CMS Forms and Insurance Billing Idiosyncracies

Saturday, November 10, 2007
Posted in: Practice Management

In other posts and in responses to users, we have often given out the link to a PDF file thaf has very detailed information about which CMS-1500 fields should have what information in them.  (Click here to download the file now.)  Not only did we put the file up on our website (under the HIPAA section) to give you all a leg-up on insurance companies and MediCare to make sure you were filling out the form correctly, we also used that form in the production of AcuBase.  For instance, many fields on our CMS screens pop up with the exact information from the "’official" guidelines from the above-mentioned form.  Further, many of our competitors have downloaded this same form from our website and offered it up to their customers.  Good for them--proof that we all need help with medical billing.  

But here’s the thing.  As many of you may have surmised by now, insurance companies are all about making money, and one of the ways of doing that is to delay paying you and hope that (a) you won’’t respond to their demands for further information; and/or (b) you won’t fight their rejections.  One reason they may choose to reject your claims is because the CMS form was not filed out to their liking, and something we’ve found a lot lately is that they are asking practitioners to put certain codes in areas of the CMS that were not originally intended for said codes.  For example, one customer of ours was recently told by an insurance company that they needed to put a long code into Box 24 B, which only holds 2 digits by default.

So what do you do when an insurance company rejects your claim based on their ‘changing’ of the CMS form?  One thing you can do is print out a copy of the official form guidelines and reference the field(s) they are disputing.  Beyond that, offer to submit the form as a superbill and see what they say.

In the end, all I wanted to say here is that, while we are supposed to do the CMS form in a very specific way, insurance companies may ask you to do otherwise.  There’s not a lot we can do about it as practitioners, we can only do our best to stick to the official form rules, and hope that the insurance company reviewers do the same. 

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