Archive for April, 2012

How To Write an Effective Appeal Letter

April 30, 2012

The following is a list of steps to preparing an appeal:

  1. Address the appeal letter to the Insurance Company who paid/rejected the claim.
  2. If this is your 2nd Level Appeal or 3rd Level Appeal, notate that on the header also.  If it is your first there is no need to be specific.
  3. Put the Date that you are preparing the appeal on the appeal letter.
  4. Address the appeal to:  To Whom It May Concern.
  5. Include the Patient Name, DOB, ID#, DOS and Billed Amount of the claim originally submitted.
  6. Point out the reason for claim denial.  Example: This claim was denied for timely filing however according to our records this is incorrect.
  7. Provide an explanation as to why this is incorrect based off of:  Contract, Fee Schedule, Timely Filling Submission Dates, Coding Guidelines, State Rules & Regulations (resources for Texas: TID, TMB, TMA, TCMS), Federal Rules & Regulations (CMS, AMA, HIPAA, OIG, HHS, FDCPA, PHI, Prompt Pay Act), Payor Guidelines, Provider Information or Credentials that rendered the services, Medical Necessity, Patient Benefits, Authorization on file, Any other applicable reason for an invalid denial
  8. Close with expectations:  Please reprocess for payment according to our contract, Please reprocess according to our fee schedule, Please see attached proof of submission for timely filing, Please reprocess per coding guidelines (list the exact coding guideline), Please reprocess according to rules & regulations (list the exact rule or regulation that they violated), Please correct the CPT Code/ICD9 Code, Please reprocess with attached information regarding medical necessity, Please make additional payment within 14 business days
  9. Attach any applicable documents:  Contract (if necessary), Fee Schedule (if necessary), Proof of Timely Filing, Documentation on Coding Guidelines, Documentation on any State and/or Federal Rules & Regulations, CPT, HCPCS or ICD9 Code information, Copy of Provider information (Provider License, Provider Credentials, Practice Information, etc), Medical Records, Copy of Patient Benefits, Copy of Authorization, Or any other further documentation to support the denial

Utilize these 9 steps and you will have the foundation for an effective Appeal Letter to win the fight against the insurance carrier!  We wish you great success!  If we can assist you further, please to not hesitate to contact us at 817.239.6595

[The steps are written for Providers in the State of Texas…some of the resources listed may not apply to your state.]


Poll: Did you take a Medical Billing Course?

April 27, 2012

We would like your participation in a Poll that we are doing.  If you wish to participate, please email me.

Did you take a Medical Billing Course to learn your field of study?  If so, was it a Certified Medical Billing Course?  Will you share with us who you took your course through?  What did you spend to take the course?  If you would take the course again given what you know now?  Are you in the field you went to school for?  How long have you been in Medical Billing and/or Medical Coding?

We would appreciate your participation in this questionnaire!  If you would like to email us your story, we will publish it on our blog.


April 26, 2012

The most common cause of executive failure is inability or unwillingness to change with the demands of a new position. The executive who keeps on doing what he has done successfully before is almost bound to fail.

– Peter Drucker, management expert

I met you at a Networking Event…

April 25, 2012

I met you at a Networking Event.  We exchanged business cards.

That does not mean:

  1. I will refer to you.
  2. You can add me to your Email Marketing Campaign, just because you have my information without my permission to do so.
  3. We are Strategic Business Partners.
  4. I want to be apart of your downline.
  5. You are professional and someone I wish to work with.

It does mean:

  1. I have an opportunity to get to know you, learn about what you do, and how I can be of service to you.
  2. You may ask to add me to your Email Marketing Campaign, but if I don’t want to, that is okay, it is my choice.  Note:  If you don’t ask me first, it is guaranteed that I will be opting out.  If you don’t have that option, I will make sure you understand that you must remove me because you violated this.
  3. I will do my best to get you the connections you need in business.
  4. I am working to build my business just as much as you are yours and I would like the same respect.
  5. I will encourage you in your Entrepreneurship.  I will be a supporter in every way possible.

People do business with people they know, like and trust.  Give me a chance to get to know you, learn what you do, why you do what you do, how you do what you do, an opportunity to see what you are like, if you are professional, trustworthy, and how you respond to our interactions.  These things will create a relationship and give us both a better chance at referrals and being a Strategic Business Partners.  Please don’t kill any chance of this by SPAMING me with your information, products, newsletters, and like materials.  Nobody wants pushy people in our lives, we have plenty of them we can’t control.  You will kill any opportunity with me if you do this.


April 24, 2012

The goal of many leaders is to get people to think more highly of the leader. The goal of a great leader is to help people to think more highly of themselves.

– J. Carla Nortcutt

Lessons learned from Beta Client experience

April 23, 2012

If you follow my blog, you would have read a post here about my latest Beta Client experience.  This is not my first time to ever do this and I have never had a previous bad experience in being a Beta Client; however there is always a first for everything.

Anytime something doesn’t go as planned, I always try to evaluate it.  With that, here are 5 Lessons I learned from the latest Beta Client experience:

  1. Don’t take people at their word.  People change.  When the going gets tough, many times people quit and don’t fulfill their commitments and follow through on their promises.  This means even great Entrepreneurs that state they will do whatever it takes to make something happen.
  2. Define expectations in writing of what a Beta Client means and who will be doing what.  Even though someone says they will work with you jointly on a project, if they don’t do what they said they will do, you need something to fall back on.  No assumptions on what that means.
  3. Don’t expect the other party to put in as much “free” services as you do.  You will always have to give 150% more than the other party does.  Don’t go into a deal unless you are willing to be the one doing 150% of the work (or more).
  4. Be sure to have a backup plan in case the current plan doesn’t work out as anticipated.  You have heard the saying “Don’t have your eggs all in one basket”.  Another wards, don’t be so into this deal that you don’t have another option if it falls through.
  5. When the deal is off, realize its a done deal and move forward.  Don’t cry over spilt milk.  It is already spilt and no way to get it back into the cup.


A Beta Client Experience

April 20, 2012

Working with Physician’s offices that are start-ups, means they do not have the same capital to build their Medical Practice with.  This places challenges on many fronts when trying to find ways to be compliant with the Federal Regulations and making the Practice efficient and profitable.

In seeking to assist a client with the implementation of a Practice Management System with an Electronic Medical Records System (EMR), we (the software consultant for my client, my client and I) opted to be a Beta Client for a Texas-based company.  Their system was built for Chiropractor’s and they wanted to be able to advance and take their product to the next level.  The system was web-based, very user-friendly and had met the Meaningful Use requirements and was certified.  The company agreed to provide support and enhancements to meet the criteria needed by our specialty in exchange for us building the database, providing the feedback and testing the product for free along with a very low monthly maintenance fee.

After 5 months of working in the database, building the templates, creating the profiles, loading the CPT Codes, creating the Fee Schedules, loading the ICD9 Codes, inputting our patient base, etc the vendor has reneged on their agreement with us.  Their decision really made this a tough week to learn that they are not willing to fulfill their part of the deal with us.  The hard-core facts of the amount of time I have spent on something I won’t get a return on and the money spent to pay employees to load information in a system that we won’t be using, is gone.  We are back to square one, 4 months into a new year, with no more headway now then we were in the Fall of 2011 towards meeting Meaningful Use. This is a huge setback and a difficult situation that I currently am not aware how I am going to address, other than a meeting this next week with the Software Consultant and my client to discuss our options.


April 19, 2012

The quality of a leader is reflected in the standards they set for themselves.
– Ray Kroc

Classics to a Business Woman’s Wardrobe

April 18, 2012

As a Business Woman, I want to look professional.  I want to be distinguished and classy, but not over the top.  I want to not be so elaborate in my clothing and jewelry that you are distracted and don’t see the fact that I am a servant, there to work for you.  I am not here to look like a model but I still want to have an image that conveys business.  That does not mean what I wear is not cute or can’t be flattering.

There are many articles out there on what to wear and not wear.  This post is not going to be about that.  It is going to be  me sharing some information as to why I dress the way I do.

  • I wear a skirt or dress.  I don’t wear pants, never have.  Doesn’t meant there are not situations for them, but I am a lady, want to be seen as a lady, and want to act like one.  I don’t care what your views are on woman in pants, a woman in a skirt or dress brings automatic respect, especially when dealing with business men.
  • I wear lots of black.  Black is classic.  Black goes with nearly 100% of all other colors (navy and brown are the only two colors I know of that it doesn’t look good with).  Black is slimming.  Black is considered business dress.  You can never go wrong in black.
  • I introduce more white into my wardrobe from April – October here in Texas, depending on the weather.  White is a crisp, clean and fresh look that is classy, just like black.  It is not quite as businesslike, but it still is professional.  I don’t remove black completely, just don’t use it exclusively.
  • I do not want to have a suit or outfit for every day of the week.  Everything I have can be mixed and matched with at least one or two more outfits, if not with everything.  This cuts down on the number of items I have to have in my closet and things I have to take care of (from washing, mending, ironing, maintaining, storage, etc).
  • I have 5 classic pieces of jewelry that are always my standbys and coordinate with nearly all outfits.  A thin silver jewel necklace.  A cream large pearl bead necklace with black ribbon.  A fancy vintage diamond like necklace.  Silver beads.  A long silver necklace with a round piece of silver metal.  All of these pieces match with nearly all outfits, this means I don’t have to have a wardrobe full of stuff to accent an outfit.  I simply won’t purchase items that can’t accessorize any outfit.
  • I either wear a watch on my left hand or a bracelet.  I have very few big or bulky bracelets and only wear those if my outfit needs for boldness because it is too plain.  I have three watches, a plain grey faced/silver one, a red faced/silver one and a vintage one.  I wear a bracelet when it fits the outfit more and a watch when it doesn’t.  I also wear a watch if I am going to need to know the time and won’t have my cell phone with me (and may not be in a room with access to a clock).
  • I buy leather shoes and ones that are versatile with everything.  A pair of shoes that can’t be worn with various styles is a waste of money and means that I must pack more when going on a trip, let alone have more in the closet, and more to clean and care for.
  • I need my outfits to be versatile to be ready quickly and without a bunch of fuss.  Life is too short to be spending hours getting prepared for your client appointments, networking events, business meetings, and/or business trips.  I take the time ahead of time so that there is no last minute rush on trying to figure out what to wear, what matches with what, it all will coordinate or it won’t work for me!  That means very few items that are dry clean only.  Most of my blazers have to be dry cleaned, but the shirts and skirts I avoid that as much as possible.

What tips do you have for creating a Classic Business Woman’s Wardrobe?  What colors do you wear?  I would love it if you would share something that will help each of us to have a better wardrobe and maximize it.

Quit While You Still Can!

April 16, 2012

I am continually amazed at the number of people in the Healthcare Industry that smoke.  I am allergic, severely allergic, to it.  I choke up, start itching, and have breathing issues when I am around cigarette smoke.  It never ceases to amaze me that when you go into a healthcare facility, you will find healthcare workers right outside the entrance puffing away like it is their only lifeline.  They, above others, know the hard core reasons not to smoke and what smoking does to your body and the issues it causes to your health.

I know a doctor who doesn’t like it that he/she smokes and wants to stop, but is doing nothing to do so.  This physician puts this up in his/her office to help be a reminder as to what smoking does to you.  Do you think this will work?  What if when you sit in your office your back is to it?  Would you still smoke after seeing this?

Quit While You Still Can…is a great message…if you are listening.  But if you don’t read the fine print and your back is to it, it probably won’t do you much good.


April 12, 2012

“When you dare to dream, dare to follow that dream; dare to suffer through the pain, sacrifice, self-doubts and friction from the world.”
– Laura Schlessinger, talk-show host

ICD-10 is delayed another year…

April 11, 2012

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced Monday, April 9th, a proposed rule that would establish a unique health plan identifier under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The proposed rule would implement several administrative simplification provisions of the Affordable Care Act.

The proposed changes would save health care providers and health plans up to $4.6 billion over the next ten years, according to estimates released by the HHS today. The estimates were included in a proposed rule that cuts red tape and simplifies administrative processes for doctors, hospitals and health insurance plans.

“The new health care law is cutting red tape, making our health care system more efficient and saving money,” Secretary Sebelius said. “These important simplifications will mean doctors can spend less time filling out forms and more time seeing patients.”

Currently, when health plans and entities like third-party administrators bill providers, they are identified using a wide range of different identifiers that do not have a standard length or format. As a result, health care providers run into a number of time-consuming problems, such as routing errors of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility.

The rule simplifies the administrative process for providers by proposing that health plans have a unique identifier of a standard length and format to facilitate routine use in computer systems.  This will allow provider offices to automate and simplify their processes, particularly when processing bills and other transactions.

The proposed rule also delays required compliance by one year– from Oct. 1, 2013, to Oct. 1, 2014– for new codes used to classify diseases and health problems. These codes, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes, or ICD-10, will include new procedures and diagnoses and improve the quality of information available for quality improvement and payment purposes.

Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date. The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.

The proposed rule announced today is the third in a series of administrative simplification rules in the new health care law. HHS released the first in July of 2011 and the second in January of 2012, and plans to announce more in the coming months.

More information on the proposed rule is available on fact sheets at

The proposed rule may be viewed at Comments are due 30 days after publication in the Federal Register.


April 10, 2012
Set peace of mind as your highest goal, and organize your life around it.
– Brian Tracy, Speaker, Author, Consultant

Credentialing with Insurance Companies

April 9, 2012

We will be doing more Blog Posts on the subject of Credentialing, but today’s is simply an overview for you to understand what it is.

Credentialing, as defined by Texas Administrative Code (TAC) §10.82, is the “process for selection and retention of network doctors and health care practitioners” (providers). Credentialing is the process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy.  The credentialing process is part of the required Quality Improvement Program described in 28 TAC §10.81 and Texas Insurance Code, §§1305.301-1305.304. All certified workers’ compensation networks are required to document, create policies and procedures, and develop written criteria for credentialing network providers.

The initial credentialing process may begin with a provider submitting a completed Texas Standardized Credentialing Application to the Insurance Company and Network in which they wish to participate. The Credentialing Department and/or Committee will verify items such as the applicant’s work history, current professional liability insurance, education, board certification (if applicable), history of loss, sanctions or other disciplinary activity. The process may also consist of an on-site visit to assess the applicant’s location of practice or facility.  The applicant must be notified of the credentialing committee’s decision no later than 60 days after the decision. The WCNet is required to re-credential each participating credentialed provider every 3 years.

Many health care facilities, institutions and providers conduct their own credentialing, through this is a service that can be paid for and done by a credentialing specialist or electronic service, with review by a medical staff or credentialing committee.  It may include granting and reviewing specific clinical privileges, and medical or allied health staff membership.

As Texas is not an “any willing provider” state, the WCNet is not required to contract with a provider applicant. However, pursuant to 28 TAC §10.82, a provider has the right to review the information submitted to support the credentialing application, correct erroneous information and the right to be informed of the status of their credentialing or re-credentialing application.

The process is generally an objective evaluation of a subject’s current licencee, training or experience, competence, and ability to provide particular services or perform particular procedures.

Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment).  Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly.


Do you do your own credentialing or do you hire someone else to do it?

What are you passionate about?

April 6, 2012

In a quest to help some friends, I want to get feedback from you…

What are you passionate about?  How did you learn what that was?  Are you doing work that matters?  Do you love what you do?  What motivates you?  Will you share with me your story?


April 5, 2012

A good leader inspires other men and women with confidence. A great leader inspires them with confidence in themselves.

– Reed Markham

7 things to consider in taking a Medical Billing Course

April 4, 2012

I get asked all the time how to get into Medical Billing.  What is the best course to take?  How to be able to do it and work from home?  All of us really would love to have a job that paid well that we didn’t have to work very hard at. I don’t know of many of those types of jobs out there.  Good money for little effort?  Convenience of working from home with a guaranteed income?

You can read my story of how I got into Medical Billing here along with some information on the Medical Billing Industry here.  I want to give you some things to consider if you are looking to do a Medical Billing Course:

  1. Evaluate the course.  What do they teach you?  If they only are teaching you Medical Coding (ICD9 & CPT Codes) this is not going to give you all the skills you need to do the job, though it will be a start.  Medical Billing and Medical Coding are not the same thing.  You can learn more about the difference here.
  2. Evaluate the teachers.  How many years experience do they have in Medical Billing and/or Medical Coding?  What types of specialties have they worked in?
  3. Evaluate their promise to get you a job.  Many of these courses promise to get you a job in the Medical Field.  In my experience, this happens very rarely.  Physician’s offices don’t just hire people because they have schooling.  You have to be willing to start at the ground up and work up, just like anyone else.  Schooling does not replace on the job experience nor actual hands on experience.  Schooling is just knowledge.
  4. Evaluate the cost.  How much will you spend for this course in time, energy and money verses if you took a job at a local Medical Practice and worked your way up to this position?  Many times spending time, energy and money on something helps you, but that is not always 100% the case.
  5. Evaluate why you want to take the Medical Billing Course.  Is it because you want to learn something new?  Is it because the industry and career field intrigue you?  Or are you simply wanting money and an easy way you think you can get it?  Many of these programs guarantee you will be making lucrative money working from home.  In all seriousness, you can make money, but it is not going to be this huge income that will allow you to be “rich”.  It takes a lot of hard work, determination, understanding of all the industry rules & regulations (both on a State and Federal level), attention to detail, accuracy and prompt response.  Secondly, working from home doing Medical Billing is not the common everyday scenario.  Is it possible?  Yes, but in all liklihood you will not start out that way.
  6. Many of the advertised Medical Billing Courses out there are scams.  Research them.  The software they train you on is one of many that are out there; literally there are hundreds of different programs.  You need to learn the skills of the job, not how to operate a system.  Check with the Better Business Bureau to see if there have been complaints.  Ask to speak with other students who have taken their course, would they recommend you to take the course?  Would they spend the money for the course all over again?  Did they achieve their goal by taking the course?  Are they in a job that is what they went to school for?  What sort of pay range are they at?  If they can’t give you the answers you are looking for, then it is probably not going to work for you either.
  7. If you do take a Medical Billing Course, you may need to volunteer at a Non-Profit Medical Center to get your foot in the door.  You may have to take a position as a Medical Receptionist first to be able to help the Medical Billing Team.

Attend all the Seminars and Coding Classes that are offered in your area to make connections and even find someone who will mentor you.  Remember that you will have to continue to learn, do research, train and educate yourself on your own, for free, to continue to stay up in the Industry and be an employee a company out there wants to hire.  You must understand that Physician’s need confidence that you are going to be handling their money appropriately and accurately, whether you are in-house or out-sourced.  If you want to be successful at Medical Billing, you can, but YOU must put the effort into it.

Texas Clean Claim Requirements

April 2, 2012

Each states has its own guidelines and regulations set forth in various forms of the Healthcare Industry.  The Texas Department of Insurance has guidelines on specific requirements that are needed on a HCFA1500 in order for it to be considered as a Clean Claim.  You can review those documents here on the Texas Secretary of State website.

Do you wonder if the Texas Clean Claim Requirements apply to you?  You can read and find that information here.

A clean claim must be submitted in order for the Prompt Pay Guidelines to apply.  We will review those with you soon!