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Medical Billing Assistance



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Ilya Mirolyubov

System Administrator

(718)934-6714 ext 1111



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Medical Billing FAQ

Questions about patient’s eligibility and benefits details:

1. Question:  I would like WCH not only bill claims, but also check eligibility for my patients. Is there a remote receptionist service?

Answer: Yes, WCH provides remote receptionist services. Please contact your account representative requesting receptionist services agreement.

2. Question: CAP For Physical and Occupational therapy for the benefit year was reached according to Medicare records, what should I do?

Answer: A process to allow for exceptions to the caps has been established in cases where continued therapy services are medically necessary. The KX modifier is added to claim lines to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record. For further therapy cap information, review CMS publication 100-04, Medicare Claims Processing Manual, chapter 5, section 10.2.

3. Question: Our claims got denied for no authorization on file, what should we do?

Answer: Make sure your front desk obtain information about patient’s benefits before services are rendered as well as authorization requirements verification. If authorization is required for the certain services, it should be obtained prior to visit. If authorization was obtained for the continuous treatment, your office staff has to make sure that all of the following visits are covered and/or extend authorization for additional visits.

Questions about Billing features:

4. Can I bill initial evaluation and management services if patient’s insurance has been changed?

Answer: No. Initial evaluation and Management services should not be billed only because patient had changed the insurance. Whether a patient is new or established is determined by the length of time it has been since that patient has seen that physician. If the patient has had a face-to-face encounter with the physician in the last 3 years, the patient is considered established. Also if the patient sees a physician in the same group practice, you will need to determine if the two physicians are of the exact same specialty and subspecialty. If they are, and the patient has seen them in the last three years, the patient will be considered an established patient.

5. Question: Can physician bill for the work of the social worker, even the MD did not see the patient, but was present during the visit? Social worker is an employee of the MD

Answer: Yes, it is possible, but the following requirements should be met:

a) The Client must be initially seen by the MD and she/he must stay involved in the care;

b) The care provided by the social worker must integral, although incidental. “Incident-to a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”;

c) Documentation – The MD must write an order for treatment that includes the Incident to work in the chart. For example, “Client will benefit from weekly individual therapy to address depression.” This should be included in the MD’s evaluation or treatment plan;

d) Location: The services must be performed in an office, and a supervising MD must be in the same office suite. The supervising MD is the one you will bill Incident to. The supervising;

e) MD does not need to be the same one that sees the client for the initial evaluation or treatment. You should be able to prove that the supervising MD was on site during the time period that the incident to services were being performed. The best way to do this is a two pronged approach – 1. Keep a log of the MD on site and 2. Be able to show that the MD was billing for their own services at the same time as the incident to services were being done. The MD should also sign in and out of the log. The MD must also be readily available should her or his assistance be needed;

f) Your staff needs to perform the service. The “incident to” services must be provided by personnel that represent a direct financial expense to the physician, or agency, such as a W2 employee, leased employee, or independent contractor.

Source: http://www.solutionsinbh.com/2011/05/incident-to-billing/

6. QuestionWhat date of service should be used when billing 96118-Neuropsychological testing, the date of test or the date when report was generated?

Answer: In line with Centers for Medicare and Medicaid guidelines, the date of service should always match the date that the Psychological or Neuropsychological testing took place. If time was taken to prepare the report on a day other than the day the patient was seen, this should not be billed separately. This service is reimbursable under the date of service that the testing took place. Additional billing is not necessary.

7. Question: When can I do new appliance for the patient, replacement?

AnswerOral appliances are eligible for replacement at the end of their 5-year reasonable useful lifetime (RUL). These items may be replaced prior to the end of the 5-year RUL in cases of loss, theft, or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). Replacement due to wear-and-tear as the result of everyday use will be denied as statutorily non-covered prior to the expiration of the 5-year RUL.

8. Question:  Can I do a second initial psychiatric evaluation on a patient who I have followed up on but was hospitalized and came back to the nursing home?

Answer:  Initial psychiatric evaluation (90791/ 90792) may be utilized again for the same patient if a new episode of illness occurs after a hiatus or on admission or readmission to an inpatient status due to complications of the underlying condition, and when reassessment is required.   The medical record must support the reason for more than one diagnostic interview.

9. Question: Can I bill family psychotherapy separately for each individual?

Answer: More than one group therapy code billed on the same date of service by the same provider is not allowed although one individual and one group therapy billed on the same date of service by the same provider can be paid if reasonable and necessary for the condition of the patient and fully documented in the patient’s records.

You should be billing 90847 onetime per couple. It is NOT appropriate to bill both of them a 90847. You can bill both of them individually if they each get own treatment individually, but so long as seen together, bill 90847, one time .

10. Question:  Can physician bill for regular office visit and group psychotherapy on the same day?

Answer: According to the NCCI edits group psychotherapy is allowed on the same date with office visits.

Questions about claims and submission process:

11. Question: In what time frames I can expect my claims to be sent out to insurances?

Answer: Designated time frame for billing the superbills according to Billing Contract is 7 calendar days from superbills receipt date.

12. Question: How often claims are sent to insurances? If I send billing twice a week, can I expect two claims batches submission per 1 week to ensure no disruption in my revenue cycle?

Answer: WCH submits claims to Medicare/Medicaid and all commercial insurances electronically 5 days a week, except weekends and holidays. You can arrange the claims submission cycle that is most appropriate for you, by contacting your account representative and setting up a schedule of claims submission days for your account.

13. Question: I would like to have permanent access to all billed/submitted claims and payment information, as well as current status of claims. Is there software that WCH offers?

Answer: WCH can install customer version of our software, so you will be able to track your claims and payments at any time. Customer Support is available per your call.

Questions about provider payments:

14. Question: Payment by insurance company is issued directly to my bank account, when should I expect to receive this money?

Answer: You will be able to get this money by the next day from the issued date.

15. Question: How often will I receive Explanation of Benefits (EOBs)/ Remittance Advices (RAs) from WCH for paid claims?

Answer: EOBs are submitted to you by Account Representative by e-mail or fax (whichever is preferable to you) on a weekly basis (each Monday).

16. Question: I have received an EOB from WCH for the claims that have been paid, but I have not received/misplaced the paper check.

Answer: Provide insurance name, check#, check date and check amount to your Account Representative, and lost check will be reissued at the time frames designated by health insurance that released the check.

17. Question: I have questions about multiple unpaid / no status claims, how should I address this issue? Should I call my account representative for each claim?

Answer: Provide a list of unpaid / no status claims to your account representative by fax or e-mail, and s/he will get back to you with a response as soon as possible.

18. Question: I have another office that is billing claims on my behalf, and they are already receiving EOBs. Is there an option to split EOBs by submitting entity?

Answer: This will depend on each particular insurance, for example, NGS Medicare allows only 1 entity to receive ERAs (no matter how many entities submitted those claims); most insurances allows splitting EOBs by TAX ID of facility. Please refer this question to your account representative directly, so s/he can advise the best solution for your account.

Questions about patients invoicing:

19. Question: I want to bill patient, do you provide such services?

Answer: Yes, after your request for patient billing we create a patient bill and submit it to a patient 3 times with a 1st submission copy to your office in order to keep it in the patient’s chart for the records.

20. Question: Can I bill active Medicaid beneficiary?

Answer: NO, you cannot, unless Medicaid does not cover specific services and it was agreed with a patient prior to the services rendered and this information is documented in the patient’s chart, that patient is agree to pay out of pocket. Service, which is paid by patient personally, could not be reported to Medicaid.

21. Question: Can I collect deductible upfront?

Answer: Yes, you can if patient has only one insurance coverage and there is no secondary or supplemental policy that may cover expected deductible applied by primary carrier. But you have to make sure, that there might be a refund submitted by you to a patient, if insurance applied fewer amounts than you collected from the patient.

Questions about Reports provided by WCH:

22. Question: Will I be notified about total number of claims submitted to insurances per week (or about the number of claims submitted to each particular insurance)?

Answer:  You may receive Billed Claims Report after each batch claims submission by e-mail or fax; please contact your account representative for detailed information on Billing Report data.

23. Question:  Can you provide me with information about how much I’m paid for a certain patient/for a certain procedure code?

Answer:  Yes, we can prepare for our providers such type of report.

24. Question:  I would like to track aging claims and payments receivables; are there any customized reports that WCH can provide?

Answer:  WCH can provide aging/payments receivable reports on monthly basis per clients request. Outstanding reports for unpaid claims are provided on quarterly basis by Account Representative.

25. Question:  Can you provide me with information about all my earnings statements for the last year?

Answer:  Yes, we can prepare for our providers such type of report.

Questions about insurances contract‘s details:

26. Question:  I have a CAP agreement with Commercial insurance and don’t know if I have to report services rendered or not, as such claims are never paid under such arrangements

Answer:  Your CAP contract with commercial insurance has information about services that are applied to CAP according to the agreement, but there might be services which as not in a list and you going to be reimbursed for such services which are not in a list. Please follow you contract terms and agreements. Moreover, there are different types of the CAP contracts and claims submission might be mandatory even if they will be applied to CAP.

27. Question: I’m a not contracted Medicaid HMO provider, can I see patients still and get paid?

Answer: Generally, all Medicaid HMO plans are not allowed this, but rare in case of emergency only.

28. Question: I’m a not contracted Medicare Advantage plan provider, can I see patient still and get paid? 

 Answer: Yes, please obtain prior authorization for the services.

29. Question: Part of the services is got to be denied, as I’m not eligible to be reimbursed for the services rendered, what should I do in this case?

Answer: Please review your contract with insurance and if you would have any questions, you may directly contact your network area representative for verification.

30. Question: I’ve got revalidation request from Medicare, what should I do? 

Answer: You have 60 days from the date of the letter to submit all required documentation to Medicare in order to revalidate your records and track this process until it will be completed.

Questions about insurance’s audits and review:

31. Question: I have received letter from commercial insurance or Medicare contractor stating that my practice is subject to post payment/prepayment claims sample review, what should I do in this case?

Answer: You have to follow all instructions given in a letter received, prepare all documentation requested and mail to Assigned person who is responsible for this Audit within set time frame.

32. Question: I have a prepayment/post payment review by commercial insurance or Medicare contractor and I have to submit medical notes/charts to them for review, but prior to submission I want to make sure that all of my records comply with state/federal/insurance regulations. Can WCH assist me with this?

Answer: Contact your account representative and provide the following information:

A)     Records request from insurance (with indicated final dates when records have to be received by insurance)

B)      List of patients and dates of service and/or procedures that have been requested review

C)      All records that have been requested (with legible signatures and/or signature log)

Upon receipt of this information, account representative or assigned WCH coder/auditor will contact you for further information verification (if necessary), and will provide you with written report on audit findings and recommendations.



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