The difference between a professional fee insurance claim process and a facility fee insurance claim process is primarily in how the services provided are billed to insurance companies. Professional fee insurance claims are submitted by individual healthcare providers, such as physicians or nurse practitioners, for services they have provided to a patient. These services may include office visits, consultations, diagnostic tests, or procedures. The professional fee typically covers the cost of the healthcare provider's time and expertise.
Facility fee insurance claims, on the other hand, are submitted by healthcare facilities, such as hospitals, clinics, or ambulatory surgery centers, for services provided to a patient. These services may include the use of equipment, supplies, and staff within the facility, as well as any overhead costs associated with providing care. The facility fee covers the cost of using the facility and the associated resources.
In some cases, a patient may receive both professional and facility services during a single visit, such as a surgery performed in a hospital setting. In such cases, both types of fees may be billed separately to insurance companies.
It's important to note that insurance companies may have different coverage and reimbursement policies for professional and facility fees, which can impact the payment rates and amounts. Healthcare providers and facilities need to understand these policies and ensure that they are submitting accurate and appropriate claims to insurance companies to receive timely and accurate reimbursement.
Understand the coding mechanics behind some of the most common obstetrical US examinations.An outsider looking in might think diagnostic radiology coding is as simple as knowing the number of views of an X-ray or whether contrast was used on a computed tomography (CT) or magnetic resonance imaging (MRI) scan. But to say that’s even the tip of the iceberg would be an understatement.
The reality is that you’ve got to be cognizant of a handful of guidelines dedicated to each diagnostic subcomponent within the radiology specialty. With the plethora of rules and guidelines to consider, obstetrical ultrasound (US) coding is almost a subspecialty in its own right.
Let’s dive into the coding dynamics behind one of the many staples of diagnostic radiology coding: obstetrical US.Meet This Set of 76801 CriteriaA good chunk of diagnostic radiology coding involves using a theoretical (and sometimes literal) checklist to confirm you’ve got enough components and elements documented to achieve a given code. When it comes to obstetrical US coding, this checklist concept becomes especially important because your CPT® coding depends on it. The CPT® code book lays out a strict set of criteria necessary to reach a given obstetrical US code that varies depending on certain diagnostic components, such as trimester.
Start out with a look at the criteria you’ll need to meet to report codes 76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation and +76802 … each additional gestation (List separately in addition to code for primary procedure):
If the report inadequately documents why one or more of the above criteria is missing, then you should either query the physician regarding an addendum or report the limited obstetrical US code 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses in place of 76801.
Know When to Factor in Amniotic Fluid Assessment
Determining whether the physician’s documentation meets the criteria for the assessment of amniotic fluid can be challenging. The ACR explains that “among the required elements, ‘qualitative assessment of amniotic fluid volume’ refers to the radiologist’s statement, based on his or her experience and knowledge, that the volume is adequate or inadequate.”
Amniotic fluid is never mentioned on the earliest obstetrical USs of seven or eight weeks gestation because the assessment doesn’t typically become relevant until weeks 13 or 14. Most often, amniotic fluid will be evaluated and documented on the fetal anatomical structural evaluation at around 18 to 20 weeks. When providers document “no free fluid” on the seven- to eight-week fetal US, they are referring to free fluid within the peritoneal space, not amniotic fluid.
Compare and Contrast 76801 With 76805
You’ll find a similar set of criteria for codes 76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation and +76810 … each additional gestation (List separately in addition to code for primary procedure):
With respect to the “survey of intracranial/spinal/abdominal anatomy,” the ACR explains exactly what you should be looking for within the report:
Fetal Measurement Abbreviations
For second and third trimester US, you’ll come across a variety of fetal measurement abbreviations included in the physician’s dictation report templates. These abbreviations and their respective measurements will act as sufficient documentation to check off a required element. Examples include:
Go a Little Further With 76805 Criteria
Although amniotic fluid index (AFI) is not specifically documented as a key element, documentation should include amniotic fluid measurement with the second element for 76805: Measurements appropriate for gestational age (older than or equal to 14 weeks, 0 days). The ACR adds:After the first trimester, the amniotic fluid might be measured (quantitative), or the report may document this with a qualitative assessment — either is acceptable. If measured, this might also appear in the report simply as an abbreviation and a number.
Just as you would with 76801, you may still report 76805 for an unaccounted-for element if the provider documents why the element could not be visualized or measured. If the provider fails to elaborate on the missing element, either query the physician as to whether an addendum is needed or report code 76815 instead of 76805.Other Requirements for 76811 Reporting
When coding for a patient in their second or third trimester, you may have to make the distinction between a traditional US (76805) and its more detailed counterpart, 76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation. This involves a thorough analysis of the dictation report.
In addition to each of the elements needed to meet the requirements for 76805, the provider must also document the following to code 76811:
When discerning between 76805 and 76811, do not make a coding determination based on exam header alone. In some cases, the exam header may be formulated to state nothing more than the exam involves a 14-week or greater US examination. Outside of any extenuating circumstances, the provider usually has no need to perform a more substantial evaluation than what’s included in 76805. To qualify for 76811, the provider must document each element listed. Similar to 76805, if the provider does not document a given element, the dictation report should include a reason for non-visualization. Consider Quick Look Exam Coding Scenarios
If you’re coding a report in which the provider does not document enough elements to reach the complete fetal and maternal evaluation codes, then you should resort to coding 76815. This exam is referred to as a “quick look” exam and includes one or more elements listed in the code description.The ACR elaborates a little further on code 76815:
It is important to note that 76815 includes in its code description, “one or more fetuses,” and should not be coded more than once per study, or per fetus. If a study is done to reassess fetal size, or to reevaluate any fetal organ-system abnormality noted on a previous ultrasound study, 76816 is appropriate.
Without a thorough examination of the report and surrounding context, it’s easy to mistakenly assign code 76815 when the documentation actually supports code 76816 Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus. Begin with a few important notes offered in the CPT® code book:Code 76816 describes an examination designed to reassess fetal size and interval growth or reevaluate one or more anatomic abnormalities of a fetus previously demonstrated on ultrasound, and should be coded once for each fetus requiring reevaluation using modifier 59 for each fetus after the first. If a study is done to reassess fetal size, or to re-evaluate any fetal organ-system abnormality noted on a previous ultrasound study, 76816 is appropriate.
Code This Real-World Example
In the following case study, your first point of order in distinguishing between codes 76801, 76805, 76811, 76815, and 76816 is to examine the clinical indication. If the clinical indication states that it’s a follow-up obstetrical US, you need to check the patient’s chart history to determine the correct code. Keep in mind that the exam header for a fetal reassessment may look identical to that of a complete fetal and maternal evaluation as described in code 76805. Put what you’ve learned to the test by coding the following clinical example.
Example: Patient admitted to emergency room (ER) for vaginal bleeding in pregnancy. A transvaginal obstetrical US is performed. The radiologist documents two subchorionic bleeds with a gestational age of eight weeks and three days. One week later, the patient presents for a first-trimester fetal and maternal US evaluation. The indication reads: “Evaluation of early pregnancy for dating. Follow-up of subchorionic hematomas.” One week following, the patient returns for a follow-up fetal and maternal US evaluation. The indication reads: “Follow-up of subchorionic hematomas.”
There are more than a few instances in this patient scenario that can cause problems for a coder. The first exam is relatively straightforward. The patient presents to the ER for a transvaginal obstetrical US. Given the circumstances of this exam, you should not consider any obstetrical US code outside of 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal. Code 76801, for instance, is a planned transabdominal procedure that involves an extra set of criteria not included in 76817. Where this situation gets tricky is when you look at the planned evaluation one week following the ER encounter.
Assuming this exam at the second encounter includes all the necessary criteria to report 76801, you should code it as such. However, there’s plenty of room to get tripped up when examining the indicating diagnosis. Obstetrical radiology coders are often conditioned to see “follow-up” in the indication and immediately opt for code 76816. Evaluating the patient’s entire obstetrical examination history before making any coding considerations is always important.
Looking at the bigger picture, the “follow-up” is in reference to the original ER visit, not a prior fetal and maternal evaluation exam. Since this fetal and maternal evaluation occurs at approximately nine weeks, the next point of order is to evaluate the dictation report to confirm that the exam meets all the required elements for 76801 coding.
Lastly, you’ve got to make a coding determination regarding the third and final follow-up examination. Based on the clinical indication and chart history, this third examination qualifies as a true follow-up obstetrical examination. Similar to the example above, providers will routinely order these exams for patients with documented subchorionic bleeding to make sure the hematoma has not progressed. As long as this exam meets the necessary CPT® elements, you will report code 76816.
Midwifery Billing Tips
As a midwife, billing can be a complicated and time-consuming process. Here are some tips to help you streamline your billing and ensure you get paid for the services you provide:
In the world of medical billing, shorter revenue cycles are crucial. Today's midwifery practices can handle more claims in less time than ever before by automating billing processes, building built-in clearinghouses with approved practice management software, and incorporating artificial intelligence into their workflows. However, not every practice is utilizing all of the technologies at its disposal, which is why we've compiled this list of the top five suggestions for accelerating billing procedures while lowering errors.
1. The Essence of Tabbing your Books
The first piece of advice will improve your coding accuracy. A wonderful strategy to keep organized and productive at work is to categorize your books. One of the greatest ways to become familiar with and find the key sections of your books is to tab your code manuals.
2. Optimize your Tools
In any task, having the proper tools makes a huge difference. Being a midwife biller in the modern era that still uses paper-based procedures is equivalent to being a carpenter who doesn't utilize power tools. You can automate clerical activities and fundamental billing procedures with the use of cloud-based practice management software and other medical billing software solutions, freeing up your workers' time to focus on tasks that demand a real human touch. Time will be saved, errors will be reduced, and reimbursements will be increased.
3.Increase Your Areas of Expertise
You might believe you're finished if you already have the Certified Professional Coder (CPC) credential. But have you given a specialty certification any thought? This not only improves the salability of your resume but also significantly raises your earning potential. If you want to become a better medical coder, think about enrolling in a specialty certification course.
4. Prepare an Ahead-of-Time Strategy for Line or Complete Denials
Millions of dollars are being unpaid as a result of increasing numbers of claims being denied. Surprisingly, however, many providers do little to recover this lost income; up to 65% of rejected claims are never resubmitted. Any billing department should make recovering this lost money a top priority, especially considering that the typical hospital has millions of dollars in unpaid claims. Ignoring these rejected claims is the same as throwing money away. Thankfully, intelligent PM software can schedule reminders for investigating refused claims and recovering lost money
5. Demand Accuracy for Coding and Claim Submission The timely submission of claims, which requires swift and precise CPT coding, is a crucial component of revenue cycle management. Effective coding procedures speed up the processing of claims and lower insurance denial rates. As it can help with code entry and automatically verify that codes have been added correctly, excellent PM software is crucial in this area as well. One of the easiest strategies to reduce denied claims and enhance your revenue cycle is to double-check everything before submitting a claim.
6. Keep an Eye on Important Statistics These days, data is key, therefore midwifery practices must monitor KPIs and other crucial information to stay in business. You should be able to view details like the processing time for claims, all denied claims, their justifications, the number of pending claims you currently have, and more. You can become more successful and efficient by better understanding the data that underlies your operation.
7. Stay Updated
Finally, keep up with the market so you're the first to learn about any news or updates about medical coding. Be sure to subscribe; the Midwives Advantage blog is an excellent place to start. Another fantastic resource is the AAPC Knowledge Center. Finally, you can follow specific online personalities. The more you understand, the more distinctive you'll be as a medical coder.
Help Avoid Surprise Billing to Clients
It is no secret that the healthcare sector is flourishing, and future expansion is anticipated. Thus, the billing procedure is essential to the ongoing operation of any hospital or midwifery office. Creating billing claims and submitting them to insurance companies are both involved. This guarantees that the hospital or midwife's office is paid the appropriate sum for the services they render to patients. Keeping your patients informed about their bills is a difficulty that all midwives encounter.
When receiving emergency treatment, non-emergency care from out-of-network midwives at in-network institutions, or air ambulance services from out-of-network providers as of January 1, 2022, patients will have new billing protections. Emergency services must continue to be covered without any prior authorization and regardless of whether a midwife or birth center is in-network thanks to new regulations intended to protect consumers.
Before, if patients had health insurance and sought treatment from an out-of-network practitioner, their health plan would typically not cover the whole out-of-pocket expense. Many ended up paying more as a result than they would have if they had seen an in-network provider. In an emergency, when customers might not be able to select the supplier, this is very typical.
A client may receive treatment from out-of-network providers at a facility even if they go there. In many instances, the out-of-network providers may charge patients the difference between the fees they billed and what was covered by their health plan. This practice is called balance billing. A surprise bill is a balance that appears out of the blue.
The No Surprises Act under title I and Transparency under title II are just two of the many measures in the Consolidated Appropriations Act of 2021 that assist shield customers from unexpected bills. This law was passed on December 27, 2020. Learn more about consumer protections, anticipating prices to avoid unpleasant surprises, and what happens when disputes over payment develop after obtaining medical care.
What are the new protections if I have health insurance?
If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.
Are there exceptions to these protections?
These protections don’t apply in all situations.
Policies are crucial since they outline what is and isn't permitted within the healthcare industry. They will make sure that all actions conducted within the healthcare provider are done so that the organization may reach its goals if they are created properly. They can assist in determining the type of work they do, the types of jobs they won't do, and the values they uphold. Policies are created to improve the situation of the healthcare sector. When properly followed, it will assure productivity and prevent problems that could affect patients as well as healthcare providers. If you feel wronged or in an unjust situation. Feel free to visit the CMS website at https://www.cms.gov/nosurprises/consumers
Ending surprise medical bills. CMS. (n.d.). Retrieved January 2, 2023, from https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills
Are you passionate as a midwife to offer breastfeeding support? All midwives want the best option for feeding a baby. Consider the profitability options for breastfeeding visits. You can either bill to insurance plans a home visit for breastfeeding or office visit. With the Affordable Care Act, most insurance plans cover breastfeeding visits one hundred percent (grand fathered insurance plans rarely cover this service – do a verification of benefits before providing any care to women and her babies to let you know what is covered by her insurance plan and what is a cash option for services with your practice). The insurance reimbursement for 30-60min visits range from $90-250 depending on billing codes utilized.
Breastfeeding support can be marketed with benefits of breastfeeding stressing both newborn and mother aspects. Newborns have lower chance of obesity, sickness, allergies, automimmune conditions, and diabetes with prolonged breastfeeding. Mother’s metabolism is actually higher with breastfeeding than pregnancy (demand of extra 500 calories/day versus 300 calories/day). Longer mother breastfeeds decreases her chances of breast and ovarian cancer, obesity, diabetes, heart disease, and depression. Cost savings alone from breastfeeding compared to formula can be part of your marketing tactic.
Breastfeeding support can be focused on availability for problem visits. I like to stress marketing in a direction of prevention and education. Create breastfeeding educational topic timelines:
*Prenatal prep for initial latch techniques, skin to skin when baby is born, advocating for yourself and baby in the immediate postpartum period. Women can be taught about breast pumps and how to get one prior to baby’s arrival.
Find out the needs in your area. Are there any support groups for women to attend for breast feeding? There are billing codes that cover the midwife offering these services. Prenatal and postpartum breastfeeding classes including support groups would be billing code S9443 (Lactation Classes, Non‐Physician Provider, Per Session). Office visits with Certified Nurse Midwife would be 99201-99205 new patient depending on time spent with pt (10-60min). Established patients would be 99212-99215 depending on time (10-60min). Your note for visit needs to stress more than 50% of visit was spent counseling and write exact time spent in front of patient.
Home visits are paid if patient’s insurance plan has home visit coverage. Those billing codes are 99341-99345 for new patients and 99346-99350 for established patients depending on time spent and complexity. Code 99404 can be used if a Lactation Consultant is seeing patient in your office. Short and long term benefits to community of supporting breastfeeding need to be promoted. Having a financial backing to your cause only makes it that much sweeter!
The fee schedule defined by the Centers for Medicare and Medicaid Services (CMS) is a complete list of charges for health care services on a fee-for-service basis. Fee schedules play a critical role in reimbursing practitioners for clinical laboratory services, durable medical equipment, ambulance services, prosthetics, orthotics, and other supplies.
Understanding the breaking point between discount and making a profit, setting a defensible fee schedule helps in overcoming many problems. Updating the fee schedule every 3 to 12 months is mandatory so that you are not missing out on revenue. The updated fee schedule will keep up with market dynamics, such as your liability insurance rates and patient volume, by cross-checking with private and public payers to avoid any glitches.
How to decide the fee schedule?
First and foremost, a self-cost study or hiring a consultant to account for every cost is essential. It is so much so that you have a reasonable margin to reinvest in your clinic. Perhaps the simplest way is to break down your cost and margin into hourly units of work. It is essential that your service includes a list of all overhead charges, margins, and the actual charges. For instance, the fee for a flu shot should contain nursing staff’s pay, a fraction of the rent, insurance premium, electricity bill, your take home pay, and a fraction of the cost of an upcoming x-ray machine.
It is important that your fee schedule ensures that you stay in business using the Centers for Medicaid and Medicare services on the resource-based relative value scale (RVUs) plus your expense. RVUs are relative values, so every code is multiplied by the conversion factor to get a fee schedule. Once the total cost is calculated, list every CPT code to your practice bills, excluding the ones w/o an RVU. Figure out the RVU for every code, practice expense & liability, and practitioner’s work RVU. Next, with the total cost and total RVUs billed each year, allocate a dollar value to each RVU. Finally, multiply each RVU cost factor with the RVU per code to have a fee schedule. If you choose to create a fee schedule on the hourly rate, calculate how much time each service takes. After the calculation, you get an idea of what others are charging without breaking antitrust laws.
Having Accurate Fee Schedules to Reflect Your Services Being Billed to Insurance Plans
Accuracy of your Fee Schedules helps you bill insurance companies faster and easier. Fee schedules are confidential information. Insurance companies often have strict policies about disclosing this document to anyone but the provider named on the contract. Fee schedules cannot be shared between providers. If you share the fee information with patients, don't share the entire fee schedule. You can tailor the information to your patient by only sharing the CPT codes and associated cost to their treatment.
You can request the fee schedule from your insurance company if you have not received it. This is similar to requesting a contract. We recommend that you request both your contract and the fee schedule from the insurance company if you're also missing them. Fee schedules are usually only available to contracted providers. If you have not been credentialed with insurance companies, you won't be able to see their fee schedule. This depends on the policy of your insurance company. It is possible for a credentialed provider to access your fee schedule online. You could then call the insurance company to request it.
It is essential to know your fee schedule in order to run a successful practice, particularly with the implementation of the No Surprises Act. The best tools for providing accurate estimates to patients are your fee schedule and eligibility checks. Our article on the No Surprises Act provides more information about good faith estimates and compliance to the new law.
A copy of your fee schedule is very helpful so you can confirm that you are being paid the correct amount by your insurance company. It is helpful to have a copy of your fee schedule in order to submit claims and provide information for benefit checks. To determine how much a patient would owe for coinsurance, you will need to have a copy of your fee schedule. This is because the contracted rate is used to calculate the amount.
You can use information from your fee schedule as a practice owner to project revenue. This method is more accurate than an aging report because it shows the actual cash value of each session, not the contracted amount. To project income for your practice, you can either use the fees schedule numbers or set goals on how many sessions you will need in a given time period to achieve a certain income level. If you feel lost, make copies of your fees and contracts, you might be ready to set up a consult with us to see if we are the right fit to work together!
Practice Solutions, L. L. C. (2022, March 29). What is a fee schedule? practice solutions llc. Retrieved November 29, 2022, from https://www.practicesol.com/single-post/what-is-a-fee-schedule#:~:text=It%20is%20 extremely%20 helpful%20for,company%20 according%20to%20your%20 contract.
What is the fee schedule in medical billing? Revenue Cycle Management. (n.d.). Retrieved November 29, 2022, from https://www.caplinehealthcaremanagement.com/what-is-the-fee-schedule-in-medical-billing/#:~:text=It%20is%20 important%20that%20your,to%20get%20a%20 fee%20 schedule.
Insurance reimbursement is the bread and butter of many midwifery practices. If you have a cash paying only population like Amish or Mennonite home birth practice, you can just skip this posts. For the rest of the midwives out there needing to understand this confusing health insurance game, continue reading. Medical expenses are a huge burden for Americans and to be able to run your practice long term successfully, you will need to learn this system.
Insurance reimbursement is the bread and butter of most midwifery practice. If you have a cash paying only population like Amish or Mennonite home birth practice, you can’t just skip this posts. My resources are available for the rest of the midwives out their needing to understanding this confusing health insurance game. Medical expenses are a huge burden for Americans and to be able to run your practice long term successfully, you will need to learn this system.
The goal of this blog article is to help with basics of billing and coding. We will do further posts about details of different aspects of practice and insurance billing. There are billing codes (CPT codes) that are sent to an insurance company for services rendered by a CNM and her team. The diagnosis code applicable with CPT codes are needed to be attached to the claim.
Verification of benefits is strongly recommended prior to seeing a patient to make sure coverage for service being offered are covered, no prior authorization is needed for services, and what level of patient financial responsibility for care is warranted. Does today’s visit go towards deductible, co-payment, or co-insurance? Is it covered completely even if deductible isn’t met due to the Affordable Care Act? Will the insurance plan cover a birth with a CNM, but only in hospital setting versus home? Is the midwife in network or out of network with insurance plan? If out of network, does insurance have out of network benefits (called a PPO plan). HMO listed on the card states only in network provider coverage. These are all examples of really important questions to ask when checking into an insurance plan.
You can directly do your billing, hire a Billing Specialist as part of your team, or out source the Billing Services. Each one has pros and cons. With a small midwifery practice, it does make sense to directly do your own billing for care. You would directly know the services rendered, be in charge of how quickly claims are sent out and paid by insurance plan and patient, and not have to pay additional commission to billing staff or agency. Downside is billing and coding is a complicated system and many providers would rather care for patients and not deal with billing regulations and jargon involved.
Having someone in house is cheaper if the practice is large enough to support the employee costs. With having a smaller practice, paying a commission for services actually paid for with a billing agency makes the most sense.
I have always liked using a Electronic Health Records (EHR) system that is a one stop shop for resources for my practice. Having an EHR system that does your billing for you is really helpful. Athena Health has been my “go to” system for years. I have been really impressed with their small practice customization. I can use all or none their administration services like billing, charting, appointment reminders, scheduling, patient portal, e-prescribing, lab and imaging ordering, and electronic referrals to specialists.
There is no up front costs and they are paid when I get paid. It is a great option when there is little start up funds for practice and long term knowing that the EHR system will continually try to improve their services. If I don’t get paid, they don’t get paid. WIN-WIN!
Youtube video: https://www.youtube.com/watch?v=jUZuJrrGcOo
Tips For Appealing Midwife Claim Denials
A health insurance denial happens when your health insurance company refuses to pay for something. If this happens after you've had the midwifery service and a claim has been submitted, it's called a claim denial. Insurers also sometimes state ahead of time that they won't pay for a particular service, during the pre-authorization process; this is known as a pre-authorization--or prior authorization--denial. In both cases, you can appeal and may be able to get your insurer to reverse their decision and agree to pay for at least part of the service you need. There are literally hundreds of reasons a health plan might deny payment for a healthcare service. Some reasons are simple and relatively easy to fix, while some are more difficult to address.
Why Would a Health Insurance Claim Be Denied?
A health insurance company may deny a claim for many reasons, including:
As a maternity care provider, claim denials are pain in the butt. Even practitioners who take precautions to avoid insurance payment pitfalls sometimes find themselves faced with a claim’s denial. Handling denied insurance claims can be a frustrating, time-consuming and complicated process for practicing psychologists and their administrative staff. Knowing some basic strategies for resolving claims denials can save practitioners time and improve their practice’s cash flow. Some basic pointers for handling claim denials are outlined below.
1. Take the time to review all notification regarding the claim Although it sounds obvious, this is one of the most critical steps in claims processing. You should carefully read any notification you receive from an insurance company about a claim. Notifications should state whether the claim has been paid in full, partially, delayed or partially. If the claim is deemed "unclean" or contestable, the carrier will provide instructions on how to resubmit the claim with any missing or corrected information. In the event that the claim is not paid in full or denied for any reason, the notification must state the reasons and the procedures and documentation needed to resubmit or appeal the claim.
For more information, contact the carrier if the notification is unclear. You may discover that the claim was incorrectly adjudicated by the payer, in addition to the stated reason for denial. It is possible that your submission processes do not meet the requirements of the payer. However, you may be able to make simple changes to improve your claims submissions.
2. Be persistent
If you feel the insurance provider has wrongfully denied your resubmitted claim, you can appeal. You should be clear about what information you must include with your appeal. Keep in mind, appeal procedures can vary depending on the state law and insurance company.
An explanation of your appeal and any supporting documentation such as a copy of the claim, and copies of communications to the company regarding the matter, should be included in your appeal. Additional information may be required to prove medical necessity if your claim is denied. It is important to comply with your obligations under the Health Insurance Portability and Accountability Act, (HIPAA), to protect psychotherapy notes and provide only the "minimum required" information.
Sometimes, you may have to submit the claim again or appeal multiple times to reverse an insurance company's decision. But don't lose heart. The insurance company will appreciate your persistence in resolving the issue and getting paid.
3. Don’t delay
It is crucial to submit and resubmit claims within the deadlines specified by the company, or any applicable laws in your particular state. If you don't, your claim could be dismissed based on information already provided.
4. Get to know the appeals process
Make sure to familiarize yourself with the appeals process of your carrier before you file an appeal. You will be better equipped to respond to your carrier's actions if you have a good understanding of their policies. You should keep current information about the appeals and claims adjudication processes for every carrier you work with. This information is often available on the websites of carriers. If applicable, you should also keep hard copies of it whenever you sign a contract.
5. Maintain records on disputed claims
Keep a written record of all information that you receive from an insurance company regarding a claim. Also, make sure to include the name and contact information of the representative you spoke with. This information should be kept with key information about your claim such as the reason the claim was delayed, partially paid or denied, the actions taken by your office to follow-up on it, and the final outcome.
These records could be used to help you in the future, whether it is to appeal to higher levels or to complain to the state insurance commissioner. These records can be used to help your office avoid or resolve future claims denials.
6. Remember that help is available
Although handling claims denials is frustrating, it can help you save time and money by alerting to the expectations of the insurance companies you contract with. You may be able to reduce rejections and denials by ensuring your billing procedures conform to the requirements of the company. If you have any reimbursement issues with an insurance company, please contact your state insurance commissioner for assistance.
Insurance denials are very frustrating. It will give a huge impact to your practice if you are not mindful enough of every action you take. But it is preventable if you collect the right information and verify it thoroughly.
American Psychological Association. (2005, March 1). Six tips for handling insurance claim denials. https://www.apaservices.org. Retrieved November 28, 2022, from https://www.apaservices.org/practice/business/finances/insurance-denial
Martin, E. (2022, November 16). How to appeal a health insurance claim denial. Forbes. Retrieved November 28, 2022, from https://www.forbes.com/advisor/health-insurance/appeal-health-insurance-claim-denial/
Insurance billing can be daunting with running your own midwifery practice. It is easy to bill for services with cash, but many families are very dependent on getting their insurance to pay for care. Especially maternity and newborn care since the Affordable Care Act legally requires insurance companies to cover preventative care.
Midwives that deliver in the hospital typically don’t do newborn care (pediatrician on call covers that service). Even though it is part of the CNMs scope of practice to care for babies first month of life, most in hospital practices don’t provide that aspect of care. Out of hospital birth practices, midwives typically do the newborn care (especially the initial newborn exam). How is billing for babies done? Do all insurance companies reimbursement midwives for that service?
Most insurance companies are easy to bill for newborn care. CNMs are recognized with most insurance plans as a covered provider for that service. I have had a couple plans state as denial reason “not covered provider type.” That is part of importance in thorough verification of benefits (VOB). I have trained my staff to ask VERY DETAILED questions to insurance reps if a phone VOB is done. They don’t just ask maternity care coverage with plan. We state, “Does this plan cover a CNM in the home setting for delivery care?” “Does this plan cover an independent Certified Nurse Midwife for newborn care codes 99381 or 99391 in the home setting?” There are some plans that won’t cover a midwife not working under a physician, newborn care in the home setting, or home visit codes for these services like 99349.
Available billing codes for newborn services revolve around screenings and care offered in the first month of life. Our practice offered the vaccinations to families. We gave the Hepatitis B vaccination at the birth center prior to discharge if families desired it. We billed to insurance companies codes 90744 (Hepatitis B Vaccination) and 90471 (immunization injection). Some families wanted eye ointment and vitamin K injection given. Those billing codes were J3490 (erythromycin eye ointment), J3430 (vitamin K injection), and 96372 (IM injection).
Newborn assessments are vital to make sure baby is transitioning well to life outside its mother. Don’t you want to get paid for all your valuable being provided? You have two patients in the postpartum recovery period, make sure you are getting reimbursed for everything you are doing. Initial newborn exam billing code is 99381. Repeat exams 99391. If it is done in the home setting, some insurance companies want you to bill a home visit code and others want the initial newborn screening placed in home setting on claim paperwork. I would usually do 99350 for initial exam and then 99348 for subsequent home visits during postpartum care when insurance plan wanted home visit codes submitted.
Make sure families are aware that coverage level is different for preventative codes like newborn exams versus home visit codes. Many insurance plans don’t have home visit coverage. If coverage present, it may be a co-payment or completely count towards their deductible versus newborn exam codes being covered 100% in the office.
I have had families drive to office for 24hr postpartum exam versus me coming to the home purely because their insurance had no home visit coverage, but would cover a newborn exam 100% in office setting. Families should have a right to know their coverage level and be given options of your services based on what their insurance coverage is actually like.
Newborn hearing screen and newborn metabolic screening (state mandated in many places) are covered 100% by insurance plan. You can refer families out to local resources lab or audiology to complete these screenings or offer them as part of your services. Hearing screen code is V5008 and metabolic screen is 83516. Capillary sample collection billed in conjunction with metabolic screen is 36416.
Another state mandating testing in Michigan is pulse oximetry reading on newborn. That code is 94760. Some insurance plans will recognize all these subset screening codes and others won’t. Unfortunately when most babies are born in the hospital, many of these services are bundled with the hospital facility or nursery charge placed to insurance companies.
Newborn care is very important part of a midwife’s job. Being able to have another revenue stream come into your practice from those services that many people a Pediatrician can only do, really helps your bottom line of business success. I had an average extra $500 from each family’s care come into the practice by performing those newborn exams first month of life.
It was also great to keep the baby’s out of a sick doctor’s office and let mother and baby truly stay home the first few weeks after delivery. Last thing a recovering mother and baby need is getting out into Michigan winter to get all those check ups completed.