Month: April 2025
Billing Tips by “Physicians Practice”
- Correct Data Entry and Demographics at Check-in
Accurate data entry during patient check-in is critical. Gathering complete insurance and demographic information helps ensure proper billing and reduces potential claim denials. Make sure you always collect a photo of the patient’s insurance card, and most importantly, a photo of the back of the card. The back of the card is often more important for billing than the front.
2. Understand Your Insurance Payer Contracts.
Knowing exactly what your contract allows in terms of reimbursement rates, covered services, and billing guidelines helps prevent underpayment or denials.
3. Accurate Coding of Symptoms vs. Diagnoses.
Use the appropriate diagnosis codes for billing, avoiding the use of symptoms as primary codes. Insurance companies typically require specific diagnoses for proper reimbursement.
4. Frequent and Proactive Denials Management.
Actively follow up on denied claims and address the issues promptly. Letting accounts receivable (AR) build up can lead to financial complications and decreased revenue. Analyzing denial patterns, rectifying errors, and resubmitting claims correctly are essential steps. In particular, don’t leave denial follow ups to biweekly or monthly batched processes. The best practice is to build denials into your standard, weekly claims, and payment posting processes. In addition, the first time you receive a denial, your billing team should call the insurance payer to understand the reason behind the denial. This way, you can prevent the same error from occurring in future claims
5. Thorough Documentation.
Maintain detailed and accurate medical records for each patient. Poor documentation not only affects patient care but can also lead to audit risks and billing disputes. Proper documentation is not only required under your insurance payer contract but also required as a part of your state license as a health care practitioner.
6. Proper Secondary (2ndary) Insurance Filing.
Understand the proper procedures for filing claims with 2ndary insurance. Know the coordination of benefits (COB) and which insurance is the primary one. Often, the patient may not even be clear as to which is the primary. Have the patient contact their insurance payers and verify the primary and 2ndary insurance. Secondary payers often require physical documentation of the primary payer rejecting the claim first and this explanation of benefits (EOB) must sent along with the claim.
7. Medicare Billing Compliance.
Follow the guidelines set by Medicare’s Local Coverage Determinations (LCDs) when billing for services. Noncompliance could lead to denied claims and financial penalties.
8. Access to Insurance Portals.
Ensure you have access to the online portals of all insurance providers you work with. This will help you track claims, check eligibility, and communicate efficiently.
Superior: New Availity Claim Features and Webinars.
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Superior: Appeal Submissions
IMPORTANT: Post-Service Medical Necessity Appeal Submissions
Superior HealthPlan would like to remind providers that post-service Medical Necessity Appeals must be mailed or faxed using the submission information below. Submissions must include the reason for appeal and any additional clinical information for appeal review..
Centene Management Company
ATTN: Medical Management Appeals
5900 E. Ben White Blvd
Austin, Texas 78741
Fax number: 1-866-918-2266
Post-service appeals for reconsideration of a Medical Necessity Denial on behalf of a member should not be sent to the Claims Appeal address.
For questions about post-service Medical Necessity Appeals, providers can contact 1-877-398-9461.
Submit 2024 MIPS Data by April 14th
The data submission period for Medicare’s 2024 Merit-Based Incentive Payment System (MIPS) performance yeard has been extended to April 14th at 7 pm CT.
At Stake is a pay cut of up to 9% in the 2026 payment year.
Prior Auth for Certain Sleep Studies, No Longer Required by Superior as of April 1, 2025.
For all Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter from Superior HealthPlan members, Superior will no longer require prior authorization for the following Current Procedural Terminology (CPT) codes:
For Medicaid, CHIP and Ambetter members 17 years of age and younger, Superior will no longer require prior authorization for the following CPT codes:
Aetna Fee Schedule Update Effective Today
However, Aetna tells POET the fee schedule is not ready for them to send out, yet.
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