Author Topic: Not sure what to do... Please help  (Read 2194 times)

AllAboutU

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Not sure what to do... Please help
« on: July 07, 2014, 08:57:22 PM »
I have a Medicare Provider here in TX that has roughly $3k outstanding since the end of March, with no Medicare check since 5/2/14. I came on board on 4/11/14. When I started the biller previous to me was still paper billing on the CMS 1500 version 8/05. I rebilled his claims from the end of March that rejected for claim form and the new billing from April on paper using the CMS 1500 version 02/12. The claims came back rejected again for missing the back page. I have a program that is form fillable to the red HCFA form, I bill Medicaid without the back form and sent the claims to Medicare without the back page of the CMS in error. Once I received the rejection I re-mailed the claims ((this time with the back)). The re-mail was done on 6-11-14 and as of this past Friday the claims are still not on file. I have the DR I am billing for in box 17, a DN Qualifier in 17a and the doctors NPI in 17b. In box 21 I also have the ICD indicator marked. Also, the NPI is populated appropriately in 24J, 33A and 32A. What could be causing the rejections for the paper claims :-[?

He and I agreed to send the paper claims while I set him up electronically, well that's another problem. I set him up with Novitas Texas as an added user under my submitter ID. I get the approval that he is added on 6/21/14, submit the 25 "test" claims in order to go into live production. I call on this past Friday and I'm notified that the physician cant be set up under my submitter ID because I am not billing "live". Per the Novitas rep since I am using a software that uses Office Ally as their clearinghouse, I should have added the provider to the clearinghouse submitter ID. My software vendor emailed me today stating ALL the claims I have submitted electronically for Medicare came back rejected due to NPI/Tax ID mismatch to the EDI clearinghouse/submitter ID.

I am refaxing the paperwork tomorrow morning first thing linking the provider to the Office Ally clearinghouse submitter ID. But the doctor is pissed to say the least. His commercial claims are going over fine, but he wants the Medicare check like last month. He stated he can't have it held up any longer. I am thinking of emailing him and waiving his July payment. But I feel like there's nothing but excuses on my part. I truly didn't know he had to be on the clearinghouses submitter, and for the life of me I cant figure out what to do about the paper claims.

So ready to quit :-( I feel so down about this

Does any possibly know what could be wrong with the paper claims?  Is waiving the pay a good idea since he hasn't received Medicare payment in the 3 months I've been on board?

Christy

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Re: Not sure what to do... Please help
« Reply #1 on: July 08, 2014, 10:54:03 AM »
ugh! Hate medicare!!!!

hang in there....The Office Ally paperwork for Medicare usually goes through in a few days and you should then be able to submit the claims....

Perhaps you could reduce your fee a little (not sure if it's flat or per claim, etc.) just to the amount of the time it took you to resubmit the claims.

I have had these snafus (always with Medicare) and in the end, it's always a learning experience.

good luck!

PMRNC

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Re: Not sure what to do... Please help
« Reply #2 on: July 08, 2014, 11:05:12 AM »
Quote
I set him up with Novitas Texas as an added user under my submitter ID. I get the approval that he is added on 6/21/14, submit the 25 "test" claims in order to go into live production. I call on this past Friday and I'm notified that the physician cant be set up under my submitter ID because I am not billing "live". Per the Novitas rep since I am using a software that uses Office Ally as their clearinghouse, I should have added the provider to the clearinghouse submitter ID.

Tough call because it was an error on your part. You don't setup new clients under your submitter ID.
Linda Walker
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RichardP

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Re: Not sure what to do... Please help
« Reply #3 on: July 08, 2014, 02:22:17 PM »
You don't setup new clients under your submitter ID.

Linda, can you make sure I'm understanding this correctly please?

1.  I'm thinking the only reason a biller would have a Submitter ID is because that biller is submitting directly to Medicare, electronically??

2.  Any biller who submits directly to Medicare can submit claims for new clients under their Submitter ID, provided they do what Medicare requires for billers who are submitting directly??

3.  In this situation, the problem is caused because biller is not submitting directly to Medicare.  In fact, it is Office Ally that is submitting to Medicare.  So, yes, the MAC needs to have the providers numbers and Office Ally's numbers linked properly in their system.

I recently went through this for two clients who had been let go by their biller - a biller who was submitting multiple clients to Medicare directly, except for the two who were handed off to us.  Those two were being billed through Office Ally.  I was informed by Office Ally of the hoops we had to jump through to have us rather than the original biller bill these two providers through Office Ally.

We acquired these two clients at exactly the same time we had to switch from Palmetto to Noridian.  Clients were registered with Palmetto, through Office Ally.  That info did not get passed to Noridian (or was passed but ignored).  Noridian required doctors to go on-line to establish accounts for both, and then connect them to Office Ally.  Noridian would not allow us to do it for the doctors, they had to do it themselves.  They couldn't/wouldn't - so no Medicare payments for about three months while we obtained permission from Medicare to submit paper claims for the two.  We got requested permission and are currently billing with paper claims on the new form.  These two are difficult/problematic clients.  We took them on only as a favor to a client we already have.

PMRNC

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Re: Not sure what to do... Please help
« Reply #4 on: July 08, 2014, 03:16:12 PM »
Quote
1.  I'm thinking the only reason a biller would have a Submitter ID is because that biller is submitting directly to Medicare, electronically??

I have no idea.. I have not done that in years..I don't have a submitter ID. I use the practices existing setup or I set them up with their own.

Quote
Any biller who submits directly to Medicare can submit claims for new clients under their Submitter ID, provided they do what Medicare requires for billers who are submitting directly??

I think that's true.. but again.. that's something I've not done.. old scenario.

Linda Walker
Practice Managers Resource & Networking Community
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www.billerswebsite.com

RichardP

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Re: Not sure what to do... Please help
« Reply #5 on: July 08, 2014, 03:29:52 PM »
Thanks.

kristin

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Re: Not sure what to do... Please help
« Reply #6 on: July 08, 2014, 09:17:30 PM »
Okay, where to begin...

I know you said the previous biller sent Medicare claims on paper. Does the doctor still have an exemption on file with Medicare to send the claims on paper? This exemption comes up for review/renewal every few years, so if he isn't exempt still, paper claims won't process.

You said the NPI's/doctor's info was populating correctly on the CMS form. But is the practice address, etc, also populating correctly? For instance, are the service facility address and billing provider address(box 32 and 33) matching to the NPI's in 32A and 33A? Is the Signature on File done in box 31 and dated? Is box 25 populating?

As far as what to do about charging the provider...if it was me, I would charge him only for what was done on the commercial claims, and not for the Medicare claims. But that is just me. I look at it like I am the one who should know how to get claims paid, and most providers are clueless about it, so it is on me. That said, if you find out there is something the provider needs to do to help this process, that you cannot do for them, and they aren't doing it, that is on them, for future invoices.

Don't get down and want to quit...these things happen, I have personally seen two billing companies I work for not be prepared when they took over client accounts, and in both cases, the providers stayed with them. And it wasn't over what I consider to be a small amount of money, like in this case. We are talking about $3K right? Three thousand dollars? The ones I was involved with weren't receiving ANY money, one for three months, one for four months. Medicare money alone in these cases was $30,000 to $60,000. Not to mention the commercial money they weren't getting. Your provider will not get the money any faster if they decide to switch billers, in fact, it could probably take longer. And while the provider might want the money yesterday, that doesn't mean beans. Medicare will pay when Medicare gets clean claims.

The only thing that concerns me here is the time frame you have laid out. You came on 4/11. With your initial paper claim submittals, you should have followed up within seven-ten days to make sure the claims were received and were processing. But then you jump to 6/11 as your resubmittal date. What was going on during those two months? And once you resubmitted on 6/11, the followup should have been done by 6/18-6/21, but you say it was this past Friday(7/4). I see a lot of time passing with no follow-up, and if I was the provider, I would be ticked off also. So unless there are things you left out of your original post that you did to follow up on the claims, the lesson here is when you are dealing with Medicare, you need to stay on top of things like white on rice.  ;)

Michele

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Re: Not sure what to do... Please help
« Reply #7 on: July 10, 2014, 10:14:59 AM »
I rebilled his claims from the end of March that rejected for claim form and the new billing from April on paper using the CMS 1500 version 02/12. The claims came back rejected again for missing the back page. I have a program that is form fillable to the red HCFA form, I bill Medicaid without the back form and sent the claims to Medicare without the back page of the CMS in error. Once I received the rejection I re-mailed the claims ((this time with the back)). The re-mail was done on 6-11-14 and as of this past Friday the claims are still not on file. I have the DR I am billing for in box 17, a DN Qualifier in 17a and the doctors NPI in 17b. In box 21 I also have the ICD indicator marked. Also, the NPI is populated appropriately in 24J, 33A and 32A. What could be causing the rejections for the paper claims :-[?
It's really hard to say without seeing a rejection.  Bottom line it really is better and much faster to send electronically.  One big reason is because the clearinghouse helps to make sure all info is in the correct places.  Also, you get notified quicker when something isn't right.


He and I agreed to send the paper claims while I set him up electronically, well that's another problem. I set him up with Novitas Texas as an added user under my submitter ID. I get the approval that he is added on 6/21/14, submit the 25 "test" claims in order to go into live production. I call on this past Friday and I'm notified that the physician cant be set up under my submitter ID because I am not billing "live". Per the Novitas rep since I am using a software that uses Office Ally as their clearinghouse, I should have added the provider to the clearinghouse submitter ID.
If you are submitting electronically through OA then you would do the Medicare EDI paperwork using OA's submitter information.  They have the forms available on their website and they give you all information that you need to use.  It is under the payer enrollment forms section.  Go to TX, then click on TX Medicare.


My software vendor emailed me today stating ALL the claims I have submitted electronically for Medicare came back rejected due to NPI/Tax ID mismatch to the EDI clearinghouse/submitter ID.

I am refaxing the paperwork tomorrow morning first thing linking the provider to the Office Ally clearinghouse submitter ID. But the doctor is pissed to say the least. His commercial claims are going over fine, but he wants the Medicare check like last month. He stated he can't have it held up any longer. I am thinking of emailing him and waiving his July payment. But I feel like there's nothing but excuses on my part. I truly didn't know he had to be on the clearinghouses submitter, and for the life of me I cant figure out what to do about the paper claims.

So ready to quit :-( I feel so down about this


This business definitely can be discouraging.  We all have BAD days.  It's all in your perspective.  What you are gaining her is invaluable experience.  This stuff can't be taught.  Keep going til you get it right.  Apologize but don't overdo it.  Be HONEST ALWAYS!  Tell him that you are very sorry and offering him a discount may help.  It will show him that you are trying to be fair and you are responsible.  (Only since this was your error.)
 


Does any possibly know what could be wrong with the paper claims?  Is waiving the pay a good idea since he hasn't received Medicare payment in the 3 months I've been on board?

Waiving the fee is ok, or telling him he doesn't have to pay until the Medicare money comes in is another option. 

Don't give up.   You will get it straight!
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