I was recently going on a vacation to Orlando, Fla., from my home in Atlanta. I set out on my journey by taking Interstate 75. When I hit Chattanooga, Tenn., I realized that I had gone in the wrong direction.
Hoping it was the right way, I took a chance and turned onto Interstate 24, but then I ended up in Nashville. When I stopped at a gas station to ask directions from the cashier, he advised taking Interstate 65 — but it landed me in Birmingham, Ala. At that point, I simply headed back home.
Unfortunately, this is how many companies work their billings and claims. A referral is called in. The relatively untrained intake person takes the order, not even knowing if the caller qualifies for the equipment. The equipment is then delivered. The paperwork is sent to the physician and comes back. The biller does not know if the PO or CMN is answered such that any of the equipment the company has put out meets Medicare guidelines. A claim is then submitted.
A denial is received. The biller, not knowing how to work the denial, retransmits the claim or asks a co-worker — who is also not very knowledgeable — how to get the claim paid. A review is performed, incorrectly, and more paperwork that does not support qualification results in another denial. Eventually, the claim goes untimely.
The unfortunate part is that the recipient never qualified for the equipment that was put out. The company not only loses out on the rental income but also the cost of the equipment that cannot be recouped — not to mention all the time that employees were paid to work and rework a claim that was never going to get paid in the first place.
All of this is due to poor intake and knowledge of Medicare guidelines. So, the question is, how do you avoid this kind of scenario?
Part of the answer is in training. Unfortunately many home care companies have a product line so broad — and employee retention so short — that the intake and billing staff never seem to learn all of Medicare's qualifications and guidelines.
The other part of the answer is software. Unfortunately, much of the software out there for billing does not look for these interrelationships, or tell you if a claim qualifies per Medicare guidelines based on the way the PO or CMN was answered. The products assume you have a person doing your billing who knows the Medicare manual cover to cover, and we all know that is a bad assumption.
Much software also assumes the biller is aware of all “if-then” scenarios. For example, consider a patient who received a CPAP (a 7034) mask last month. They call or come in to get another mask this month. But if the intake employee does not look into the billing system, you will not know that a mask was put out last month and that the patient cannot get another one for three months from the last date of issue (which would be two months from now). So, if a mask is put out, then the claim will be denied.
I am always looking for innovative solutions for providers, and while I normally don't point out individual products, I have come across a very interesting software solution for intake that can help. It allows an HME company to take a relatively untrained intake person and let them know if a patient qualifies per Medicare guidelines. It will also look for these “if-then” situations and alert the intake employee of a possible conflict so that an informed decision can be made about putting out the equipment.
According to Brian Hammond of Precision HME Forms Online, the software allows an intake person to do a quick qualification by putting in the description of the equipment, or the HCPC code, and then going to a CMN or PO. The questions on the form can be asked verbally and filled out by the intake person online. The form will tell you, based on the answers given, if the patient meets Medicare guidelines. This will, of course, not totally do away with denials, but it could help.
The key to claims is to make sure you get all the information you need at the beginning of the process. Just as important is to ensure that the beneficiary qualifies for the equipment being prescribed. Whether you use internal processes or third-party software does not matter, as long as the end result is a good claim that qualifies to be processed and paid.
Jane Bunch is vice president, HME consulting, for Atlanta-based CareCentric. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 678/264-4495 or via e-mail at jane.bunch@carecentric.com.
