HMO Billing Headaches!!

Health Maintenance Organizations commonly known as HMO's and now called MCO's (Managed Care Organizations) all have different ways in which their claims are submitted. My experience has shown that customer service within these organizations will not give out any useful information on how or why claims are being denied except for the deny codes that are sent alongside the processed claims. From my experience, Aetna insurance has one of the easiest platforms for Home Health claims processing. They do not pay as much as UHC and Amerigroup but you get paid ON TIME! Within the past year, UHC claims department is known to have loads of issues. Many home health agencies refuse to take up Therapy services under United Health Care. 8 out of 10 claims are either denied or under paid!

The purpose of these post is to get input from professional billers in the industry to know what they are doing right to get their claims processed promptly and paid as per contracted rates. I recently tried billing Amerigroup Skilled Services (G0154, G0151) and my claims were denied. A colleague told me I should use code 321 as TOB (Type of Bill). I'm waiting to see if these claims will be paid according to contract. My worst experience has been with Humana! I have billed those claims like 7 times and all denied, finally given up and accepted my losses. In the past Carecentrix used to be one of the best HMO's to work with, this is not the case now. We do not take up any client that is with Cigna or Carecentrix anymore, my experience has also been horrible with them.

Here are some tips I would like to share with my colleagues in the industry, your comments will be very helpful:

• If you receive a referral from another agency, carry out due diligence on the patients HMO. 7 out of 10 times the other agency is either not getting paid or being under paid for services rendered
• If you get a call from an HMO asking if you would take up a patient, do not be quick to take up that patient. It's either the patient lives very far away or other agencies have refused to take up the client because they do not pay!
• For traditional Medicare clients, PLEASE ensure that you meet up with the FACE TO FACE guidelines and PHYSICIAN SIGNATURE requirements. If you are among the unlucky ones to go through an ADR (Additional Documentation Request) all the monies paid to you on the clients under review will be recouped if the above are not met!
• Make sure your POC (Plan of Care/485) is properly signed by the physician before you bill for a Medicare client. It is considered fraud by CMS if they walk in to your agency and ask for documentation in this regard

I was watching the news the other day and it was stated that a home health agency defrauded Medicare and Medicaid of over 18 million dollars in false claims. I'm sure some of us here that a lot. Trust me some of the agencies labelled in this manner did not technically defraud the government, they just did not have documentations that met the required guidelines!

Please share your experience on various billing issues and events so that some of us can learn from you. Have a productive day at work :)

PS: Any news on how the HMO's plan to revert to EVV???