery only, after previous c/section (w/ or w/o episiotomy and/or forceps); including postpartum
59622 - C/section only, following attempted vaginal delivery after previous c/section; including postpartum
59409 - Vaginal delivery only (w/ or w/o episiotomy and/or forceps)
59514 - C/section only
59612 - Vaginal delivery only, after previous c/section (w/ or w/o episiotomy and/or forceps)
59620 - C/section only, following attempted vaginal delivery after previous c/section
THINGS TO REMEMBER:
Prior authorization (PA) or “Preauthorization” is the process of getting an agreement from the payer to cover specific services before the service is performed.
When to Obtain Prior Authorization
Some insurance plans require that a patient receives preauthorization from the insurance company prior to receiving certain medical services to confirm they are covered and medically necessary. Be sure to check if PA is required BEFORE the service has been rendered. Most insurances that require PA, give you 24 hours after the service is rendered-longer if the service qualifies as “emergency”.
Prior authorizations are typically needed for:
· Planned inpatient admissions
· Certain behavioral health services
· Certain prescriptions
· Rehabilitation therapies
· Home health services
· Pain management
· Complementary & Alternative Health Services
· Medical Equipment
· Certain counseling services
How to get Prior Authorization
Most insurances allow you to submit PA requests via their provider portal.*
1. First, check the plan’s policy to understand if the treatment or service requires a PA. This can be found via the plan’s website or by contacting the provider service line of the policy.
2. If PA is required, ensure that the PA request will follow the plan’s guidelines and double-check that you meet all requirements before submission. (Requirements could include a specific number of follow-ups before the service is approved.)
3. Obtain any required PA documentation such as office notes, labs, ultrasounds, etc. Be sure the records you send with your submission support the reason for the visit or procedure being requested.
Once the PA is submitted, the insurance company may approve, deny, or further medical review required.
APPROVED: The patient will be able to receive the requested treatment or service.
DENIED: Find the specific reason for the denial, this should be located in the denial letter or notification. If denied for an administrative reason, such as: “lack of documentation”, be sure to restart a new request with records attached. If denied for a clinical reason, such as: “not medically necessary”, report this information to the doctor or nurse.
NEED MORE INFORMATION: Contact the insurance and speak with the nurse to answer any questions they may have regarding the service. Sometimes the nurse with the insurance company will request to speak with the Doctor.
PLEASE NOTE: AUTHORIZATION IS NOT A GUARANTEE OF BENEFITS OR PAYMENT.
Quick PA Tip: It’s significant to have a pleasant attitude when talking with the service member to ensure the process goes smoothly.
Should you Follow up on Prior Authorizations?
Yes! You should always follow up on PA’s and you should follow up consistently.
Be sure the Doctor has not changed his/her procedure or treatment plan. This would require you to contact the insurance to change the CPT code, if necessary. If not done in a timely manner, the claim will deny for “no auth obtained” or “not medically necessary.”
Be sure to track your requests and follow up to prevent delays or denials that often occur. It is best to create a reminder system that can be easily implemented into the billing departments’ daily workflow.
ICD-10-CM UPDATES: 2018 FY
The following information should be used for discharges occurring from October 1, 2017-September 30, 2018 and for patient encounters occurring from October 1, 2017 - September 30, 2018.
Q: What’s Changed?
A: Many ICD-10 codes were removed, deleted, and replaced. To see a complete list of these codes, see the resources attached below.
Q: When does this go into effect?
A: The Director of NCHS and the Administrator of CMS make the final coding decisions. Changes take effect October 1st of each year. There is no grace period for implementing new ICD codes.
DON'T FORGET ABOUT THE...
Many times, a patient’s “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit into something more.
According to CPT, separate, significant physician evaluation and management (E/M) work that goes above the physician work normally associated with a preventive medicine service or a minor surgical procedure is additionally billable. The code that tells the insurer you should be paid for both services is modifier -25. Used correctly, it can generate extra revenue.
Modifier -25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service.
***Unfortunately, not all insurers will pay you for the separate E/M service even if you code in compliance with CPT rules. Be sure to have your staff appeal any denied or bundled claims. A review of your documentation by the insurer may result in payment for your work.
The use of modifier 25 has specific requirements.
7 strategies to close the year strong
We know that the end of the year is a busy time for all medical offices. Generating reports, submitting last minute claims, and managing insurance recoupments can create a lot of stress for your office in December. Right now is the time of year when your office really needs attention to detail. Having a great "battle plan" not only helps you close out the current year on a high note, but it also sets you on the right track for a great start for the new year.
Here’s what you need to do for your medical office before the end of the year.
1. Run Year-end Reports
While most offices will benefit from running general reports monthly, it's never a bad idea to evaluate your overall fiscal year and billing performance. Running reports at the end of the year, not only provides important financial and billing information, but also can detect areas that can be addressed in the following year to help maximize your reimbursements. Two vital reports we run are your Accounts Receivable and your Mismatch reports. Both should be available from the EMR system your office is using. When running your reports be sure to compare them to the previous year to gauge any snags that may need improvement. Keep in mind that there are many other reports that can be run to help assess how your year went.
2. Make Sure All Claims are Submitted
There's a saying that goes: "If you're early, you're on time. If you're on time, you’re late." A common misconception in healthcare is that claim submissions are untimely and can be submitted at any time. It is a good rule-of-thumb to develop a consistent workflow that will allow for daily or weekly claim filing and submissions. At the end of the year, it is good to try and submit all outstanding claims to avoid timely filing, denial deadlines, or troublesome appeals. Insurances typically have all hands-on deck and the priority is shifted during the enrollment period, so the claims are managed more relaxed than usual. If you find you're having trouble submitting your claims on time, reach out to us for a free timely-filling workflow sheet. Our timely-filing sheet lists all major insurances timely filing deadlines.
3. Prepare for Year-end Recoupments
Happy Holiday’s! This time of year, also means: "Recoupment Season". Insurances slow down with their processing and reprocessing of claims around this time and begin performing their own audits. By definition, insurance recoupment occurs when the insurance company has processed a claim and then take back or recoups the payment when they have determined that those benefits should not have been given. Almost every medical office and hospital has experienced some type of insurance recoupment at some point and time. We recommend offices perform an in-office audit or follow up on claim submissions to determine the most common take-backs and keep up to date with the latest regulations. This is important as some insurances can perform recoups as far as 6 years back.
4. Authorizations & Verifying Eligibility
The best way to kick off the new year is to get a jump start on the enrollment changes. After the new year, you can expect many patients to have different changes to their primary and/or secondary insurances. For the first month or two, practice heavily into getting in the habit of asking every patient (for every visit) for insurance information, recent changes, and getting any additional information on file. It is extremely important to maintain verification and authorization records in case the insurance arises later to deny your claim for “not medically necessary”. Remember, it is never OK to assume that just because a patient comes in on Monday with BCBS, that they will return on Friday with BCBS. A patient can experience a change in their coverage/policy at any time for various reasons. Check all the time, every time.
5. Perform Write-offs
Let’s face it, no one likes taking a loss, but unfortunately sometimes things just happen. Write-offs can apply to claims that are denied due to timely filing, inaccurate or incomplete documentation, non-medically necessary services, etc. The good news is there are some cases in which appeals can work if you can provide the insurance with all necessary documentation. The bad news is some claims will fall under the write-off umbrella. The best way to prepare for write-offs is to thoroughly check your billing workflow, ensure that all has been done in attempt to fight a claim before giving up, and re-visit/understand your insurance contract terms each year.
6. Create or Reshape a New Year Workflow
Whether your office is coming off a challenging year that was full of transitions or your office is riding high in the sunset, everyone can benefit from a workflow evaluation. Depending on your office needs, will determine how extensive some changes should be implemented. You will be amazed at what a simple end-of-the-year team meeting with everyone to reflect and collaborate can do for your office. You can take this opportunity to share and shape the goals for your office or even bring in a medical consulting specialist/company to help provide some further guidance in your workflow. Utilize this meeting to discuss the difficulties and accomplishments of the year. If you ask us, a Growth Mindset is always better than a Fixed Mindset.
7. Tackle your Patient Collections
With the recent healthcare changes, patient financial responsibility has increased significantly due to higher-deductible policies and larger co-pays. This does not only put financial strain on the patients, but also your office. Before the year ends, it is a great idea to take a look at your Patient AR to determine the appropriate course of action.
A couple of things to consider:
The start of your office workflow begins when a patient schedules an appointment with your office and it ends when all encounters all closed and all payments have been received. Errors or mistakes in your workflow can lead to your office receiving delayed payments or no payment at all. Medical Coding & Billing is getting increasingly more complicated and having a proper office workflow ensures that billing errors are reduced, reimbursements from the insurance companies are maximized, and patient responsibilities are collected. Everything must connect In-office to have a successful billing workflow.
We've put together a simple and basic workflow that is super effective! Let's take a look:
Appointments must be scheduled and communicated effectively. Obtaining patient insurance information via phone and reminding them that payment is due at time of service will help alleviate issues at check in.
Once appointments are scheduled, the billing staff or billing company should keep watch and contact patients' insurances before their arrival to determine their coverage and costs for the appointment. Contact the patient for a reminder appointment if possible, and make them aware of their copay, deductible, or coinsurance. By performing this step, the patient will be more inclined to arrive prepared to pay for their service without conflict. Always document to make everyone in office aware of patient coverage and communications.
3. Front Desk & Check-In
Front Desk should be aware and prepared to collect patient responsibility upfront. This can be a challenging task, but to make things easier always, let the patient know of any bill or balance at the time of their arrival. ALWAYS COLLECT! If the patient states they are not able to pay the full amount, collect half and ask them when we can expect payment for the remaining balance. Always add a note to their chart so the billing staff or billing company will be aware.
Document, document, document! The provider must be aware of the basic guidelines for each insurance . Proper documentation is key when seeing your patient. Be sure to review Medicare E/M ’95 & ’97 for office visit documentation directions. When you are not sure, always ask your billing staff or billing company for clarification.
Be sure the patient stops at check-out every single visit. This is commonly referred to as a “double check” system. In case check-In misses something, check-out will be able to catch and resolve any issues. Check-out should also schedule the patient for their next appointment and if necessary, check for any balances that may need collected. This is imperative, if the provider performed additional testing that may affect a high-deductible patient. Always double check so the patient is aware of their costs.
6. Coding & Billing
The coding/billing staff or billing company should be responsible for triple checking and coding/creating claims. There should be a thorough check of the provider’s documentation to ensure it correlates with the claims being submitted to the insurance company. The billing staff or billing company should check for patient balances and if something is missed, contact the patient to make them aware of their balance. The billing staff or billing company should audit all documentation and coding once every 3-6 months depending on size of office.
Patient collections are much more than collecting $10 copay's: those days are long gone. Patients are paying a greater percentage of what you get paid and will be paying an ever-higher percentage in the years to come. Smart and consistent patient collections tactics must be a part of every practice's financial strategy.
❖ Educate your patients: Most patients don’t understand- Include your payment policies (e.g.,
copays are required at the time of service) in your new patient paperwork to help patients understand
their financial responsibility. Consider including a glossary of health insurance terms (copay, coinsurance,
deductible, provider network) in your orientation packet. This will keep your patients well
informed and allow them a better understanding of how insurance works.
❖ Communicate: When a new patient with insurance makes an appointment always state, “Payment is
due at the time of service, unless you bring your current insurance card, in which case only the copayment
and deductible amount will be due.”
❖ Proactive-Know in advance what your patients will owe: Check coverage prior to patient’s
arrival. If you assign a staff member to check their coverage upfront you will be able to collect the
allowed amount upon their arrival. This not only keeps the patient informed of their costs, but also keep
balances from going to patient collections.
❖ Collect: Collect upfront costs at time of service. If the patient has a high deductible, train your staff to
take note of this and inform the patient upon arrival. (e.g.- “Mrs. Jones we will bill your insurance for
today’s service. Please be aware it looks like you have a high deductible plan so your insurance may not
cover today’s service at 100%. We will collect $57 today based on your insurance coverage details.”)
❖ Enforce: Be sure you have a payment policy set in place for your office. Most patients are not able to
pay their balances from high deductibles up front. By having a payment policy in place, your staff will
be able to offer reasonable payment arrangements to your patients