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Patients who sue a hospital for medical malpractice are not entitled to records documenting the hospital's internal examination into what went wrong, the state Supreme Court has ruled, upholding a 2004 law intended to encourage medical professionals to learn from and prevent future mistakes. The ruling, released Monday, stems from a medical malpractice lawsuit brought by Esther and Gedalia Applegrad, who alleged their daughter's brain injury and seizure disorder were caused by a series of mistakes made during the baby's delivery and care at Valley Hospital in Ridgewood in May 2007.

Rapidly advancing fields such as molecular diagnostics pose some of the newest challenges for providers, who must bill with precision or risk losing reimbursements.

This article appears in the September 2014 issue of Managed Care Contracting and Reimbursement Advisor.

Billing accuracy and efficiency are as important as ever, and some of the top mistakes that hold up reimbursement will sound familiar even though you still need to address them. But healthcare reform and evolving managed care policies are introducing a few new pitfalls to avoid.

The cost of having anything but a clean claim continues to increase for physician practices, says Doug Moeller, MD, general internist and medical director with McKesson Health Solutions, a San Francisco health services provider that works with 20% of all American physicians. Moeller spent 10 years in the company's claims auditing group.

Rapidly advancing fields like molecular diagnostics pose some of the newest challenges.

Driving Down Claims Denials

"The challenge is that the coding and processing of these claims continue to get more intricate as the number of codes increases," Moeller says. "With something like molecular diagnostics, there is a whole new fron­tier of codes and tests and a whole new jargon. There are pitfalls everywhere in that situation."

For both old and new coding challenges, the process can be broken down into a series of decision points and data verification, Moeller explains. He has created a graphic representation that shows how a physician practice should move through that process to ensure a clean bill.

Most of the steps involve an electronic interaction data check, such as verifying information transmitted with 837P, the standard format used by healthcare professionals and suppliers to transmit healthcare claims electronically to Medicare. At that checkpoint, you should verify that the file fields and codes are actually codable according to electronic standards.

Eligibility always in question
Another vital check is for patient eligibility, Moeller notes. Is the member still covered by the health plan? Is the date of service a covered date, or did coverage terminate a week beforehand?

"The rapidity with which that information gets up­dated in the data system continues to be as important as ever," he says.

The evolution of healthcare networks is beginning to pose billing challenges because of the complexity of those networks, Moeller says. In the commercial world, contracted networks sometimes require a payer to have a whole new inventory.

"I think we're going to start to see this in Medicaid and maybe in Medicare," he says. "The real frontier in payment is going to be, following the Obamacare enrollment, figuring out how to get Medicaid to be a lot more efficient for those services that are covered. Since there are 50 different versions, the complexity for the average provider trying to keep track of that is going to continue to be more challenging. That's especially true if you work near a state line and see patients from both states."

Get bills out the door in time
Timely filing is another hurdle for physician prac­tices, says John Hansel, the vice president of health­care provider solutions for MedeAnalytics, a healthcare data analytics provider based in Emeryville, California, focused on improving the financial health of payers and providers.

Many practices have trouble capturing all the charges and getting them coded, reviewed, and sent to the payer before the payer's deadline, Hansel says. Many smaller practices do not have good processes for capturing charges and their bills are delayed for weeks, resulting in timely filing denials from some payers.

Some practices may become accustomed to a per­centage of claims being denied for tardiness, but Hansel says any such denials are reason to improve your process.

"The remedy to that is to put a process in place to reconcile your charges on a daily or at least weekly ba­sis to make sure you have an efficient pipeline for get­ting the claims out the door on time," he says. "There is no magic to that, just knowing the deadlines and having a way to flag a bill if it is approaching its timely filing date."

Modifiers crucial to good billing
An increasingly common filing error involves medi­cal necessity. When payers deny a claim and say the procedure was not medically necessary, the problem usually comes down to improper use of modifiers, Hansel says. If a practice is billing for performing the same procedure a second time on a patient in the same week, for instance, that second bill must include a modifier that indicates why the second procedure was necessary.

"Physician practices can get lazy in their use of modi­fiers," Hansel says. "Modifiers are left off all the time and the claims are denied. A lot of those claims are eventually paid after the practice bills again with the modifier, but that just added 30 days to the accounts receivable cycle, and it costs $25 to $30 in internalcosts to send the bill again."

The move toward more high-deductible coverage also is beginning to trip up some physician billing, Hansel says. Patients who previously had coverage provided by employers may be part of health insurance exchanges now, and they might not fully understand their benefits and deductibles.

"There's a lot of figuring that out as people go to the doctor for the first time after changing plans. They don't know what's covered and what's not, and neither do the registrars," Hansel says. "That's another reason to verify eligibility every time, or else you run the risk of more eligibility-related denials."