Where's the money?

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Author: Isenberg, Steven F. sisenberg@good4docs.com

Your billing software should provide you with a summary report that will show where unpaid services exist in your practice (figure).

The example illustrated here begins with a list of "Charges on Hold." Each of these charges is annotated with a reason why the charge has not been filed.

The next category ("Collection") lists charges that are ready for collection.

The "Contracted Variance" section lists those claims that were not paid according to the terms of your contract with the carrier. In the first example, the payer did not pay $104 as contracted. If the patient does not pay the difference between $104 and $69.80, the carrier must be notified that it is in breach of contract.

The figures in the "Denials" category are annotated with the reasons that have been given for the denials. These are self-explanatory. Your software should keep track of your success and failure in appealing these denials so that your staff can learn the most effective, carrier-specific way to appeal.

Charges on Hold

Charge: 55161 with Procedure: 69436 is            1      31.35
 considered comprehensive with one or
 more other charges on DOS: 3/10/2005
Charge: 55162 with Procedure: 69210 is            1       4.58
 considered comprehensive with one or more
 other charges on DOS: 3/10/2005
Missing/Invalid FormType for claim: edit          2     164.99
 carrier to correct trading partner setup
Missing/Invalid Hospital AdmitDate (required      4     608.71
 when POSCode is 21,31,51,52, or 61)
No BaseFee for claim                              1       0.00
No FilingOwnerAddress1 for claim                  1       0.00
No FilingOwnerPolicyNo for claim                  2       0.00
Outstanding profile change request. Please        5     304.46
 check Profile Management Workfile screen

Workfile Total:                                  17   1,114.09

Collection

Campaign reached collection state                50   1,804.01
Campaign reached collection state                26      47.61

Workfile Total:                                  76   1,851.62

Contracted Variance

Allowed amount did not meet contract amount       1      69.80
 of 133.90 with variance of 0.00%
Allowed amount did not meet contract amount       1      82.90
 of 90.00 with variance of 0.00%
Allowed amount did not meet contract amount       1      12.28
 of 133.90 with variance of 0.00%
Allowed amount did not meet contract amount       1       1.58
 of 15.00 with variance of 0.05%
Allowed amount did not meet contract amount       1     263.67
 of 327.80 with variance of 0.05%
Allowed amount did not meet contract amount       1      72.53
 of 419.45 with variance of 0.00%
Allowed amount did not meet contract amount       1      20.96
 of 99.03 with variance of 0.05%

Workfile Total:                                   7     523.72

Denials

Held by system due to allowed amount of zero      1   1,760.00
Procedure not payable separately                  3   1,495.00
Additional info needed to process and pay claim   3     712.94
Assistant surgeon fee not payable by this         1     -40.00
 carrier
Claim not covered by this payer/contractor. You   6     851.23
 must send claim to the correct payer/
 contractor
Claim received but still pending                  1       0.00
Electronic Remit Denial                           1       0.00
Need medical records to support claim             4      42.42
Needs refiled with remit                          1      20.00
Patient cannot be identified as our insured       1       0.00
Procedure not payable separately                  1       0.00
Claim forwarded to the medical group              1     130.00
Duplicate EOB, no previous response to claim      2   1,165.00
Electronic Remit Denial                           1     130.00

Workfile Total:                                  27   6,266.59

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By Steven F. Isenberg, MD

Dr. Isenberg is an otolaryngologist in private practice in Indianapolis; sisenberg@good4docs.com.