I keep receiving letters that my claims will not be processed unless I submit medical records in advance. Then when I submit, I am still being tied up and sometimes denied. My ARs are really suffering. What do I do now?
Dr. F, you are on pre-payment review. What you have to do now is work with the payor (you did not specify whether private carrier or Medicare/Medicaid), but regardless of the third party flagging your claims, now is the time to figure out why your claims are being flagged. Figuring out why your claims are being flagged is a process in itself - you should not be calling yourself, or even your office or your billing company. You are being flagged because the payor is concerned about your activity, whether that is from a utilization standpoint, medical necessity or straight up fraud concern. This is a job for your healthcare attorney, if for no other reason to keep distance between you personally and the practice. What has to be done at this stage is to determine the cause for the flag and the steps necessary for unflagging. Also, coordination and tracking of your unpaid ARs needs to be documented, which hopefully your in-house biller or outside billing company is already doing. If the payor is not abiding by its prompt payment responsibilities - payment within 30 days of electronic claims submission or 45 from paper submission - or notice of a disputed portion or pre-payment review notice is not received in the requisite time, you may have recourse against the insurer and be eligible for interest payments.
Once the initial reason for pre-payment review has been addressed, use this "flag" as an opportunity to protect your practice by implementing changes to your documentation and coding practices. Now may be the right time for an outside coding expert to come in and look at your records (under attorney client privilege), or time to consider adopting a billing compliance program.
The one thing you do not want to do here is nothing. The record reviews will not stop until you rectify whatever issue had you flagged in the first place. For direct assistance on this, contact Jennifer
or Rachel Weinrib