Improving your billings - Statgo

If you’re going to bill correctly, you need to know what you are eligible to claim. Keep these general rules in mind. Billing codes have compatibilities and incompatibilities – codes that can or cannot be billed together or in certain combinations. If you do bill these together, your claim can be rejected. Procedures also have maximum time units and procedure units. If you go above these, your claim will be underpaid. Lastly, and in our experience the largest error category, is missed modifiers. Correct application of modifiers is key to improving your billing outcomes.

Part of knowing the rules is knowing the submission timelines. It’s simple, but we’ve seen big losses because physicians didn’t submit their billings within the allowable claim timeframe. These time frames apply when resubmitting rejected claims as well, so make sure you (and your biller) don’t get behind on paperwork.

Insurance plans aren’t trying to make this easy – billing rules are complex, differ by insurance payer, and are changed regularly. Use available resources to ensure you are following the most up to date rules. The Alberta government issues bulletins, detailing rule changes, code removals and new codes on their website https://www.alberta.ca/bulletins-for-health-professionals.aspx. The Alberta Medical Association provides a useful fee navigator https://www.albertadoctors.org/fee-navigator that allows you to look up codes and their associated applications. Other payers, including Alberta WCB, provide fee schedules on their websites.

Claims get rejected. Depending on your specialty and practice type, up to 5%-10% of claims get rejected on first submission. This can be caused by code incompatibilities, supporting text requirements, supporting report requirements, and errors made by insurance payers. (That’s right – insurance companies make mistakes!). Rejected claims need to reviewed and resubmitted promptly and within the allowable submission timelines. Many physicians underestimate losses from rejected claims – and their biller may not provide the transparency to see the rejections claims and/or reason. It takes extra effort to get rejected claims paid, so make sure your biller is doing that work.

Not all billers are the same. A biller that knows the rules and diligently follows up on rejected claims will improve your billing outcomes. The improvements are not insignificant. In our experience, we can improve physicians billing outcomes by 2%-10%. The average Alberta based specialist earns over $400,000, so this equates to $8,000 – $40,000 in additional earnings.