Missed appeals, MUE denials and more in Vachette’s latest audit roundup

May 31, 2017

As we’ve continued to add new clients in 2017, Vachette’s audit team has been hard at work uncovering and correcting a host of billing and compliance issues in an effort to put missing revenue back in our group’s pockets. As always, failure to properly appeal various denials has continued to be an issue we see with alarming regularity. We’ve also identified a host of issues tied to outdated fee schedules, missing contracts and other often overlooked problems that prevent groups from maximizing their revenue.

If you’re interested in learning more about any of our findings or our audit process in general, feel free to contact us directly at 517-486-4262. For updates on our latest finds, follow us on Facebook, Twitter and LinkedIn or visit our website, www.vachettepathology.com.

Below are Vachette’s top auditing findings so far in 2017:

 

Ignoring too many appeals — January 4, 2017

Too often, billers let appeals slip between the cracks and voluntarily write off a large source of potential revenue in the process. Case in point: This week, our team discovered that 16 percent of the cases we reviewed for our client during a billing audit were lacking appeals. Even if you assume only a third of the appeals would be successful, we still projected our client could have lost $775,000 in revenue for the year if the error rate held constant!

 

Maximizing your fee schedule — January 11, 2017

We cannot stress enough how important it is to ensure your fee schedule is set at a level that maximizes the reimbursements you receive from various insurance carriers. During a recent billing audit, we noticed our client’s fee schedule for 85060 was just $40, a figure that was significantly lower than the amount four different carriers were willing to pay for the service! This is lost revenue!

 

Missing documentation leads to MUE denials — January 18, 2017

Ensuring your reports are properly documented is crucial, especially as MUE denials become increasingly prevalent. We recently had a client whose biller submitted a claim to Medicare with eight 88361 units and filed an appeal in the report since the MUE for the code is six. Although Medicare acknowledged eight stains were performed, they still denied the claim because the report lacked documentation stating 88361 is computer assisted. We’ve since helped our client install a process to ensure the proper documentation for these cases will be included on all future cases moving forward.

Missing codes lead to denials — January 25, 2017

As insurers become increasingly diligent with its denials, groups must be more cautious than ever when it comes to ensuring claims are properly coded. During a recent billing audit, we discovered 4 percent of the cases reviewed showed Medicaid secondary insurance was denied because the taxonomy code in box 33B on the claim form was missing, causing the claims to be denied as NPI not matched. Unfortunately, our client’s biller adjusted the balance off the system and did not refile when the issue was corrected, which left potential revenue on the table

 

Failure to appeal costs client big time — January 31, 2017

$227,000 — That’s the amount we projected our client could have lost over the course of a year after we discovered their biller was not submitting appeals on cases denied for medically unlikely edits or those that lacked prior authorization. Fortunately, our audit identified the biller’s poor practices before they could cause significant damage to our client’s revenue stream!

 

Outdated remittance address leads to missing payments — February 6, 2017

During a recent audit, we discovered three different insurance carriers were sending our client’s payments to previous remit address despite the fact that they changed billers more than a year ago. Fortunately, we were able to help correct the issue and payments to the correct address are now on their way.

 

Missing info nearly leads to timely filing denial — February 15, 2017

While we usually highlight high-dollar audit findings, we often uncover flawed process issues that are equally as important. In this instance, we discovered a charge that was on hold more than three months because it was missing the name of the referring provider. Although it was eventually filed and paid, the length of time it was held could have easily led to a denial for timely filing!

 

High coding error rates lead to costly mistakes — February 22, 2017

Is your biller responsible for coding? In our most recent audit, we found that 10 percent of the cases we reviewed had coding errors and 6 percent of the cases were under coded by our client’s biller — a pair of mistakes that combined to potentially cost our client more than $50,000 last year! Just another reason why somebody should be reviewing your billing (and self-audits don’t count!)

 

Diligent denial follow-up leads to lump sum payment — February 28, 2017

Throughout the past year, a group in Northern California we work with received a number of denials totaling $83,000 from a particular payer for CP services that should have been paid. We worked with the group for several months to appeal for payment of these services before finally receiving a letter from the payer that admitted the denials were incorrect and provided a lump-sum payment to our client to cover the withheld money.

Does your biller show the same level of diligence with your denials?

 

Missing sequestration creates potential compliance issue — March 3, 2017

During a recent billing audit, we uncovered a system issue that was causing sequestration to be missed when posting electronically for a few insurance carriers, which led to adjustments being adjusted as small balance write-offs. We’ve since recommend our client’s biller fix this issue to prevent possible compliance issues, such as statements being incorrectly sent to patients.

 

Inquiries spur biller action — March 9, 2017

It’s amazing how often our billing audits seem to spur billers into action. Case in point: We recently identified a $400 claim dated June of 2016 that had not been billed out because the case hadn’t been coded. When we inquired about it, the biller stated it had been requested from the group, but only after we questioned them about it. Makes you wonder how long this claim and others may have sat around collecting dust if we hadn’t been looking!

 

Missing accessions cause cases to go unbilled — March 21, 2017

It’s always disappointing when we see our clients’ cases go unbilled due to their revenue cycle manager’s failure to follow up. In one recent instance, we found multiple cases that had not been billed because of missing accessions — an issue that could have easily been resolved with some simple communication. Instead, the billing team left cases and the revenue they would have generated to gather dust.

 

Payer routinely underpays for surgical specimens — March 29, 2017

It’s amazing how billers sometimes identify major mistakes on their own when we request a caseload to audit. This week, a third-party biller informed us they just realized a payer has routinely paid for fewer units for surgical specimens than the actual number that was performed by our mutual client. The biller said this wasn’t apparent in their system until they pulled cases for our request, but they assured us they are now appealing the underpaid claims and are working to fix their processes to avoid a this issue in the future.

Makes you wonder what else our audit team will find once they start reviewing the caseload.

 

Failure to load updated contracts leaves patients responsible for payment — April 6, 2017

This week, a biller we were working with discovered a $10,000 refund was due to multiple patients while pulling cases for our audit. Apparently, updated contracts for our mutual client had not been loaded into the biller’s system, which in turn caused contracted adjustments to be missed and left the patients fully responsible for the payment! Yikes!

 

Missing accessions lead to missing charges — April 24, 2017

We saved a client an estimated $84,000 this week after discovering 2 percent of the cases we reviewed in their billing audit were missing accessions, which led to the corresponding charges being missed. Fortunately, the charges were loaded into the biller’s system after we identified them, but it’s unlikely they would have been found had we not been brought in for a review

 

National biller tries to charge client to acquire current contracts — May 3, 2017

Recently, we signed a client who has used a large national biller for many years. During our audit process, we asked the biller for copies of the managed care contracts so we could compare payments to negotiated rates. Imagine our surprise when the biller said they don’t have these contracts. (How did they verify payment amounts?) Then, the biller proceeded to actually try to CHARGE the client a fee to acquire the managed care contracts they should have already HAD! Amazing…

 

Incorrect billing creates compliance issue — May 8, 2017

Are your biller’s oversights causing compliance issues? This week, we discovered a client’s biller incorrectly billed the technical component of IHC stains as a professional charge on 8 percent of the cases we reviewed. Since the TC in this case is performed elsewhere and shouldn’t be billed, this data-entry error caused the number of stains on each claim to be mistakenly doubled!

 

CCI edit denial isn’t appealed — May 22, 2017

We always stress the importance of being diligent with appealing denials, but we still routinely find appeals being missed during our billing audits. Last week, we informed a client that their biller failed to appeal six charges denied by an insurer due to a CCI edit and instead adjusted the charges off their system. Since this occurred on 2 percent of the reviewed caseload, we determined our client could have lost as much as $24,750 if this error rate held constant over a year!

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