Few things more frustrating than discovering your AHCIP medical billings have been rejected. Equally frustrating is discovering your submitted billings were underpaid for less than the accurate amount. Correcting these errors can be time consuming and exhausting and as we’ve documented previously, many physicians experience lost revenue from inaccurate medical billings.
Alberta medical billings can be complicated, but we’ve documented 5 simple tips to reduce your rejections and improve your billing results. Make these tips habits, and over time, these habits will help you capture significant lost revenue. Let’s jump in.
In our experience, invalid health care is the one of the biggest sources of Alberta medical billing rejections. Checking for the correct healthcare number will ensure the claim is sent to the correct insurance payer to be paid. Each patient in Alberta is issued with a Unique Lifetime Identifier (ULI). For patients with AHCIP insurance coverage, this ULI will match their Alberta Personal Healthcare Number (PHN). For out of province patients (OOP), the ULI and PHN will be different.
Different health regions display these numbers in different ways on the patients stickers, so it is important to familiarize yourself with what you are looking for. Here are three possibilities:
1. Showing PHN with Province – Some Alberta health regions show the PHN and the patient’s home province on the sticker.
2. Showing ULI with Province – Other health regions show only the ULI number with the patient’s home province. If AB follows the ULI, then you have an Alberta PHN. If it’s a different province, you have an out of province patient, and you must look-up their OOP PHN on Netcare.
3. Showing ULI only – On the newly released Connect Care stickers, only the ULI is shown, so physicians must look up every patient on Netcare to find the patients province of insurance.
If the patient has no provincial health care coverage, you will need to submit via non-provincial health coverage. This could be Workers Compensation Board (WCB), Department of National Defense, refugees, prisons or private insurance coverage. Note that the Alberta government recently removed Good Faith claims that allowed physicians to bill for presumed Alberta residents not yet enrolled in AHCIP.
There are many restrictions on how AHCIP medical codes can be billed. Make sure you submit claims with all the required information and avoid conflicts
Include the correct functional centre – Certain medical billing codes can only be claimed with specific functional centres. For example, AHCIP code 10.04B – Intubation performed in an emergency room may only be claimed when performed in the emergency room, function centre AACC or UCC. If you submit a 10.04B code with different functional centre, the claim will be rejected.
Avoid fee code conflicts – Certain medical billing codes can not be claimed with other medical billing codes. For example, AHCIP code 03.08CV – Comprehensive consultation via telephone or secure videoconference may not be claimed on the same day by the same physician for the same patient as other telephone/videoconference codes (03.01AD, 03.01S, 03.01T, 03.03CV, 03.03FV, 03.05JR, 08.19CV, 08.19CW, 08.19CX)
Correctly use of premium modifiers – Premiums modifiers increase the value of a AHCIP codes and and they are an important part of correctly optimizing your claims. But invalid use of a premium will result in the claim being rejected. For example, if you work at 1730 on a Wednesday and add a weekend (WK) premium modifier, the claim will be rejected. Only the correct evening (EV) premium modifier will be expected and allowed.
Include referring physicians – All consultations require a referring physician to be indicated on the claim. If you miss providing the referring physician, your Alberta Health medical billing claims will be rejected.
Tracking your time is one of the most important habits you can build to improve your billings. A 2019 study of physician billing in Canada highlighted time premiums as some of the most commonly missed billing codes [link to blog post]. Recording precisely how much time you spend with a patient will allow you to ensure your claims are accurate. Here’s how you can use time records with your AHCIP medical billing:
After hours time premiums – There are 4 after hours time premiums Alberta physicians apply to their medical billings. These premiums can be added to claims for services performed during the relevant time periods.
NTAM (Night time AM) – covers 0000 – 0700 for everyday of the week
NTPM (Night time PM) – covers – 2200 – 2400 for everyday day of the week
EV (evenings) – covers 1700 – 2200 for weekdays
WK (weekends) – covers 0700-2200 for weekends and Statutory holidays
Be careful to use the correct after hours time premium during the applicable period. If you submit an after hours time premium that is incorrect, even if a different equivalent after hours time premium is applicable, the claim will be rejected.
Complex modifiers – Complex modifiers are used to indicate a complex patient consultation or visit requiring that the physician spend above a certain number of minutes or more on management of the patient’s care. These include CMGP, CMXV15, CMXV20, CMXV30, CMXV35, and CMXC30. Note the total time you spend on the patient’s care is applicable (not just the time you spend with the patient), but you have to use them on the same day your patient was seen. Each modifier is restricted to use with designated AHCIP billing codes, so check to see which complex modifiers are applicable. Accurate record keeping is essential to documenting how much time you spent with each patient to ensure the correct complex modifier can be applied.
Regardless of improving your billings, the Alberta Medical Association billing advice recommends that when billing any time based codes physicians should record (at a minimum) the start and end times of their work for that day. Physicians should also note any non-working period during the day. Other advice can be found here (https://www.albertadoctors.org/services/physicians/compensation-billing/billing-help/billing-tips/documentation-PCA-billing-tip)
Despite diligently following all the advice above, AHCIP rejections are going to happen. Rejections can arise from entry errors, submission errors, requests for further documentation, or even assessment errors by the insurance payer. It is important to promptly address rejections, particularly following the Alberta Government Schedule of Medical Benefits changes, which have reduced the applicable window to resubmit claims.
AHCIP mails physicians Statement of Account and Statement of Assessment reports that include error codes. These reports detail which of your claims have been paid, underpaid, or rejected. These statements include Alberta health billing explanatory codes. Each error code corresponds to a description that can be looked up to know what the code means.
Rejection management can be the most time consuming and painful parts of physician billing, but it is important to getting all your billings paid. Failure to properly manage medical billing rejections will result in significant lost revenue over the long term – so make sure your biller is following up on rejected claims. If a claim hasn’t been paid, make sure there is a valid reason.
For Statgo clients, we handle all rejections and resubmit them for you. We believe in total transparency. You should know where every claim is and what is being done to get it processed and paid. You can use the Statgo app to track claims and view explanatory codes for all underpaid and rejected claims. You can follow all actions taken by agents to resolve rejected claims. If further input is required from you to get a claim paid, we will send you a note detailing what we need to get the claim paid.
Physician medical billing in Alberta can be complicated and frustrating, but watching out for these tips and developing them into habits will help ensure you get paid accurately.
Our last tip: The ability to follow all your claims as they are processed is a big help in understanding what’s getting paid and what isn’t. Following your claims is a great way to learn more about your billings and avoid errors that result in unpaid claims. Make sure your biller provides you with transparency to all your claims. If you use the Statgo app, you can view all your claims, their latest status, and all follow-up activity by Statgo agents on rejected claims.
If you have any other questions, tips or input, we’re happy to hear from you! Reach out to our billing team and we’d be happy to help.
