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Reimbursement Delays and Doctors’ Bottom Lines

Doctors can struggle to pay bills too. A few years ago, California switched Medicaid payment contractors, and the botched handoff resulted in months-long delays in payments to health care providers. As a result, providers had to lay off staff and beg drug companies for shipments.

The 2008 California crisis underscores the fact that many doctors rely on prompt reimbursement from Medicaid or private insurers to run their practices. Even minor delays can put providers in a pinch.

The Centers for Medicare & Medicaid Services (CMS) is the government agency that processes and monitors payments under Medicaid and Medicare. Since the Affordable Care Act took effect, CMS has been more aggressive in rooting out abuse and fraud. This means that an error in a claim, however innocent, could cause problems.

In the past, physicians submitted a paper Form 1500 to get reimbursed by CMS and some private insurers. An error in a patient’s Social Security number or date of birth could hold up a payment. Even though almost all Medicare billing is now done electronically via Form 837P, prompt payment still depends on correct information.

The Medicare Claims Processing Manual is an online manual created by CMS to provide billing instructions to health care providers. Different categories of health care professionals have different standards. If a radiologist, for example, followed the instructions for endocrinologists, reimbursement could be delayed.

Each diagnosis and procedure a doctor performs has a unique CMS code. Each code is outlined in Chapter 23 in the manual. Codes can be long and complex, and CMS requests that they be as specific as possible. A coding error could delay payment.

A fact sheet from CMS explains Medicare billing and provides links to other online resources. If you need help pursuing payments from Medicare, Medicaid or a private insurer, speak to an attorney experienced in representing health care professionals.

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  • Posted on: Dec 17 2013