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Inus Solutions
An Extension Of Your Business
We + DME/ HME Providers = Pioneers in
Outcomes-Based Billing
Private and Confidential
Extend Your Team through INUS
If you have better things to do other than reading lengthy Medicare Billing manuals, our range
of DME billing service can help. If you are talking to yet another customer service person
asking why your claim has not been paid, let us help.
It’s our mission to help respiratory equipment providers and other DMEs prosper in the new
era of value based care. Our experts helps you to handle the Patient and Payer
Authorizations, Verifications, Billing, Coding, Cash Posting and Collections, who are available
24/7 to meet your needs.
Private and Confidential
DME Billing Service Overview
Inus billing team has experience processing claims in the following areas:
Oxygen and Respiratory Equipment
PAP (Positive Airway Pressure) – CPAP / BIPAP
Enteral Nutrition and Parental Nutrition
Mobility Equipment
Wheelchair-Scooter
Diabetic Supply & Diabetic Shoes
Major areas on which several check points been initiated are
Pre-Coverage Criteria Appropriate usage of Codes Sales Order Entry
Verification of Delivery Ticket, Purchase Order, AOB, Physician Order ( Accurate CMN and/ or
Prescription, Title XIX, Detailed Written Order ) on File before the submission of each and every
claim
Reduces 35 % of the Denials
Private and Confidential
Eligibility Verification
& Initiate
Authorization
Fast & Immediate EV
response & along with
Same-Or-Similar check to
make sure the Medicare
Patient hasn’t received the
product recently.
Authorization is duly
initiated for commercial
payers. If the Patient is not
eligible , or had similar
product recently, or
authorization not on file, the
first trigger point comes into
play.
Sales Order Entry
The second trigger point
comes into play at the time
of entering a Sales
Order, when Certificate of
Medical Necessity (CMN) or
DME Information Form
(DIF) is invalid. An
immediate escalation would
be sent to the provider to
stop order delivery or
confirmation if data is
missing, delaying claim
submission until valid
document is available.
Documentation Audit
After successful
EV, Benefits and
Authorization initiation, there
is the third trigger point
indicating the manual run or
check point on DT, CMN
and/or Prescription or
DIF, Sleep Laboratory and
Polysomnography Report
whichever required for the
case before claim
submission.
Three Tier Trigger Points
Private and Confidential
Gap Analysis Between Pre Inus and Post Inus
1.82
65%
0.5
18%
0.31
11%
0.17
6%
Collectible AR 90+ days -Total Value $2.8 Million ( Federal Payers )
CO 50, CO 4
CO 151
CO 96
Others
Pre Inus
Major Denials
Note : Pre Inus, the Client had a lot of AR piled up in 360+, about 65 % of AR was in 90+. After analyzing
found CPAP is most frequently billed item. Out of the 65% in 90 + days, the major denials had been
segregated with appropriate percentages as shown above.
Private and Confidential
Invalid Diagnosis Code
Missing Documentation
Invalid Capped Rental Modifiers
CO 50
CO 4
Same/Similar ProductCO 151
CO 96
Non Covered Items
Causes for Denials
327.23 for CPAP and 327.27 for BIPAP
should be appropriately billed
Delivery Ticket, Initial face to face evaluation
notes , CMN, PSG, Detailed written order, Face to
Face Re-evaluation notes, Titration test
report, Compliance report and Plan of Care. All
the above documents should be mandatory on file
to avoid any suspension or VOID during Medicare
RAC audit .
For the 1st month rental claim should be billed
with RR, KH, KX. 2nd & 3rd month claim should
be billed with RR, KI, KX. From the 4th month
and for rest of the months claim should be
billed with RR, KJ, KX.
A equipment can be replaced only once in every
5 years. Henceforth the denial occurs If the
patient had acquired same or similar equipment
during the course of time. A complete and
thorough verification needs to be done during EV
stage to emphasize on accurate billing.
An effective HCPCS payer mapping, GA
modifier and ABN validations needs to be
done to avoid these denials on a longer run.
Precautionary Measures
Private and Confidential
Blue Cross versus Other Commercial Payers
Blue Cross Other Commercial Payers
Horizon NJ, IL pays 3 months rentals with
compliance for CPAP and 4th month as
Purchase.
UMR pays 2 months rental and 3rd month as
Purchase.
Generally other state plans of Blue Cross pays
10 rentals for CPAP.
Aetna will pay only as Rental for CPAP and will
pay for 10 rentals.
KX modifier is must when we file for CPAP to
BCBS of NJ.
For all commercial payers, Authorization is
mandatory for PAP and Oxygen & Respiratory
equipments.
The DME provider must participate with the Blue
Plan in the state where the DME supplies are
being purchased or shipped in order to process
at the In- Network level of benefits.
Most of the commercial payers pay humidifiers
as Purchase when we bill with NU modifier.
Horizon NJ does not accept 3 months supplies. Few Commercial payers pay CPAP/BIPAP as a
straight away purchase unlike Blue plans or
federal payers.
If the state plan pays CPAP only for 3 months
rental, then we need to bill the 4th month as
Purchase along with Authorization.
Coventry pays PAP for 15 month rentals.
Private and Confidential
Impact of trigger points on denials
How trigger points arrest major federal denials ?
First trigger point: Once the provider prescribes the equipment, the account will be immediately
forwarded by the front office executives to our EV team. Our Eligibility
Verification team needs to undergo three level check points under the first
trigger successfully for the Provider to do further follow up on the particular
patient.
Eligibility inclusive of coverage on supply items.
Same or Similar Check for Medicare Patients.
Authorization check on file for Commercial Payers.
If any of the above check points is not met i.e. Patient not Eligible / Patient had
same or similar product recently, immediate trigger will be escalated to the
Providers office.
Arrest majority of CO 151 and CO 96
denials
Second trigger point:
Arrests majority of CO 50 denials
After necessary EV and Authorization engagements, our front end billing
personals need to undergo three level check points under the second trigger
before forwarding the essentials to the Claims transmission team.
Validate CMN / DIF on file.
Authenticate Delivery Date or Date of Service (DOS) not to precede the
“Initial Date” or DIF or the start date on the written order.
Validate the medical necessity of the item billed by ensuring the Delivery
Date/Date of Service to be within 3 months after the “Initial Date” of the CMN or
DIF or 3 months from the date of the physician’s signature.
Private and Confidential
Third trigger point : Why CO4 denial occurs? The major reason behind this denial is due to missing
capped rental modifiers.
How? This majorly occurs in the fourth month rental and usage of KJ modifier.
After first 3 months rentals, our billing personals undergoes two mandatory
check points under this trigger before forwarding the essentials to Claims
transmission team.
Face to Face Re-evaluation notes.
Compliance report.
The above check points needs to be met before the Claim is transmitted with
KJ & KX modifiers for the fourth month rental and for rest of the months.
Eliminates CO 4 denials for the last 8
months
Brings down CO 50 to the minimal
Other federal denials which are kept in check :
CO 173 – No CMN on file
CO 176 – Invalid CMN / Prescription is not current
PR 16 – ABN modifier
CO 97 – Inclusive / Patient in SNF
CO B15 – Patient in Hospice
Private and Confidential
Gap Analysis Between Pre Inus and Post Inus
Post Inus
Collectible AR 90+ days -Total Value $1.1 Million
0%
5%
10%
15%
20%
25%
30%
35%
CO 4 CO 151 CO 50 CO 96
Pre Inus
Post Inus
With the use of three tier trigger points, AR aging was drastically reduced, especially 90+ AR days was brought down from
65% of total AR to 15 % ( Value of $1.1 Million ) in the last eight months. One of the major denial CO4 (Invalid Capped
Rental Modifier) was totally eliminated and the other major denial CO50 was brought down to minimal during Post Inus
period. HCPCS Payer Mapping played a significant role in reducing Non coverage denials.
Private and Confidential
Enteral Nutrition
Two major billable codes are B9000 (Enteral Nutrition Infusion Pump – Without Alarm) and
B9002 (Enteral Nutrition Infusion Pump – With Alarm)
Collectible AR 90+ days – Total Value $2.2 Million ( Federal Payers )
32%
21%
17%
11%
CO 50/ Remark Code N115
CO 151/ Remark Code N362
CO 176
CO 109
Major Denial Codes
Above percentages were derived through Pre Inus aging reports. Also note that Claims can be denied for multiple
reasons therefore the percentages of reviews may not add upto 100%. Based on review of the report received, the
following are the primary reasons for the denial.
Clinical Documentation Issues
Detailed Written Order Issues
DME Information Form (DIF)
Private and Confidential
Detailed Analysis behind primary reasons
DME Information Form (DIF)
6 % of the denied claims were missing a DIF. 1 % of the denied claims were missing Enteral Pump
HCPCS Code on the DIF.
Detailed Written Order Issues
16 % of the denied claims did not include a detailed
written order.
8 % of the denied claims had date of the detailed
order was incomplete / physician signature could not
be authenticated.
Clinical Documentation Issues
26 % of the denied claims did not have any medical
record documentation submitted.
17 % claims had insufficient clinical documentation
to justify the LCD criteria.
Apart from the above reasons, there are quite few claims which were denied for no Proof of Delivery (POD) or
Incomplete delivery information. With Three Tier Trigger Points System, all the major denial reasons
were eliminated.
Private and Confidential
Other Enteral Nutrition Billable Codes
Some of the other billable codes are B4149, B4150, B4152, B4153, B4154, B4155, B4158 & B4160.
Major
Denials
• CO 16 / Remark Code N64
• CO 151 & CO 151 / Remark Code N362
Primary
Reason
behind the
denial
• Date Span / Number of Units – All the claims were denied for missing date span or for
inappropriate number of units.
• Medical Documentation does not support the level of service as per LCD guidelines.
Resolution
• For each nutritional code, date span and number of units needs to be manually checked, in
reference with LCD under the third trigger point.
• Henceforth through the above initiative, we had brought down the denial to minimal.
If the number of units or date span was a billing/clerical error, we can reprocess the claim
through Telephone Re-opening Request for Medicare beneficiaries.
For Commercials, we need to follow the unique appeal process for each and every payer.
Private and Confidential
Power Mobility Equipments
Some of most frequently billed base items are K0008, K0001, K0800,K0816, K0820, K0821 and K0823.
CO 50 / Medically non necessary
31 % of the denied claims had
insufficient clinical documentation
to meet the General Coverage
Criteria as outlined in LCD.
With the 3rd trigger point, the
denial was drastically brought
down since all items will undergo
a manual run or audit on the
documentation before the claim is
submitted.
CO 150 / Remark Code N115
19 % of the denied claims were
found to be decoded from Power
Wheelchair to Standard
Wheelchair and had been the
primary reason for the denial.
The 2nd trigger point helps to
validate the medical necessity with
support documentation. This
measure has brought down the
denial to minimal.
CO 176
This denial majorly occurs when
we bill the claim outside of the end
date on a CMN, which could be
the end of capped rental period.
Mostly it occurs when we bill the
item continuously for 12 rentals &
we did not bill for the subsequent
month as the beneficiary was in a
SNF. Anticipating this denial, EV
team submits the claim with
narration to increase the rental
period under the 1st trigger.
Major Denials / How we arrest the denials in conjunction with 3 Tier Trigger System
Note : Above numbers or facts derived through a review of 90 claims submitted Pre Inus. Found
Additional Documentation Request (ADR) were not met for 28 (31%) of the claims. For the remaining
62 claims for which requests sent, 12 of the claims were allowed and 50 of the claims were denied.
Private and Confidential
Oxygen and Oxygen Equipment
Upon review of 1195 claims submitted during Pre Inus, found HCPCS E1390, E0431 and E0439 are frequently billed
items. Below percentages were derived through Pre Inus aging reports. Also note that Claims can be denied for
multiple reasons therefore the percentages of reviews may not add upto 100%.
32%
21%
17%
11%
CO 50
CO 35
CO 176 / Remark Code M60
CO A1 / Remark Code N370
Collectible AR 90+ days – Total Value $3.1 Million (Federal Payers)
Major Denials
Note : Out of 1195 claims, found Additional Documentation Request (ADR) were not met for 602 (50%) of the claims. For the remaining
593 claims, 175 claims were allowed and 418 claims were denied resulting in a claim denial rate of 70 %.
As the denial percentage was sky high, a lot of analysis and proactive measures were put in to bring down the
denial percentage to minimal. All the ADR’s (Additional Documentation Requests) were first segregated and tracked
down the primary reasons behind the denials.
Private and Confidential
CO 50 / Medical Necessity /
Missing Documentation
Major reasons are missing
detailed description of the item in
the written order and initial CMN
not on file or invalid.
With the 3rd trigger point, the
denial was drastically brought
down since all items ordered will
undergo a manual run or audit on
the clinical documentation before
the claim is submitted.
Primary Reasons Behind The Denials / Align 3 Tier Trigger System to Workflow
Oxygen and Oxygen Equipment
CO 35 / Lifetime Maximum
Benefit Met
This denial occurs when all 36
months of rentals had already
been paid unless we bill for
replacement oxygen.
With the 2nd trigger, our Order
Entry team completely validates
the necessity behind the
replacement and would generate a
sales order only when a new initial
CMN is on file. Claim will be
submitted with RA modifier to
indicate the replacement.
CO-A1 / Remark Code N370
It occurs when there been any
break in medical need or the
same equipment been
provided by another provider.
With Same or Similar check
under the 1st trigger, item
provided by another provider
reason was brought to
minimal. If documentation
supports a break in medical
need, claim will be resubmitted
with narrative info.
CO 176 / Remark Code
M60
This denial majorly occurs
when no recert or revision
Certificate of Medical
Necessity received.
If Oxygen recert CMN is
required, a trigger or alarm
would alert the Front End
personals and the claim will
be submitted only when
revised CMN is obtained.
Private and Confidential
Inus’s 5 Phase Audit For Each & Every Claim
All our proactive measures, 3 tier trigger system and strategies have been set up based upon this 5
Phase Audit
Our Front End
Personals can ensure
all documentation are
collected as per specific
payers requirements
through Payer Mapping.
Excessive Validations
had been set up in
Payer Mapping which
consists of HCPCS &
Prompt Documentation
for all payers.
All monthly invoices are
linked to the original
sales order & supporting
documents. All
documents can be
effectively gathered
incase of audit.
Several Checkpoints
been installed to trigger
if any document is
missing or
inaccurate, the claim
wont be submitted until
the file is complete.
Through well defined
process and workflow
with checkpoints, all
actions are thoroughly
tracked which result in
higher volume of
cleaner claims.
Accurate Intake Validation Set Up Match the Documentation with Billing
Align Document Management to WorkflowThorough Follow-up on All Actions
Private and Confidential
Few DME Tips and Links……..
Advance Beneficiary Notice ( ABN ) ABN on file ABN not on file
GA modifier
should be
used
GY modifier
should be
used
E0562 ( Heated humidifier )
If Commercial is Primary and Medicare is
Secondary, and the equipment is billed as
Purchase, Primary would pay but we need to
take a write off for Medicare
PAP
If the equipment is damaged or
lost, it can be replaced along
with all new test results.
Use of RA Modifier
If the Patient was done with 5 years and
Medicare also paid for 13 rentals and still
Patient needs the equipment, then we can
start afresh again with RR, KH, KX, RA.
E0470 & E0471 ( BIPAP )
If Patient needs to use BIPAP, then there should a CPAP
failure statement on file.
Private and Confidential
Few DME Tips and Links……..
CMS - Centers for Medicare and Medicaid Services
Department of Health and Human Resources
American Medical Billing Association
NHIC
CGS
NGS
Noridian Medicare
PalmettoGBA
AMA
AHIMA
Private and Confidential
Send an email to sriram@inussolutions.com
Call us at +1 818 235 5416
Private and Confidential

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Your DME / HME Partner

  • 1. Inus Solutions An Extension Of Your Business We + DME/ HME Providers = Pioneers in Outcomes-Based Billing Private and Confidential
  • 2. Extend Your Team through INUS If you have better things to do other than reading lengthy Medicare Billing manuals, our range of DME billing service can help. If you are talking to yet another customer service person asking why your claim has not been paid, let us help. It’s our mission to help respiratory equipment providers and other DMEs prosper in the new era of value based care. Our experts helps you to handle the Patient and Payer Authorizations, Verifications, Billing, Coding, Cash Posting and Collections, who are available 24/7 to meet your needs. Private and Confidential
  • 3. DME Billing Service Overview Inus billing team has experience processing claims in the following areas: Oxygen and Respiratory Equipment PAP (Positive Airway Pressure) – CPAP / BIPAP Enteral Nutrition and Parental Nutrition Mobility Equipment Wheelchair-Scooter Diabetic Supply & Diabetic Shoes Major areas on which several check points been initiated are Pre-Coverage Criteria Appropriate usage of Codes Sales Order Entry Verification of Delivery Ticket, Purchase Order, AOB, Physician Order ( Accurate CMN and/ or Prescription, Title XIX, Detailed Written Order ) on File before the submission of each and every claim Reduces 35 % of the Denials Private and Confidential
  • 4. Eligibility Verification & Initiate Authorization Fast & Immediate EV response & along with Same-Or-Similar check to make sure the Medicare Patient hasn’t received the product recently. Authorization is duly initiated for commercial payers. If the Patient is not eligible , or had similar product recently, or authorization not on file, the first trigger point comes into play. Sales Order Entry The second trigger point comes into play at the time of entering a Sales Order, when Certificate of Medical Necessity (CMN) or DME Information Form (DIF) is invalid. An immediate escalation would be sent to the provider to stop order delivery or confirmation if data is missing, delaying claim submission until valid document is available. Documentation Audit After successful EV, Benefits and Authorization initiation, there is the third trigger point indicating the manual run or check point on DT, CMN and/or Prescription or DIF, Sleep Laboratory and Polysomnography Report whichever required for the case before claim submission. Three Tier Trigger Points Private and Confidential
  • 5. Gap Analysis Between Pre Inus and Post Inus 1.82 65% 0.5 18% 0.31 11% 0.17 6% Collectible AR 90+ days -Total Value $2.8 Million ( Federal Payers ) CO 50, CO 4 CO 151 CO 96 Others Pre Inus Major Denials Note : Pre Inus, the Client had a lot of AR piled up in 360+, about 65 % of AR was in 90+. After analyzing found CPAP is most frequently billed item. Out of the 65% in 90 + days, the major denials had been segregated with appropriate percentages as shown above. Private and Confidential
  • 6. Invalid Diagnosis Code Missing Documentation Invalid Capped Rental Modifiers CO 50 CO 4 Same/Similar ProductCO 151 CO 96 Non Covered Items Causes for Denials 327.23 for CPAP and 327.27 for BIPAP should be appropriately billed Delivery Ticket, Initial face to face evaluation notes , CMN, PSG, Detailed written order, Face to Face Re-evaluation notes, Titration test report, Compliance report and Plan of Care. All the above documents should be mandatory on file to avoid any suspension or VOID during Medicare RAC audit . For the 1st month rental claim should be billed with RR, KH, KX. 2nd & 3rd month claim should be billed with RR, KI, KX. From the 4th month and for rest of the months claim should be billed with RR, KJ, KX. A equipment can be replaced only once in every 5 years. Henceforth the denial occurs If the patient had acquired same or similar equipment during the course of time. A complete and thorough verification needs to be done during EV stage to emphasize on accurate billing. An effective HCPCS payer mapping, GA modifier and ABN validations needs to be done to avoid these denials on a longer run. Precautionary Measures Private and Confidential
  • 7. Blue Cross versus Other Commercial Payers Blue Cross Other Commercial Payers Horizon NJ, IL pays 3 months rentals with compliance for CPAP and 4th month as Purchase. UMR pays 2 months rental and 3rd month as Purchase. Generally other state plans of Blue Cross pays 10 rentals for CPAP. Aetna will pay only as Rental for CPAP and will pay for 10 rentals. KX modifier is must when we file for CPAP to BCBS of NJ. For all commercial payers, Authorization is mandatory for PAP and Oxygen & Respiratory equipments. The DME provider must participate with the Blue Plan in the state where the DME supplies are being purchased or shipped in order to process at the In- Network level of benefits. Most of the commercial payers pay humidifiers as Purchase when we bill with NU modifier. Horizon NJ does not accept 3 months supplies. Few Commercial payers pay CPAP/BIPAP as a straight away purchase unlike Blue plans or federal payers. If the state plan pays CPAP only for 3 months rental, then we need to bill the 4th month as Purchase along with Authorization. Coventry pays PAP for 15 month rentals. Private and Confidential
  • 8. Impact of trigger points on denials How trigger points arrest major federal denials ? First trigger point: Once the provider prescribes the equipment, the account will be immediately forwarded by the front office executives to our EV team. Our Eligibility Verification team needs to undergo three level check points under the first trigger successfully for the Provider to do further follow up on the particular patient. Eligibility inclusive of coverage on supply items. Same or Similar Check for Medicare Patients. Authorization check on file for Commercial Payers. If any of the above check points is not met i.e. Patient not Eligible / Patient had same or similar product recently, immediate trigger will be escalated to the Providers office. Arrest majority of CO 151 and CO 96 denials Second trigger point: Arrests majority of CO 50 denials After necessary EV and Authorization engagements, our front end billing personals need to undergo three level check points under the second trigger before forwarding the essentials to the Claims transmission team. Validate CMN / DIF on file. Authenticate Delivery Date or Date of Service (DOS) not to precede the “Initial Date” or DIF or the start date on the written order. Validate the medical necessity of the item billed by ensuring the Delivery Date/Date of Service to be within 3 months after the “Initial Date” of the CMN or DIF or 3 months from the date of the physician’s signature. Private and Confidential
  • 9. Third trigger point : Why CO4 denial occurs? The major reason behind this denial is due to missing capped rental modifiers. How? This majorly occurs in the fourth month rental and usage of KJ modifier. After first 3 months rentals, our billing personals undergoes two mandatory check points under this trigger before forwarding the essentials to Claims transmission team. Face to Face Re-evaluation notes. Compliance report. The above check points needs to be met before the Claim is transmitted with KJ & KX modifiers for the fourth month rental and for rest of the months. Eliminates CO 4 denials for the last 8 months Brings down CO 50 to the minimal Other federal denials which are kept in check : CO 173 – No CMN on file CO 176 – Invalid CMN / Prescription is not current PR 16 – ABN modifier CO 97 – Inclusive / Patient in SNF CO B15 – Patient in Hospice Private and Confidential
  • 10. Gap Analysis Between Pre Inus and Post Inus Post Inus Collectible AR 90+ days -Total Value $1.1 Million 0% 5% 10% 15% 20% 25% 30% 35% CO 4 CO 151 CO 50 CO 96 Pre Inus Post Inus With the use of three tier trigger points, AR aging was drastically reduced, especially 90+ AR days was brought down from 65% of total AR to 15 % ( Value of $1.1 Million ) in the last eight months. One of the major denial CO4 (Invalid Capped Rental Modifier) was totally eliminated and the other major denial CO50 was brought down to minimal during Post Inus period. HCPCS Payer Mapping played a significant role in reducing Non coverage denials. Private and Confidential
  • 11. Enteral Nutrition Two major billable codes are B9000 (Enteral Nutrition Infusion Pump – Without Alarm) and B9002 (Enteral Nutrition Infusion Pump – With Alarm) Collectible AR 90+ days – Total Value $2.2 Million ( Federal Payers ) 32% 21% 17% 11% CO 50/ Remark Code N115 CO 151/ Remark Code N362 CO 176 CO 109 Major Denial Codes Above percentages were derived through Pre Inus aging reports. Also note that Claims can be denied for multiple reasons therefore the percentages of reviews may not add upto 100%. Based on review of the report received, the following are the primary reasons for the denial. Clinical Documentation Issues Detailed Written Order Issues DME Information Form (DIF) Private and Confidential
  • 12. Detailed Analysis behind primary reasons DME Information Form (DIF) 6 % of the denied claims were missing a DIF. 1 % of the denied claims were missing Enteral Pump HCPCS Code on the DIF. Detailed Written Order Issues 16 % of the denied claims did not include a detailed written order. 8 % of the denied claims had date of the detailed order was incomplete / physician signature could not be authenticated. Clinical Documentation Issues 26 % of the denied claims did not have any medical record documentation submitted. 17 % claims had insufficient clinical documentation to justify the LCD criteria. Apart from the above reasons, there are quite few claims which were denied for no Proof of Delivery (POD) or Incomplete delivery information. With Three Tier Trigger Points System, all the major denial reasons were eliminated. Private and Confidential
  • 13. Other Enteral Nutrition Billable Codes Some of the other billable codes are B4149, B4150, B4152, B4153, B4154, B4155, B4158 & B4160. Major Denials • CO 16 / Remark Code N64 • CO 151 & CO 151 / Remark Code N362 Primary Reason behind the denial • Date Span / Number of Units – All the claims were denied for missing date span or for inappropriate number of units. • Medical Documentation does not support the level of service as per LCD guidelines. Resolution • For each nutritional code, date span and number of units needs to be manually checked, in reference with LCD under the third trigger point. • Henceforth through the above initiative, we had brought down the denial to minimal. If the number of units or date span was a billing/clerical error, we can reprocess the claim through Telephone Re-opening Request for Medicare beneficiaries. For Commercials, we need to follow the unique appeal process for each and every payer. Private and Confidential
  • 14. Power Mobility Equipments Some of most frequently billed base items are K0008, K0001, K0800,K0816, K0820, K0821 and K0823. CO 50 / Medically non necessary 31 % of the denied claims had insufficient clinical documentation to meet the General Coverage Criteria as outlined in LCD. With the 3rd trigger point, the denial was drastically brought down since all items will undergo a manual run or audit on the documentation before the claim is submitted. CO 150 / Remark Code N115 19 % of the denied claims were found to be decoded from Power Wheelchair to Standard Wheelchair and had been the primary reason for the denial. The 2nd trigger point helps to validate the medical necessity with support documentation. This measure has brought down the denial to minimal. CO 176 This denial majorly occurs when we bill the claim outside of the end date on a CMN, which could be the end of capped rental period. Mostly it occurs when we bill the item continuously for 12 rentals & we did not bill for the subsequent month as the beneficiary was in a SNF. Anticipating this denial, EV team submits the claim with narration to increase the rental period under the 1st trigger. Major Denials / How we arrest the denials in conjunction with 3 Tier Trigger System Note : Above numbers or facts derived through a review of 90 claims submitted Pre Inus. Found Additional Documentation Request (ADR) were not met for 28 (31%) of the claims. For the remaining 62 claims for which requests sent, 12 of the claims were allowed and 50 of the claims were denied. Private and Confidential
  • 15. Oxygen and Oxygen Equipment Upon review of 1195 claims submitted during Pre Inus, found HCPCS E1390, E0431 and E0439 are frequently billed items. Below percentages were derived through Pre Inus aging reports. Also note that Claims can be denied for multiple reasons therefore the percentages of reviews may not add upto 100%. 32% 21% 17% 11% CO 50 CO 35 CO 176 / Remark Code M60 CO A1 / Remark Code N370 Collectible AR 90+ days – Total Value $3.1 Million (Federal Payers) Major Denials Note : Out of 1195 claims, found Additional Documentation Request (ADR) were not met for 602 (50%) of the claims. For the remaining 593 claims, 175 claims were allowed and 418 claims were denied resulting in a claim denial rate of 70 %. As the denial percentage was sky high, a lot of analysis and proactive measures were put in to bring down the denial percentage to minimal. All the ADR’s (Additional Documentation Requests) were first segregated and tracked down the primary reasons behind the denials. Private and Confidential
  • 16. CO 50 / Medical Necessity / Missing Documentation Major reasons are missing detailed description of the item in the written order and initial CMN not on file or invalid. With the 3rd trigger point, the denial was drastically brought down since all items ordered will undergo a manual run or audit on the clinical documentation before the claim is submitted. Primary Reasons Behind The Denials / Align 3 Tier Trigger System to Workflow Oxygen and Oxygen Equipment CO 35 / Lifetime Maximum Benefit Met This denial occurs when all 36 months of rentals had already been paid unless we bill for replacement oxygen. With the 2nd trigger, our Order Entry team completely validates the necessity behind the replacement and would generate a sales order only when a new initial CMN is on file. Claim will be submitted with RA modifier to indicate the replacement. CO-A1 / Remark Code N370 It occurs when there been any break in medical need or the same equipment been provided by another provider. With Same or Similar check under the 1st trigger, item provided by another provider reason was brought to minimal. If documentation supports a break in medical need, claim will be resubmitted with narrative info. CO 176 / Remark Code M60 This denial majorly occurs when no recert or revision Certificate of Medical Necessity received. If Oxygen recert CMN is required, a trigger or alarm would alert the Front End personals and the claim will be submitted only when revised CMN is obtained. Private and Confidential
  • 17. Inus’s 5 Phase Audit For Each & Every Claim All our proactive measures, 3 tier trigger system and strategies have been set up based upon this 5 Phase Audit Our Front End Personals can ensure all documentation are collected as per specific payers requirements through Payer Mapping. Excessive Validations had been set up in Payer Mapping which consists of HCPCS & Prompt Documentation for all payers. All monthly invoices are linked to the original sales order & supporting documents. All documents can be effectively gathered incase of audit. Several Checkpoints been installed to trigger if any document is missing or inaccurate, the claim wont be submitted until the file is complete. Through well defined process and workflow with checkpoints, all actions are thoroughly tracked which result in higher volume of cleaner claims. Accurate Intake Validation Set Up Match the Documentation with Billing Align Document Management to WorkflowThorough Follow-up on All Actions Private and Confidential
  • 18. Few DME Tips and Links…….. Advance Beneficiary Notice ( ABN ) ABN on file ABN not on file GA modifier should be used GY modifier should be used E0562 ( Heated humidifier ) If Commercial is Primary and Medicare is Secondary, and the equipment is billed as Purchase, Primary would pay but we need to take a write off for Medicare PAP If the equipment is damaged or lost, it can be replaced along with all new test results. Use of RA Modifier If the Patient was done with 5 years and Medicare also paid for 13 rentals and still Patient needs the equipment, then we can start afresh again with RR, KH, KX, RA. E0470 & E0471 ( BIPAP ) If Patient needs to use BIPAP, then there should a CPAP failure statement on file. Private and Confidential
  • 19. Few DME Tips and Links…….. CMS - Centers for Medicare and Medicaid Services Department of Health and Human Resources American Medical Billing Association NHIC CGS NGS Noridian Medicare PalmettoGBA AMA AHIMA Private and Confidential
  • 20. Send an email to sriram@inussolutions.com Call us at +1 818 235 5416 Private and Confidential