Billing Challenges- Why Is It So Hard Getting Paid?

By Diane McCutcheon, President

As a consultant I am called in to practices to evaluate the billing function and to answer questions like why are we getting so many denials, why aren’t our payments consistent, how do we know we are charging correctly, are we in compliance and most of all where is my money?  And this is on the heels of investing in and implementing a new billing system. 

We have all read articles on choosing the right system and they all promise that you will get better payments, stay in compliance, and your ability to charge and document will be enhanced, but the truth is, in order to get paid and get paid right the first time you need a competent, well trained staff and processes in place to support your goal – payment for services rendered. 

Doing billing in-house poses the same challenges. Our on-site assessments prove that 9 out of 10 denials are due to inaccuracies - data that was entered wrong and stopped the claim from going through.  This continues to be a consistent problem.  A great billing system cannot perform if the information you enter is not correct. 

The second most popular reason for denials is a scary one – the biller is not billing under the therapist who performed the service.  Many clinics bill various therapist’s claims under the owner’s or another therapist’s provider numbers.  Sometimes the staff therapist doesn’t even have a provider number.  Many therapists still do not have NPI numbers yet they are hired and their services are billed under another therapist.  This is a huge liability for the company and can, in fact, lead to an audit resulting in stiff fines and in some cases closing down the facility.  In a nutshell – it is fraud.  Medicare, in particular has very strict compliance guidelines that must be met and it is your responsibility to make sure everyone is aware of them.

Make sure that the therapist you hire has a valid license, an NPI number and has or is being credentialed with CAQH, BCBS, Medicare and any other insurance carriers whom you have a contract with.  A therapist cannot work without a license but can work without provider numbers if the insurance does not require that they have a provider number or if they are providing out-of-network benefit or the patient is paying cash. Do not bill services under another therapist number unless you are a licensed PTA and the PTA has a NPI#.   Insurances like Worker’s Comp, auto, and third party carriers do not require provider numbers so the therapist can treat and bill for those patients. 

The third most popular reason for denials is that the diagnosis is not correct.  It is the therapist’s responsibility to document the diagnosis they are treating.  It is not the responsibility of the front desk or biller to take the diagnosis off of the prescription and use that as a diagnosis even if in the long run it is the correct diagnosis.  Many times the therapist changes or adds to the diagnosis the doctor has on the script and that is why the therapist must make the final decision. 

Other denials issues include:  CPT codes do not have the proper modifiers attached, documentation does not support the charges, or there is no referral or authorization in place.

Make sure the front desk; billing and professional staffs are aware of each insurance requirement. If need be, call a consultant who has experience and can help you improve the staff’s level of knowledge in billing and compliance. 

Billing right the first time, staying in compliance and holding those who do not follow the guidelines accountable is key to your success.  Now more than ever, PT practices are under a microscope for how they are operating.  Having the right systems in place to ensure you are in compliance and managing those systems is the best way to limit denials and your liability.  

Diane McCutcheon, President

DM Business Management Consulting Services, Inc.
Account Matters – Billing & Collection Services
4 Charlesview Road, Suite 4
Hopedale, MA 01747
P: 508-422-0231  F:  508-422-0234
diane@dmbmcsi.com

A new billing system is not the whole answer – it’s the people using the system.  If you put good information in you will get good results.  If not, you won’t and it is as simple as that.  Our own billing company, Account Matters, tries very hard to do all they can to ensure that claims are clean and billed daily.  If we have to rely on our client’s staff to get us all the right information so we can do that.  If we get denials or if things are sent out wrong – we have to address the problem by letting our clients know what the issues are and where they stem from so they can fix the core problem so they do not continue to happen.