What constitutes an overpayment?
An overpayment is when your medical office receives money, or payments from an insurance company, patient, or both, that exceeds the amount of charges that are produced for a visit or medical services.
For example, the patient had an ear-lavage with removal of impacted cerumen, the charge is $100. The doctor is reimbursed a total amount of $150 from the health insurance company. The $50 is the amount that was overpaid.
There can be many reasons for an overpayment. The patient may have multiple insurance plans. Plan A pays $50, Plan B pays 30 and the patient pays $70.
The doctor cannot keep the overpayment. An investigator or auditor could consider the action of keeping overpayments as possible fraud because his medical billing misrepresented the charges.
If the insurance company says that the patient had other insurance, you might have the right to demand that they provide proof of this (laws may vary from state to state).
Some insurance companies use professional debt collection agencies to perform refund demands. Some of these companies can be very aggressive with trying to collect the money.
With some debt collection agencies, the agent calling makes their money based on what they individually collect, so some debt collectors can be abrasive and downright abusive. It is always best to not get involved into any detailed discussions over the phone.
Instead ask for details of their claim/demand in writing and also respond in writing sent by Certified Mail/Return Receipt, which prevents the "we never got your letter" excuse.
In addition, if the office needs to file a complaint or lawsuit, there is proof that a response was sent and it was received. This is important, because it shifts the preponderance to your side to make the case. Now, the insurance company or debt collection agency can no longer state the office never responded.
Steven M. Verno, a highly experienced Certified Master Medical Coder and Certified Master Medical Biller and Medical Coding/Billing Instructor in Florida, who also serves our Medical Billing Community Forum as a volunteer forum moderator has elaborated in great detail on medical billing and coding issues, challenges and common misconceptions and given examples and tips to remedy some of the unforeseen issues that can arise in medical billing and practice management.
Anyone in the medical billing discipline can join the forum and read Steve's comments and training primers for free, including training primers on overpayments, refunds, deductibles, uninsured and self pay, however, a username and password registration is required to access the "deeper" parts of the forum. If you have questions, please post them into the Medical Billing Community Forum.
Managing the Medical Office in Tough Economic Times
7 Tips on How to Manage the Medical Office in Tough Economic Times
One of the most commonly mentioned advice for coping with tough economic times, is to cut costs. There are many different ways you can cut costs for your businesses. So where do you start? Office management seems to be a good place to start. You can make some changes easily and quickly because you have full control over how you want to run your office.
For example, if you are running a medical practice, now may be a good time to start looking at medical office software to help manage the office more efficiently and more effectively. Consider the functions that a great piece of medical practice software can perform for you:
1 - Check patient eligibility with insurance company to make sure the patient is covered for insurance.
This is a repetitive task that may be taking up too much of your employee\'s time. Have the software do this for you.
2 - Check patient balance when they are calling for an appointment and remind them of any outstanding balance and ask them to bring a check or credit card with them to appointment to pay.
This is an important aspect of the business. The software will help generate healthier revenues from the more efficient payment collection processes.
3 - Collect patient deductible and co insurance at time of service. Offer different payment options.
With the software, you can offer different payment options. Deductible is the amount payable by the patient and cannot be claimed from the insurance company. The software helps to track that to ensure prompt collection.
3 - Followup on all insurance denials or rejections, don\'t let the insurance companies cheat you out of revenue.
Many practices simply give up on insurance claims because they find it too tedious to track the claims. The practice thus ends up losing money. With the software in place, a practice doesn\'t have to lose money due to rejections or denials anymore. Simply follow up with the claims, correct the problems, and rake in the cash.
4 - Schedule efficiently to fill up your schedule efficiently.
Your practice depends on your patient appointments for revenue. So it\'s important to have powerful software that will manage all your appointments for you.
5 - Doctors, be sure to submit info to office staff for hospital and nursing home visits and rounds.
Doctors, being busy and heavily stressed professionals, sometimes forget to submit info for office staff. They can now submit the info through the software.
6 - Immediately bill any claim to patient if insurance company denies.
Sometimes, you may have legitimate denials from insurance companies. Have your software bill patients immediately if an insurance claim fails (e.g. insurance policy expired).
7 - Send patient statements at least monthly - hire a temp if your staff complains about not having time to print, and stuff and stamp the statements. Consider an electronic statement service. For about the cost of stationery, envelopes, and stamp, a service can serve this crucial function.
Monthly billing statements take up a lot of time and the work is not just repetitive but also builds up over time. With a medical practice management software program, you can hire a temp staff to perform such tasks and free up the time of your full time staff. In the long run, you will be saving more money due to better use of your staff\'s time, and declining staff turnover.
When Coding—Remember You are NOT the Doctor—And Don't Blindly Trust the Software
Scenario:
"Someone sends me a message along the lines:
My doctor performed XXXXX and he diagnosed the patient with 000.00. The insurance company, ABC, denied the claim saying 000.00 cannot be used with XXXXX. I use XYZ Software to code and it says if we want to use XXXXX, it needs 999.99 as a diagnosis. The doctor will not change the diagnosis to 999.99. Is there another diagnosis I can use to get XXXXX paid or is there a procedure I can use with 000.00?
When we code, we must always refer to the doctors documentation of the service (procedure) rendered and the diagnosis documented by the doctor. We cannot and should never code based on the lack of observing documentation.
While software is nice, the software may have been created by an insurance company and it may be biased towards that insurance company's internal coding policies. There have been lawsuits regarding an insurance company's software where the courts have found that the software was biased for the insurance company.
While software may be a nice adjunct, it can never replace good old fashion brain matter where we open the coding book and use our coding training to look up a correct code.
In medical coding, a diagnosis is always selected by the doctor. We are not doctors and we cannot make up a diagnosis just to get a claim paid. We, as coders, take the doctors diagnosis and convert that diagnosis to a code we submit on a claim. Medical coders never diagnose. There are rules to follow.
If those rules result in a claim denial, then we may have no resolution, but we can never take shortcuts or look for loopholes or make up anything to get a claim paid. We can never code without reviewing the medical record documentation. Our commitment is to prevent and never accept or allow fraud or abuse." (Steve Verno, Certified Medical Biller).
Should Medical Coders Rely on Medical Coding Software?
Steve Verno, a seasoned and experienced certified medical biller and billing instructor has shared the following:
"I've seen billing companies undergo audits, sanctions and fines because their medical coders became too reliant on medical coding software. They couldn't code without it."
Here is an interesting story taken right-out-of-real-life illustrating what can happen if medical coders aren't properly trained bottom up to know how to hand-code using their manuals and books:
"We were hiring some coders at one time. 10 of them came in. All nurses with certification. They were put in our training room. All they had were the CPT and ICD-9 manual and paper charts. Some of the coders asked where the computers and software were.
They were told there would be no software. They were all told they had to code using what was provided to them. Only one passed the coding test. She lasted one day on the job. She went from coder to coder asking them what code they would choose. She even came to me and I didnt have coding training at the time.
The owners found her using the internet to get her codes. At her outbriefing she said she used coding software at her last job. The ones who demanded the software hired a lawyer saying the test was unfair. They lost their lawsuit.
The company eventually hired some coding students who just graduated from school. Brain power makes the best coders. Software never guarantees 100% accuracy with coding." (Steve Verno, Certified Medical Biller).
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