T
he pedorthics industry involves
specific challenges when it
comes to meeting the modern
standards for medical billing.
Doctors in all sorts of
fields have been struggling with complex
issues around medical billing that can
cause claim denials, either from private
insurers or from government payers, or
both. In addition to the general factors
that can cause a ‘flood’ of denials for a
medical provider, those in the expert and
personalized services of pedorthics also
have to deal with specific regulations
or contractual agreement details on the
precise kinds of services and equipment
that they provide to patients. Items such as
pedorthic devices, including therapeutic
shoes or shoe modifications, prosthetics, or
similar items can be hard to document on a
bill or claim. It can also be challenging to
correctly provide diagnosis and equipment
codes that will meet the standards for
various payers.
Common Medical Claim Errors
What are the common errors your practice receives? Common
errors may include duplication of claims, claims without
adequate documentation of medical necessity and outcome,
bills for non-covered services, lack of beneficiary eligibility,
absent details or details not matching between care team
notes, diagnosis mismatch or problems with bundled service
codes. Other details like an amended place of service code or
patient identity mismatch can also trigger a denial or rejection.
Another error type may relate to the provider’s accreditation,
credentialing and or licensure for services rendered. It’s
important for administrators to know how to assess and resolve
these issues proactively.
To identify denial trends and other recurring errors, utilize
your practice management’s reporting system. If your practice
management system does not offer this type of reporting, consult
your clearinghouse. Create a denial report for a specified length
of time capturing the denial code, category and payer. If you
have multiple practitioners, break this information down by
each provider. You may also want to compare this data to other
time frames. By analyzing the data, you can quickly determine
the payers that require specific documentation or have other
requirements to move a claim forward. Confirming exclusion
conditions or other special conditions on the front end can also
speed processing on the back end. Take this information and
create a spreadsheet for quick reference and continue to analyze
your denials on a regular basis. Eventually, you will be able
to catch errors before they leave your office. This is critical to
realizing a quicker cash flow turnaround.
How do you know if you have a high denial rate? Industry best
is a denial rate of less than 5% and the worst is more than 10%.
To calculate, simply divide your total dollar volume of denied
charges by the total dollar volume submitted for the same time
period. Take care to note that some line item charges may have
multiple denial codes. An alternate calculation is total charge
line items denied divided by total charge line items submitted
for the same time frame.
CMS Guidelines and Pedorthics
The pedorthics field is also responding to rapid changes in
Medicare treatment of this specialty area. Recent reports
indicate that the Office of the Inspector General and the
Centers for Medicare and Medicaid Services jointly concluded
that more regulations are needed on guidelines for federal
reimbursement for pedorthics devices, depending on whether
they are made, prescribed and delivered by ‘qualified
practitioners.’ Currently, practitioners in pedorthics can
reference a set of Durable Medical Equipment, Prosthetics,
Orthotics and Supplies or DMEPOS quality standards that are
part of existing regulations. Under the Medicare Modernization
Act of 2003, DMEPOS standards are placed on the suppliers
of devices in the pedorthics industry, with limited exemptions.
Some of these standards involve the administration of a provider
office, where critical leadership has to exist and key people must
be in control of the office or business. Items provided must also
meet FDA regulations and should provide appropriate services
Recent reports indicate that the Office of the Inspector General
and the Centers for Medicare and Medicaid Services jointly
concluded that more regulations are needed on guidelines for federal
reimbursement for pedorthics devices, depending on whether they
are made, prescribed and delivered by ‘qualified practitioners.’
Current Pedorthics
March/April 2013
39