Physicians, QHPs, and MACs Complain About Some Billing Companies

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At the 2024 Symposium on Advanced Wound Care (SAWC) Spring, this author/consultant was surprised at the number of physicians and other qualified healthcare professionals (QHPs) who were unhappy with their contracted billing company. First, they asked if I provide billing services. When I answered “no,” they then asked if I had recommendations of billing companies that were trained and experienced in supporting wound/ulcer management physicians/QHPs. Of course, I provided them with a list of several reputable billing companies in the U.S. that provide the full breadth of services that physicians/QHPs need if they have decided to outsource their billing.

While speaking with each physician/QHP, I inquired about what they did not like about their billing company and made a list of every complaint. By the time SAWC Spring was over, the complaint list was long. What surprised me the most was the similarity between the physicians’/QHPs’ complaints and the complaints that I learned about during an online seminar on April 24, 2024.¹ The online seminar, entitled ‘Compliance Training: Using Third-Party Billing Companies,” was sponsored by the 7 Part A and Part B Medicare Administrative Contractors (MACs). Participants at that seminar explained their concerns about some billing companies and reminded physicians/QHPs that they were responsible for their billing company’s actions.

Rather than share with readers the list of complaints from the physicians, QHPs, and the MACs, I thought readers would be interested in what a “good” billing company looks like. Therefore, I spoke with several billing companies in the U.S. and was happy when Amiee Coriano, the owner of AMC Medical Consulting, LLC, agreed to share how her coding and billing company operates and circumvents client complaints. Following is the interview that Amiee so graciously agreed to share with readers of Business Briefs.

KS:     Thank you for agreeing to share your company’s standard coding and billing processes for wound/ulcer management physicians and QHPs. Your organization continues to receive excellent reviews regarding your professionalism, your credentialing services, your knowledge about pertinent medical policies, your thorough insurance benefit verification and prior authorization support, your thorough documentation review, your wound/ulcer management coding knowledge, your accurate billing practices, and the education you provide to your clients.

AC:     Thank you for your kind compliments and for inviting me to share my company’s major functions. To say the least, I am very proud of my team. We do everything possible to compliantly code and bill for our wound/ulcer management physicians/QHPs and to teach them how to thoroughly document their work.

KS:     Let us start by discussing the qualifications and experience of you and your team.

AC:     I am the owner of AMC Medical Consulting and am a certified coder with the following coding credentials: RHIA, CBCS, CMAA, CPPM. I have a degree in health information management, medical office system management, and health service administration. Most importantly, I have been working with wound/ulcer management professionals for the past 16 years. I started this company because I recognized the need for a coding and billing company that understands the coding, coverage, and payment requirements for wound/ulcer management and hyperbaric oxygen therapy (HBOT) physicians/QHPs.

Unlike some billing companies, we do not employ billers. Because we review the medical record before creating clams, we employ 4 certified coders who have 19 years of combined experience coding and billing for wound/ulcer management/HBOT physicians/QHPs. In addition, we employ 8 follow-up team members who also have 19 years of combined wound/ulcer management experience. To ensure that all the claims and line items that were submitted were processed correctly, this team reviews the accounts receivable (unpaid claim reports) on a weekly basis.

Since I launched my wound care coding and billing company in 2011, reimbursement regulations constantly change. Therefore, we prioritize continuing education for the entire team. In fact, I attended many of your Wound Clinic Business seminars.

Because I am a member of the American Academy of Professional Coders (AAPC), American Health Information Management Association (AHIMA) and National Health Career Association (NHA), I receive emails regarding pending or actual changes and updates to the ICD-10 CM, HCPCS, and CPT^®2 codes. My staff and I participate in CEU accredited online webinars provided by AAPC, read their updates, and take their quizzes.

In addition to coding and payment rules, submitting accurate claims for wound care and HBOT requires an understanding of the pertinent National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and medical policies. Therefore, the entire team reads all pertinent active and proposed NCDs, LCDs, LCAs, and medical policies. We also have frequent team meetings to verify that we consistently implement the coding, payment, and coverage guidelines. We use these guidelines to review our clients’ documentation to ensure that it supports medical necessity for the codes they report on their superbills. This prevents miscoding, which leads to claim denials and recoupments.

KS:     During the MACs’ online seminar in April, I learned that the Centers for Medicare & Medicaid Services (CMS) require the MACs to track billing companies who call them for information that is readily available through the self-service internet tools, such as the interactive voice response system (IVR) or online tools that verify the status of a claim or patient eligibility. Many of the billing companies tell the MACs that they do not have internet access to the tools. Not only is the use of the self-service tools a Medicare requirement, but it unnecessarily increases costs to the Medicare Trust Fund and causes incorrect physician/QHP payments and recoupments.

Will you briefly tell us if your staff has internet access, if and how you use the MACs’ self-service tools and remittance advices, and if you are set up to receive requests from the MACs, such as Additional Documentation Requests?

AC:     Our staff needs to access this information to properly process claims. The payers often refer us to their websites to obtain a patient’s remittance advice and to learn how a specific claim was processed.

Because our clients are the administrators of their payer portals, we closely collaborate with them to gain access to those portals. This allows us to obtain the required information to support the clients’ coding and billing work. We provide our employees with internet access to these online tools. In fact, we bookmark the MACs’ coverage lookup pages so we can reference this information at any time.

KS:     How do you protect patient information?

AC:     Because it is important that our staff and our clients remember that protected health information (PHI) is very sensitive information, which must always be secured, we make sure that our staff takes a yearly Health Insurance Portability & Accountability Act (HIPAA) course. We also make sure our clients understand the HIPAA rules. We ensure all internal and external communications are HIPAA compliant. In addition, we do not email any PHI information to personal email addresses.

KS:     When you begin collaborating with a new physician and/or QHP, do you verify if they are credentialed with Medicare and with all their other contracted payers?

AC:     Yes, we have a meeting with the office business manager and/or the physicians/QHPs, during which we inquire about their current payer contracts and each provider’s credential status with each payer. If the group practice and/or wound care/HBOT physicians/QHPs are not yet credentialed with a specific payer, we gather the required information and submit the application for each professional.

KS:     Will you please tell us about each of your staff member’s responsibility once you receive a completed patient encounter?

AC:     I personally review the medical record to see if contains any documentation inconsistencies that require clinical documentation improvement (CDI). This also helps me 1) to learn how each provider/QHP documents, 2) to help improve their processes, and 3) to discover any potentially missed revenue opportunities.

If a billing company does not have coders, claims can be denied for reporting diagnosis codes in the wrong order, for reporting non-specific ICD-10-CM codes, or for only reporting one ICD-10-CM code when two are required. Example: My company was contracted to assume the coding and billing after another company was fired. One of the issues we had to correct was that the previous billing company did not report the ICD-10-CM codes in the correct order on most of the physician’s claims. All those claims were denied for 3 months.

Our coders review the entire medical record for each encounter. They look for documentation discrepancies, incomplete support for medical necessity, and missing signatures. If the coder does not read the documentation for each encounter and does not verify if it aligns with the superbill, they could incorrectly submit a claim that will either be denied or result in recoupment.

Billers and coders do not have the same duties. The coders need to know the billing regulations to correctly scrub the claims. Then it is the coder’s job to enter onto the claims the diagnosis code(s), service and procedure code(s), and product codes provided to them on a superbill.

The following are two very common mistakes that we inherit when we assume coding and billing responsibilities.

1.    A physician applied a cellular and/or tissue-based product (CTP) for skin wounds and documented that 10 sq. cm were discarded but did not report the wastage on the superbill. The biller of the physician’s previous billing company did not verify that the documentation did not align with the code reported by the physician on the superbill. Therefore, the biller did not reflect wastage on the claim. Upon an audit, the physician incurred a repayment.

2.    A physician performed debridement and the application of Unna boots or multi-layer compression bandages on the same date of service for multiple patient encounters. The physician submitted codes for both procedures on the superbill. The biller did not review the documentation and reported both codes on the claims. Because the National Correct Coding Initiative (NCCI) procedure-to-procedure edits consider that the application of compression is a component of debridement procedures, the physician incurred large repayments after an audit.

KS:     Please share your insurance benefit verification process for Medicare and other payers. Do you also verify if the physician/QHP who will perform the work is covered, if the work can be performed in the place where the patient wants to receive the care, and if the patient is also receiving home health agency care or is in a skilled nursing facility? And finally, do you consider pertinent Medicare NCDs, LCDs, and LCAs as well as private/commercial payers’ medical policies?

AC:     Some billing companies only use the Medicare Interactive Voice Response (IVR) which only confirms if the patient has current Medicare Part A and Part B insurance. Our company verifies if the diagnosis, procedure, place of service, provider and group are covered for the services the patient requires based on the provider’s documentation. Commercial/private payers often have strict coverage rules for each plan, and they do not cover all the services that Medicare covers.

If the claim is denied after our thorough insurance benefit verification, we always use the verification reference number, that the payer’s representative provided, when we appeal the claim(s).

KS:     If prior authorizations are required, do you identify the exact process for the physician/QHP to follow, exactly what information is required, where to send the request, and the expected time to receive an answer?

AC:     Yes, we always ask the payers for their prior authorization turnaround time and obtain the information needed to submit prior authorization requests. We share that information with our clients. After we receive all the needed information from our clients, we submit the request for prior authorization and follow up to ensure that all the submitted information was received and that the prior authorization was completed.

Then we advise the physician’s/QHP’s scheduling staff so they can properly schedule the patients for their treatments. We also send the prior authorization determination to the physician’s/QHP’s office. If the client’s electronic health record includes a prior authorization record, we enter the results of each authorization determination; this assists the office in tracking the number of visits/procedures based on the approved authorization. This is important because it helps to prevent the physician/QHP from performing services/procedures that are not approved and that could lead to a denial or a repayment.

KS:     At SAWC I learned that some physicians/QHPs are offended when the coders from their billing company inform them that their documentation does not support medical necessity for the service, procedure, or product that they performed and for the code they want to report. I personally believe it is the billing company’s responsibility to educate them about these deficiencies and to make recommendations, and that the physicians/QHPs should be thankful for the expert assistance. How do you manage this sometimes-difficult task?

AC:     You are correct that physicians/QHPs are not always receptive to learning about their medical record documentation deficiencies: recommendations are not always received from coders in a positive manner. In those cases, we identify a liaison in their office who understands appropriate documentation. We educate the liaison about documentation deficiencies that are preventing us from submitting their claims. Then they educate their physicians/QHPs to refine their documentation.

Refining documentation is vital because claims will be denied or will result in repayment if the documentation does not support the code reported on the claim.

For example: We often read documentation which states that the patient did not have an infection, yet the physician ordered an antibiotic. Another common documentation error states that the wound was closed/healed, but the physician reports that subcutaneous tissue was debrided. In every instance, when these claims undergo a pre-payment or post-payment audit, the physicians/QHPs are not paid or incur a repayment.
 
KS:     During the April online seminar, I learned that the MACs are very concerned about billing companies that do not understand the Medicare appeals process. For example, the billing companies do not know when to submit a reopening vs. a redetermination. Does your company understand when and how to use the various levels of Medicare appeals?
 
AC:     Yes, we understand and meticulously follow the Medicare appeals process. For example, if we need to fix a minor coding or billing mistake, like a missing modifier, we request a reopening of the claim. If a claim was denied and we believe that the documentation supports the reported service/procedure, we request a level 1 redetermination, which reviews the documentation and compares it to the codes reported on the claim. This level of appeal is particularly useful after a medically unlikely edit (MUE) denial.
 
Because we have access to our clients’ payer portals, we submit these requests electronically and receive their tracking numbers which allows us to monitor the appeal process. If the redetermination is not favorable, we request a level 2 Qualified Independent Contractor (QIC) review.

KS:     The physicians, QHPs, and MACs are also concerned about billing company behaviors that drive up charges to the professionals; eg, charging them for unnecessary calls, which they make to the payers, for information that should be obtained online; charging for appeals that were due to the billing company’s mistakes, etc. How does your company charge, and do you charge extra for these types of services?

AC:     Based on the services/procedures documented by the physicians/QHPs, AMC Medical Consulting charges a percentage of payments received from the payers. Our fee includes following up with the payers to ensure the claims are paid, submitting corrected claims, and submitting appeals. We only charge additional fees to the client if we must 1) schedule multiple calls with their office liaison due to lack of response, 2) make multiple requests to the office to gain access to their payer portals, or 3) provide coding or documentation training.

KS:     Amiee, thank you for explaining how a compliant full-service coding and billing company operates. Do you have any closing thoughts for our readers?
 
AC:     Yes, I suggest that the physician/QHP assign an employed liaison to communicate with their outsourced coding and billing company, and that this liaison understands the revenue cycle management process and documentation guidelines and responds to the coding and billing company in a timely manner. I also suggest meeting with your coding and billing company on a weekly or monthly basis; this regular communication helps the physicians/QHPs to understand any issues or concerns that will slow their revenue.
 
As you can see, our coding and billing company’s goal is to help our clients to focus on treating their patients and to grow their businesses. Thank you for allowing me to share the qualities of our compliant coding and billing company.
 
Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.   
 
Amiee Coriano, RHIA, CBCS, CMAA, CPPM, is the owner of AMC Medical Consulting, LLC in Dallas, GA. Contact her at acoriano@amcmedicalconsulting.com or 678-402-5570.

References
 
1. Compliance Training: Using Third-Party Billing Companies: https://www.youtube.com/watch?v=9VjHffnhNrA
Last accessed June 9, 2024.
2. CPT is a registered trademark of the American Medical Association.