Wednesday, July 31, 2013

Follow This 3-Step Advice Before Waiving Copays

Follow This 3-Step Advice Before Waiving Copays

Tip: Get your own verification of financial hardship.

Every Physician wants to collect his due payment, even if it accumulates in small amounts through copays or deductible. Though you often hear advice pointing you away from offering discounts or waiving fees, there are times when that approach can be your best option. Our experts share three steps to properly waiving patient fees based on financial hardship.

1. Understand the Exception to the Rule

Routinely waiving deductibles and copayments can violate several federal laws and regulations, including the federal False Claims Act, anti-kickback statutes, and compliance guidelines for individual and small group physician practices. Doing so may also violate payer contracts.

In black and white: "Physicians or suppliers who routinely waive the collection of deductible or coinsurance from a beneficiary constitute a violation of the law pertaining to false claims and kickbacks," CMS says in the Medicare Claims Processing Manual, chapter 23, section 80.8.1. This applies not only to Medicare payers, but also those private carriers that base their regulations on Medicare rules.

Even though the rule is that you shouldn't offer waivers and discounts, you can make exceptions based on financial hardship-- if you follow a few guidelines.

"Waivers or discounts... should be made only on the basis of demonstrated patient financial need," says Barbara Colburn, president/CEO of B.C. & Associates Management Corp., a Wisconsin-based health care consulting/billing organization. According to Colburn, you must meet the following criteria:
  1. You do not offer the waiver as part of any advertisement or solicitation
  2. You do not offer waivers routinely to patients
You offer the waiver after determining, in good faith, that the individual is in financial need or after reasonable collection efforts have failed.

"In offices that i managed we always had the option of a financial hardship waiver but it was usually offered only after all the other means of collecting were exhausted such as insurance, payment plans, etc." says Marge McQuade, CMSCS, CMM, a consultant in Florida.

Note: You can offer discounts to patients with no insurance who are self-paying without proving financial hardship. Offering waivers or discounts to insured patients, including Medicare patients, "may be suspect unless they are non-routine and related to genuine hardship," Colburn says.

Pointer: "Have a financial policy in place about how you handle patients with financial hardships," advises Catherine Brink, CMM, CPC, CMSCS, owner of HealthCare Resource Management, Inc., in Spring Lake, N.J. "This is very important since it ensures you don't 'discriminate' how you handle finances with your patients."

2. Get It in Writing

Don't just take the patients word for it when it comes to financial hardship. Before you agree to debt write-off, the patient needs to be able to prove he is unable to pay.

First, document the effort you took to collect the money. "Where a physician/supplier makes a reasonable collection effort for the payment of coinsurance/deductible, failure to collect payment is not considered a reduction in the physician's/supplier's charge," CMS says in the Medicare Claims Processing Manual, chapter 23, section 80.8.1. "To be considered a reasonable collection effort, the effort to collect Medicare coinsurance/ deductible amounts must be similar to the effort made to collect comparable amounts from non-Medicare patients. It must also involve the issuance of a bill to the beneficiary or to the party responsible for the patients personal financial obligations. In addition, it may include other actions, such as subsequent billings, collection letter and telephone calls or personal contacts which constitute a genuine, rather than token, collections effort."

If you want to prove financial hardship, you'll need to ask the patient to provide you with information such as income tax returns and W-2 and 1099 forms as proof of income and essential monthly household expenditures, such as mortgage/rent, utilities, insurance, and food.

You'll then use this information to determine whether the patients earnings meet state and federal poverty guidelines. "Make sure you work within the poverty guidelines for your state," McQuade cautions.

Official Guidance: The Office of the Inspector General (IOG) states, "we do not believe it is appropriate to apply inflated income guidelines that result in waivers for beneficiaries who are not in genuine financial need."

The patient and the physician should also sign a statement detailing that the practice reviewed proof of financial hardship and listing what charges the practice is waiving. You practice should keep a copy and provide a copy to the patient as well.

"The provider should keep up with legal developments related to discounts and waivers of co-payments and deductibles," Colburn explains.

Key to success: You also should only apply the determination of financial hardship to the particular visit or service you are billing for at the time, not to any future services.

3. Don't Avoid Collections If Waiver Is a No Go

If a patient applies for financial hardship but your practice deems that the patient does not meet the qualifications for a waiver, you should send a waiver denial form. But don't let that stop your collections efforts and end up in a write off. You then need to proceed with billing the patient and letting him know you expect payment.

Option: "If a patient applied for financial hardship and doesn't qualify, the next step would be to offer a payment plan for the patient, depending, of course, on the amount the patient owes and at what point you are doing the waiver (after insurance, self pay with payment plan first, etc.)," McQuade says.

"For example, ask for a credit card to keep on file that you would charge, say $50 each month," agrees Brink. "Have the patient sign this financial agreement." If the patient doesn't have a credit card, then set up a financial payment plan signed by the patient stating that he will pay by check or cash by a certain day of each month and the amount he will pay plus the date the balance will be paid in full, Brink adds.

Courtesy of: The Coding Institute: Family Practice Coding Alert

Monday, July 29, 2013

3 Easy Ways to Increase Your Medical Practice Revenue by 25%

There are a hundred ways to streamline workflow and improve revenue in a medical practice. It’s hard to pick just a few, but in this guide, that’s just what we have done.

Here are three simple suggestions that any practice should be able to implement that can generate an increase of at least 25% revenue.

And they cost little or nothing to implement.

1. Make Money on Prescription Refills
Prescribing is a big deal for most practices. Many report the greatest percentage of in-bound phone calls to their practices are prescription related. Either the patient is asking for prescription refills or pharmacy personnel are seeking approval to fill a script. Have you ever considered how much this process is costing your practice? Have you ever asked, “How can we be compensated for this time?”
Who makes money when prescriptions are filled? Perhaps the more important question is who does not make money on prescription refills. Today, most commonly, the pharmacist is benefiting the most from the prescription renewal process. Sure, the pharmaceutical manufacturers are also making revenue from the sale. Unfortunately, the biggest loser in this process is the medical practice. But it doesn’t have to be this way.
How much does the prescription refill process cost your practice? Every patient or pharmacist contact for a prescription refill creates a cost to the practice. What is the overhead cost in your practice for the following functions? • Taking a message • Pulling a fax off the fax machine • Pulling a chart • Provider reviewing the chart • Authorizing the refill • Calling or faxing in the prescription
Even if your practice has automated some of these functions, there still is a cost, and it is important for you to calculate it.
Is it possible to transform this cost into revenue? The temptation is to believe that the prescription refill process is just a cost of doing business. It doesn’t have to be this way! The fact is that a prescription policy can generate additional revenue for the practice and offset that cost.
This policy outlines how refill and other prescription requests are handled. It should include a follow-up period for chronic disease patients. Generally, they should be seen every 90 days for evaluation and review of medications. It can be billed as 99213 with an average reimbursement of about $70.00. Also, consider including something in the policy for patients who call with acute symptoms and are “experts” at self-diagnosis. They may call and request that a prescription be called in without a visit. Your policy should focus on eliminating prescribing in these cases and getting those patients in for an appointment, ideally the same day. If you have mid-level providers, they can perform these types of services. Make sure all staff are well-versed in the prescription policies and that those policies are clearly conveyed to patients. If needed, you can create talking points for staff to help them with the change.
The average practice can spend anywhere from $4.00 to $15.00 for every single prescription refill event.

2. Use Your Schedule to Maximize Visits
Time really is money for most healthcare providers so your goal should be to see as many patients as possible each day. Unfortunately, physicians historically haven’t been good at using their schedules to generate income. So your front office staff needs to learn to be strategic in their scheduling process because every unfilled appointment represents a loss of income.
Analyze Your Patient Mix Are they primarily fee-for-service (FFS) or capitated? FFS patients pay for services one-by-one where capitated patients have a set fee that has been paid for services performed.
Fill your schedule based on the mix of patients. If you have 70% FFS and 30% capitated your schedule should reflect that, and you should triage patients accordingly as well. Try to schedule capitated patients only in your blocked capitated spaces while leaving same day and extended hours open for FFS patients. Don’t book capitated patients in the same-day slots unless necessary. You don’t want to lose the revenue from FFS patients, and they may go elsewhere if they can’t get in to see you promptly.
Categorize Your Visits You have many types of visits. Some take longer than others. A new patient visit takes a lot longer than an established patient. Acute patients are different than visits for preventive care.
Do an analysis of the types of appointments you have. Once you have identified those visits, look at how much time each visit takes and what resources need to be scheduled. You can then customize your scheduler with your practice resources (providers, rooms, equipment, etc.) and place appointments at times of the day where it makes the most sense.
For example, put longer, new patient visits at the end of the day while shorter visits can be placed earlier in the day.
If you can schedule by resource, you can also book more than one patient for the same or overlapping time slots. Having more control over your scheduling helps you get more patients each day and helps you improve their experience by reducing wait times.
Developing the perfect schedule for your practice may take some work and even some trial and error but in the end, you’ll find it’s worth it.
Consider Double-Booking According to Medicaid, one in three patients doesn’t show up. Other studies suggest 25-50% of follow up patients cancel or don’t show. Look at your schedule to identify groups of patients who are most likely to cancel or not show up. Consider double-booking those types of patients or appointments. Also, consider changing the way you discuss some of these types of visits with patients. For example, say “See you in five days” and have the patient schedule a follow up versus “Call us if you aren’t feeling better.”
Create a Cancellation/No-Show Fee Patients who cancel appointments or surgeries at the last minute can be a huge drain on your practice’s cash flow. Since you are already streamlining your schedule, consider also implementing a strategy to prevent unexpected holes to minimize the impact of last minute cancellations and no shows on your medical practice.
Set a cancellation policy, and be sure it’s communicated to every patient. Ideally, this takes the form of a document that new patients sign when they first come to the practice. Afterward, make it a point to discuss your policy at the time of booking subsequent appointments or surgery, and when reminder calls or emails go out to patients.
In the cancellation policy, many practices require patients to cancel their appointment at least 24 hours before their scheduled appointment time. For surgeries, the required notice time can be even longer. For those patients who do not comply, consider charging a late cancellation fee.
Collecting cancellation fees can be achieved much more easily than you think when your office is set up to bill for cancellations and accept credit card payments. By creating a cancellation code, you can bill the patient using electronic statements. The day of the cancellation or no-show, process a patient statement and direct the patient to pay online by credit card. Enabling patients to pay online can increase patient payments and speed the turnaround on those payments whether it is for the cancellation fee or for standard co-pays and deductible payments.
3 Easy Ways to Keep Your Practice on Schedule
It may be one of the biggest challenges in a medical practice—staying on schedule. Physicians get sidetracked with refill requests, reviewing labs, returning calls to patients. Patients take up more time than they are allotted. A registration person calls in sick and your front desk gets a little behind. There are a hundred reasons why you might get off track. But once it happens, it’s hard to get that time back. You may find that your practice is slightly behind for the rest of the day. Here are a few simple strategies that might help avoid bottlenecks or turn things around when they start to go south.
1. Easiest: Set clear guidelines for staff about not interrupting the physician with calls or questions between appointments unless it is a true emergency.  Establish a process for the physician to receive messages and manage tasks at specific times of the day—first thing each morning, at the end of the day, perhaps a break at midday. He or she can take care of refills or return calls during those appointed times.
2. Easier: Prioritize tasks for staff. Make sure your staff know what their top priorities are so that if they get busy they know what to let go of for the time being. Sometimes people are trying to do too much when they should just be focused on moving patients swiftly through their appointment. 
3. Easy: Do an analysis of your time management, including your scheduling process and task management. You may need to look at your days from nuts to bolts. Is your schedule inefficient? Maybe the problem is that your longest patient visits are at the wrong time of day and they are causing backups everywhere else. Perhaps your providers just aren’t managing their tasks well. Many practice management and electronic health record systems offer task management tools. If everyone isn’t using them to stay on top of tasks and priorities, now might be a good time to start.
In the end the most important things to remember when trying to keep things on track are making sure that everyone knows exactly what their role is, what their priorities are, and what they should do if things get busy.  Sometimes the problem is simply that people don’t know what to do next to keep things on track and they flounder.
According to Medicaid, one on three patients doesn’t show up.

3. Mine Your Data to Increase VolumeNow that your schedule can accommodate more patients, you need have to get the patients to make appointments. At no extra cost to you, you can mine the data in your medical billing software to market your practice and increase volume.
Reach Out to Your Patients According to the Medical Group Management Association, you should be spending 1-3% of your practice revenue on marketing. If you aren’t marketing your practice, reaching out to existing patients based on your own data is a good, and essentially free, way to start. If your initial efforts are successful then you can decide if it’s worth it to invest a little more to send mailers or do other marketing outreach.
Your practice management and medical billing software is full of information that you can use to increase patient volumes and revenue. Dig into your data and run reports to identify the following types of patients (depending on your practice): • Patients with chronic conditions like diabetes, hypertension, and heart disease who are due for a follow up appointment. • Patients who may be due for physicals, well-woman or well- child checks, and other preventive care. • Anyone who may need immunizations, including annual flu or pneumonia shots.
Once you identify patients you can contact for appointments, be sure you have a process in place to do the reminders via mail, email, text, or phone. Also, make sure you’ve completed step two above and your schedule is setup to accommodate an increase in patient volume.
Implement Staff Incentives By maximizing your schedule and reaching out to patients to make appointments, you’ve created more work for your staff. You might be inclined to say, “Hey, that’s their job.” But your staff is more likely to work hard to get those patients in the door if you set a clear goal for your increase in appointments and reward staff for achieving that goal.
For example, if you decide that the goal is to increase patient visits in the first quarter by 10%, offer a bonus of some kind if your practice reaches this goal. It could be gift cards or a party—whatever you think your staff would like. You can do straight cash bonuses if you think that will work best. Show your staff that their hard work is appreciated and that increases in patients and practice revenue will benefit everyone.
Tap Into Payer Incentives There may be some added bonuses to this process. Some payers are now offering incentives for certain preventive care actions or chronic care follow up. Because incentives can vary widely by payer, state and even specialty, you’ll need to contact payers to ask about incentives. Reaching out to patients, may help your practice to tap into free money from those health plans that are providing financial incentives for meeting quality indicators.
The End Result There are a lot of ways to streamline your practice functions, reduce costs, or increase revenue. But these three options can apply to almost any practice, cost little or nothing to implement, and are virtually guaranteed to increase your revenue.
Courtesy of: Kareo

Medicare Palmetto Jurisdiction 1 Part B: E/M Weekly Tip: Denials or Down codes

If you receive a denial or down code based on medical necessity, it is important to review the documentation submitted along with the E/M guidelines to determine the reason/cause for the denial. You may use the online E/M Checklist and Scoresheet Form to assist with auditing/selecting the E/M level. If you do not agree with the denial/down code you may appeal the service(s) within 120 days from the date of the initial determination.

Sunday, July 28, 2013

Time management: Tips to reduce stress and improve productivity

Effective time management is a primary means to a less stressful life. These practices can help you reduce your stress and reclaim your personal life.

By Mayo Clinic staff
Do you find yourself overwhelmed by the number and complexity of projects that need to be completed at work each day? As the day flies by, do you often feel as if you haven't paid enough attention to each task because other tasks keep landing on your desk, co-workers interrupt you with questions or you can't get it all organized?
You probably know that managing your time effectively will help you get more done each day. But it has important health benefits, too. By managing your time more wisely, you can minimize stress and improve your quality of life.
But how do you get back on track when organizational skills don't come naturally? To get started, choose one of these strategies, try it for two to four weeks and see if it helps. If it does, consider adding another one. If not, try a different one.
  • Plan each day. Planning your day can help you accomplish more and feel more in control of your life. Write a to-do list, putting the most important tasks at the top. Keep a schedule of your daily activities to minimize conflicts and last-minute rushes.
  • Prioritize your tasks. Time-consuming but relatively unimportant tasks can consume a lot of your day. Prioritizing tasks will ensure that you spend your time and energy on those that are truly important to you.
  • Say no to nonessential tasks. Consider your goals and schedule before agreeing to take on additional work.
  • Delegate. Take a look at your to-do list and consider what you can pass on to someone else.
  • Take the time you need to do a quality job. Doing work right the first time may take more time upfront, but errors usually result in time spent making corrections, which takes more time overall.
  • Break large, time-consuming tasks into smaller tasks. Work on them a few minutes at a time until you get them all done.
  • Practice the 10-minute rule. Work on a dreaded task for 10 minutes each day. Once you get started, you may find you can finish it.
  • Evaluate how you're spending your time. Keep a diary of everything you do for three days to determine how you're spending your time. Look for time that can be used more wisely. For example, could you take a bus or train to work and use the commute to catch up on reading? If so, you could free up some time to exercise or spend with family or friends.
  • Limit distractions. Block out time on your calendar for big projects. During that time, close your door and turn off your phone, pager and email.
  • Get plenty of sleep, eat a healthy diet and exercise regularly. A healthy lifestyle can improve your focus and concentration, which will help improve your efficiency so that you can complete your work in less time.
  • Take a time management course. If your employer offers continuing education, take a time management class. If your workplace doesn't have one, find out if a local community college, university or community education program does.
  • Take a break when needed. Too much stress can derail your attempts at getting organized. When you need a break, take one. Take a walk. Do some quick stretches at your workstation. Take a day of vacation to rest and re-energize.
  • Ask for professional help
    If you're too frazzled to think about trying any of these tips, it's time to ask for help. Does your life feel totally out of control? If so, contact your employee assistance program (EAP) at your workplace for assistance, or discuss your situation with your doctor.
Courtesy of: Mayo Clinic:


4 J code Options Help you Determine Strep Throat Diagnoses: ICD-9 to ICD-10

Wait for lab results before assigning the final code.

ICD-9 coding: When using the ICD-9-CM code set, you report 034.0 (Streptococcal sore throat) if the patient suffers from streptococcal laryngitis. The ICD-9 manual also directs you to 034.0 if the patient suffers from streptococcal tonsillitis or pharyngitis.

ICD-10 changes: When ICD-10 becomes effective in October 2014, you won't have a simple catch-all code for streptococcal throat infections. Instead, ICD-10 will differentiate between streptococcal laryngitis, pharyngitis and tonsillitis, so your documentation will need to specify type. The four diagnosis choices will be:
  • J02.0 (Streptococcal pharyngitis)
  • J03.00 (Acute streptococcal tonsillitis, unspecified)
  • J03.01 (Acute recurrent streptococcal tonstillits)
  • J04.0 (Actue laryngitis)
Code j04.0 requires you to use an additional code to report the infections agent. For strep, that code would be B95 (Streptoccoccus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere), with the exact code depending on the nature of the streptococcus.

Documentation tip: Don't report the strep throat diagnosis code unless your physician receives confirmation from a lab test (either rapid strep or throat culture) indicating that the patient tested positive for a streptococcal throat infection. If you don't have a positive lab test confirming strep throat, you should simply report the diagnosis codes for the symptoms (such as sore throat, fever, etc).

Vital: Your documentation must include a copy of the laboratory report confirming that the patient had strep throat before you select your diagnosis code.

The family physician will ned to clearly note which type of throat condition the patient has, so you can code accordingly to whether the pateint's streptococcal infection affected the larynx, pharynx or the tonsils.

In addition, if the patient suffers from streptococcal tonstillits, you will have to further delineate whether he is experiencing an unspecified or recurrent acute condition. If you use, J03.01 (recurrent), your documentation must confirm that the patient has suffered from the condition in the past.

Coder tips: Make sure that you print the new strep throat codes on your superbills prior to ICD-10 implementation, and let your practicioners know that they will need to differentiate between streptococcal laryngitis, phyryngitis, and tonstillits.

Courtesy of: The Coding Institute: Family Practive Coding Alert

Friday, July 26, 2013

How To Start Your Own Medical Billing Service: 5 Star Review on Amazon!

Customer Review

5.0 out of 5 stars A perfect starting point for those looking to start their own business, July 16, 2013
This review is from: How to Start Your Own Medical Billing Service: Becoming Self Employed (Paperback)
This book was all that I was hoping for when purchasing it. It gives a great overview on all aspects of starting your own medical billing service from home. It gives brief information on things you will need to start a business and gets into more detail on specific aspects of a medical billing business. I now have a better perspective and understanding of what I am getting myself into. The book is a perfect starting point. I am excited to get started and now I have a better outlook on the challenges that lie ahead and a better understanding of where to start.

How the New HIPAA Regulations Affect Billing Companies and Their Subcontractors as Business Associates

How the New HIPAA Regulations Affect Billing Companies and Their Subcontractors as Business Associates

Develop an Action Plan for Your Company and Subcontractors

An article by Robert A. Polisky, Esq.,  taken from the May/June issue of HBMA Billing.
On January 25, 2013, the Office for Civil Rights of the U.S. Department of Health & Human Services (OCR) published the anticipated final omnibus rule (the Final Rule). This rule created significant changes to the Privacy, Security, Breach Notification, and Enforcement Rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), many of which are required by the Health Information Technology for Economic and Clinical Health Act (HITECH Act). The Final Rule also implements changes to the Genetic Information Nondiscrimination Act of 2008.

The scope of the Final Rule is extensive, and enhances OCR's ability to enforce HIPAA. In the press release announcing the Final Rule, OCR Director Leon Rodriguez proclaimed that the Final Rule "marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented" and "strengthen[s] the ability of my office to vigorously enforce the HIPAA privacy and security protections…." Individuals and entities affected by the Final Rule must comply with most of its provisions by September 23, 2013.
This article addresses key provisions of the Final Rule applicable to billing companies and their subcontractors, enforcement changes, and recommended action items needed for compliance by billing companies and their subcontractors.


Business Associates and Their Subcontractors

Expanded Definition of "Business Associate"
The Final Rule expands the definition of a "business associate" to include any individual or entity that creates, receives, maintains, or transmits protected health information (PHI) on behalf of a covered entity. Companies that code, bill, and/or collect claims on behalf of a health care provider (i.e., a covered entity), are business associates under HIPAA. Notably, the Final Rule includes subcontractors that create, receive, maintain, or transmit PHI on behalf of a business associate as business associates themselves. Thus, any subcontractors that a billing company engages to assist in coding, billing, or collections, and any subcontractors that store or transmit any healthcare records on the billing company's behalf, are business associates of the billing company.

Direct Liability
As business associates, the Final Rule requires billing companies and their subcontractors to comply with the Security Rule's administrative, physical, and technical safeguard requirements as well as with the Security Rule's policies and procedures and documentation requirements. These requirements apply to business associates in the same manner as they apply to covered entities, such that billing companies and their subcontractors can be held civilly and criminally liable for violations of these requirements. Similarly, the Final Rule applies certain Privacy Rule requirements to business associates and establishes direct liability of business associates for violations of these requirements. A billing company does not need to provide a notice of privacy practices or designate a privacy official unless the covered entity designated such a responsibility in the billing company's business associate agreement.

Specifically, billing companies and their subcontractors, as business associates, have direct civil and criminal liability exposure for the following items.
  1. impermissible uses and disclosures of PHI
  2. failure to provide breach notification to the covered entity
  3. failure to provide access to a copy of electronic PHI to either the covered entity, the individual, or the individual's designee (whichever is specified in the business associate agreement)
  4. failure to disclose PHI to OCR where required by OCR to investigate or determine the business associate's compliance with HIPAA
  5. failure to provide an accounting of disclosures
  6. failing to enter into business associate agreements with subcontractors that create or receive PHI on the business associate's behalf
  7. failure to comply with the requirements of the Security Rule
Billing companies and their subcontractors also remain contractually liable for all other Privacy Rule obligations that are included in their business associate agreements.
Business Associate Agreements
The Final Rule clarifies that a covered entity is not required to enter into a business associate agreement with a billing company's subcontractor. Rather, the billing company that engaged a subcontractor to perform a function or service involving the use or disclosure of PHI is required to enter into a business associate agreement with the subcontractor. Each business associate agreement in the business associate chain needs to be at least as restrictive as the agreement above it in the chain with respect to permissible uses and disclosures of PHI.
The Final Rule expands the requirements of a business associate agreement by obligating a business associate to comply, where applicable, with the Security Rule with regard to electronic PHI; report breaches of unsecured PHI to the covered entity; and ensure that any subcontractors that create or receive PHI on its behalf agree to the same restrictions and conditions that apply to the business associate with respect to such information.

Transition Period
The Final Rule delays compliance until September 22, 2014 for a covered entity or business associate to enter into a business associate agreement with a business associate or subcontractor if, prior to January 25, 2013, the covered entity or business associate had a business associate agreement with the business associate or subcontractor, as applicable, that complied with HIPAA prior to the Final Rule (unless the business associate agreement was modified or actively renewed between March 26, 2013 and September 23, 2013). In all other cases, covered entities and business associates will need to execute business associate agreements with their business associates and subcontractors no later than September 23, 2013.

Modification To The Breach Notification Rule

Under the HITECH Act, a covered entity is required to notify affected individuals and OCR following discovery of a breach of unsecured PHI; a covered entity also needs to notify the media of a breach involving more than 500 residents of a state or jurisdiction. A business associate, in turn, is required to notify a covered entity following discovery of a breach of unsecured PHI at or by the business associate.
On August 24, 2009, OCR issued an interim final rule implementing the HITECH Act's breach notification provisions ("Breach Notification Interim Rule"). In the Breach Notification Interim Rule, a "breach" is defined as the acquisition, access, use, or disclosure of PHI in a manner not permitted under the Privacy Rule that "compromises the security or privacy" of the PHI, with certain exceptions. Moreover, under the Breach Notification Interim Rule, "compromises the security or privacy" of the PHI is defined to mean that an impermissible use or disclosure of PHI poses a significant risk of financial, reputational, or other harm to the individual (the "harm standard").
Revised Definition of "Breach"
The Final Rule significantly revises the definition of "breach" to clarify that an impermissible use or disclosure of PHI is presumed to be a breach unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the PHI has been compromised. By replacing the "harm standard" with this "low probability" standard, it is more likely under the Final Rule than under the Breach Notification Interim Rule that covered entities and business associates will determine that an impermissible use or disclosure of PHI "compromises the security or privacy" of the PHI, resulting in many required breach notifications that would not have been required previously.
Modification of Risk Assessment
Under the Final Rule, to determine whether there is a low probability that PHI has been compromised, covered entities and business associates need to conduct a risk assessment that considers at least the following factors:
  • the nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification;
  • the unauthorized person who used the PHI or to whom the disclosure was made;
  • whether the PHI was actually acquired or viewed; and
  • the extent to which the risk to the PHI has been mitigated.
If an evaluation of the above factors, taken together, fails to demonstrate that there is a low probability that PHI has been compromised, breach notification will be required.

Right to Restrict Disclosure to a Health Plan

Under the Final Rule, health care providers, upon request from an individual, must agree to restrict disclosure of PHI about the individual to a health plan if the disclosure would be for the purpose of carrying out payment or healthcare operations, and is not otherwise required by law, or the PHI pertains solely to a healthcare item or service for which the individual, or person acting on the individual's behalf (other than the health plan), has paid the covered entity in full. To avoid payment issues, a health care provider may want to require payment in full at the time of the individual's request for a restriction. Health care providers may request assistance from billing companies to comply with this new restricted disclosure requirement.


The Final Rule gives OCR discretion to use informal means to resolve HIPAA violations. However, OCR is permitted to impose a civil monetary penalty without exhausting informal resolution efforts, especially when the HIPAA violation is due to willful neglect. The Final Rule also allows OCR to coordinate with other law enforcement agencies, such as state attorneys general and the Federal Trade Commission, with respect to pursuing remedies against HIPAA violators.
Tiered Penalty Amounts
Under the HITECH Act, there are four tiers of increasing penalty amounts that correspond to the levels of culpability associated with a HIPAA violation. The minimum fines range between $100 and $50,000 per violation, and are capped at $1.5 million for all violations of the same HIPAA provision during any calendar year (see below table). The lowest category of violation covers situations where the covered entity or business associate did not know, and by exercising reasonable diligence would not have known, of the HIPAA violation. The second lowest category of violation applies to violations due to reasonable cause and not to willful neglect. The third category applies to situations where the violation was due to willful neglect and was corrected within 30 days of when the covered entity or business associate knew, or should have known, of the violation. The fourth category applies to situations where the violation was due to willful neglect and not corrected within 30 days of when the covered entity or business associate knew, or should have known, of the violation.
The Final Rule modifies the definition of "reasonable cause" to mean "an act or omission in which a covered entity or business associate knew, or by exercising reasonable diligence would have known, that the act or omission violated [HIPAA], but in which the covered entity or business associate did not act with willful neglect." The Final Rule keeps the definition of "willful neglect" as the "conscious, intentional failure, or reckless indifference to the obligation to comply" with HIPAA.
Counting Violations
In the preamble to the Final Rule, OCR states that how it counts HIPAA violations for purposes of calculating a civil monetary penalty varies depending on the circumstances surrounding the violation. OCR explains that where multiple individuals are affected by a HIPAA violation (e.g., a breach of unsecured PHI), it is anticipated that the number of identical HIPAA violations would be counted by the number of individuals affected. OCR also explained that, with respect to continuing violations (e.g., a lack of appropriate safeguards for a period of time), it is anticipated that the number of identical HIPAA violations would be counted on a per day basis (i.e., the number of days the covered entity or business associate did not have appropriate safeguards in place to protect the PHI). OCR notes that in many HIPAA breach cases, there would be an impermissible use or disclosure as well as a safeguards violation, for each of which OCR would be entitled to calculate a separate civil monetary penalty. Needless to say, the amount of civil monetary penalties that could be imposed against a billing company or one of its subcontractors for a HIPAA violation can be quite substantial.
Factors Used to Determine a Penalty
The Final Rule lists the following five factors that OCR will consider in determining the amount of a civil monetary penalty.
  1. the nature and extent of the HIPAA violation, including the number of individuals affected and the duration of the violation
  2. the nature and extent of the harm resulting from the violation, including physical, financial, and reputational harm, and any hindrance to an individual's ability to obtain healthcare
  3. the history of prior compliance with HIPAA, including whether the current violation is the same/similar to prior indications of noncompliance by the covered entity or business associate and their attempts to correct that noncompliance
  4. the financial condition of the covered entity or business associate, including any financial difficulties that could have affected compliance and whether a civil monetary penalty could jeopardize the future provision of healthcare
  5. such other matters as justice may require
Agency Liability
The Final Rule makes covered entities and business associates liable for the acts of their business associate agents, regardless of whether the covered entity or business associate knew of the violation or had a compliant business associate agreement in place. According to OCR, the key factor in determining whether an agency relationship exists between a covered entity and its business associate, or between a business associate and its subcontractor, is the principal's right to control the agent's conduct in the course of performing a service on behalf of the principal. OCR observes that a business associate agent's conduct generally is within the scope of agency when its conduct occurs during the performance of the assigned work or incident to such work, regardless of whether the work was done carelessly, a mistake was made in the performance, or the business associate disregarded a covered entity's specific instruction. OCR further observes that, in contrast, a business associate agent's conduct generally is outside the scope of agency when its conduct is solely for its own benefit (or that of a third party), or it pursues a course of conduct not intended to serve any purpose of the covered entity. To protect itself, a billing company's services agreement with a subcontractor should specify that the subcontractor is engaged as an independent contractor, not as an agent, and the billing company does not have the right to control the subcontractor's performance.


Although billing companies and their subcontractors have until September 23, 2013 to fully comply with the Final Rule, they should begin preparing soon in light of the significant number of new or modified compliance obligations. In particular:
  • Covered entities will need to revise, negotiate, and execute business associate agreements with billing companies compliant with the Final Rule by September 23, 2013 to the extent they did not have business associate agreements in place as of January 25, 2013 that were HIPAA compliant. They have until September 22, 2014 to do so to the extent they had business associate agreements in place as of January 25, 2013 that were HIPAA compliant. OCR gives a fair amount of latitude in the content of business associate agreements, so it is important for billing companies to ensure that they are not overcommitting to responsibilities or deadlines that are not required under HIPAA.
  • Billing companies that use subcontractors that create, receive, maintain, or transmit PHI on their behalf will need to draft, negotiate, and execute business associate agreements with them by September 23, 2013. Billing companies will need to ensure that these business associate agreements are at least as stringent as their business associate agreements with covered entities, and enable billing companies to meet deadlines in their business associate agreements with covered entities.
  • Billing companies, including subcontractors, will need to conduct a security risk assessment, implement a written HIPAA security plan, designate a security official, and create certain written HIPAA privacy policies by September 23, 2013 to the extent they have not already done so. OCR has posted guidance on compliance with the HIPAA Security Rule found at hipaa/administrative/securityrule that may be helpful to billing companies and their subcontractors and facilitate their compliance efforts.
  • Billing companies and their subcontractors will need to perform a gap analysis to determine what HIPAA policies and procedures need to be revised to comply with the Final Rule, and then will need to revise them by September 23, 2013 based on the gap analysis.
  • Billing companies and their subcontractors will need to update by September 23, 2013 their breach notification policies and any tools concerning how to conduct a risk assessment to determine whether breach notification is required.
  • Healthcare providers may ask billing companies to implement by September 23, 2013 a method to flag or make a notation in the record with respect to PHI concerning an item or service paid in full by an individual – or person acting on the individual's behalf (other than a health plan) – to ensure that such information is not inadvertently sent to or made accessible to a health plan for payment or healthcare operations purposes, such as audits by the health plan.
  • Billing companies and their subcontractors will need to update their HIPAA training materials and then train their workforce members (i.e., employees, volunteers, trainees, and other persons under their direct control) by September 23, 2013 to comply with HIPAA.
Given the breadth and potential penalties under the Final Rule, billing companies and their subcontractors should review their data flows (i.e., the complete lifecycle of PHI that they create, receive, maintain, or transmit) and then perform an updated risk analysis based on that review, including a risk analysis of mobile devices. Billing companies and their subcontractors will need to determine whether to encrypt these devices in light of the increasing prevalence of large penalties imposed by OCR on entities whose mobile devices, such as laptop computers and smartphones, containing unencrypted PHI have been lost or stolen. Further, covered entities and business associates should consider whether it would be cost-effective for them to purchase HIPAA liability insurance given the risk of substantial penalties for HIPAA violations.

Courtesy of:

5 Best Practices for Using Payment Plans to Ensure Patient Payments

5 Best Practices for Using Payment Plans to Ensure Patient Payments

What You Need to Know

An article by Bill Marvin, taken from the May/June issue of HBMA Billing (
As health insurance premiums continue to grow (at an average annual rate of 7.1 percent [AHIP 2010]), employers are switching to lower cost, high-deductible health plans. This trend is resulting in an overall decrease in payor payments and a consequent increase in patient payments. This will continue throughout the next decade as the Affordable Care Act rolls out. As a result, billing services and their clients are more dependent on patients for revenue. To collect more from patients, many billing services have started to use patient-centered strategies, such as payment plans. However, to improve results and increase efficiency for their clients, billing services need to ensure that they have implemented best practices.

A Growing Trend

Data from the 2011 "Trends in Healthcare Payments" report shows that the use of payment plans for healthcare payments has doubled since 2009.1 In the same report, 63 percent of surveyed patients said that they would utilize payment plans for their healthcare bills if given the option.
Five Best Practices for Successful Payment Plans
  1. Automate Payments
    Many billing services support payment plans manually by managing a calendar that shows when each payment is owed and by calling patients to collect every month. This method is a step in the right direction, but it adds to the billing service's work effort, does not ensure payment for the client, and has security flaws. Whether the payment plan is set up while the patient is in the office or after a statement is sent, billing services and their clients should securely collect and store payment information so they can automatically collect payments when they are due.
  2. Automate Communications
    Even when a patient authorizes automated monthly payments, he or she may still forget about the payment until it shows up on their next statement, which may create confusion and costly chargebacks. Improve communication and offer payment transparency by automating email notifications to patients prior to each payment transaction

    Tip: Provide clients with a one-page "FAQ" for patients explaining how payment plans work, including payment timing, notifications, and payment card security.
  3. Draw a Line
    It is great for billing services to give patients some flexibility and choice in how much they pay each month, but it is also necessary that they set parameters and stick to them. As a standard best practice, billing services should charge a minimum monthly payment of $100 or require that the bill be paid in full within 12 months.
  4. Collect Something Upfront
    Payment plans work well for patients who are unable to pay the full bill at once, but billing services should avoid allowing payment plans to become a way for patients to put off paying at all. Establish a policy that patients must pay a certain percentage of the bill upon setting up a monthly payment plan.
  5. Tailor Payment Plans to Patient Needs
    Depending on the scenario, there are three main types of payment plans to offer patients:

    • Installment: Collect payments against an outstanding balance and deactivate the plan automatically when the total balance is paid.
    • Recurring: Collect payments at a regular, ongoing interval as a subscription service.
    • Save on File: Save a patient's payment card on file to collect the remaining amount owed when the claim is adjudicated. This is useful when the patient's payment responsibility is unknown during the patient visit; for example, if the patient has a high deductible.
By following best practices when offering patient payment plans, billing services can ensure payment for their clients, even from self-pay or high-deductible patients. Automated, scheduled payment plans save billing services a lot of time and costs to send multiple patient statements and make follow-up calls to patients as well as improve patient communication and clarity around the payment process.

Commercial Payor News - Health Insurance Plan Links

Commercial Payor News - Health Insurance Plan Links

Aetna, Inc.
Affinity Health Plan
Alameda Alliance for Health
Alere Medical, Inc.
Allegiance Life & Health Insurance Company
AMA Insurance Agency
American Fidelity Assurance Company
American Heritage Life
American Medical Security, Inc.
American Republic Insurance Company
American Specialty Health Incorporated
AmeriChoice Health Services, Inc.
Amerigroup Corporation
Arcadian Health Plans
Arkansas BlueCross Blue Shield
Assurant Health
AultCare Corporation
Avera Health Plans
AvMed Health Plan
Aveta, Inc
Axis Global Accident & Health
Bankers Life and Casualty Company
Blue Cross Blue Shield of Arizona
Blue Cross and Blue Shield of Florida
Blue Cross and Blue Shield of Georgia
Blue Cross Blue Shield of Kansas
Blue Cross and Blue Shield of Illinois
Blue Cross & Blue Shield of Louisiana
Blue Cross Blue Shield of Michigan
Blue Cross and Blue Shield of Minnesota
Blue Cross and Blue Shield of Montana
Blue Cross and Blue Shield of New Mexico
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Nebraska
Blue Cross Blue Shield of North Carolina
BlueCross BlueShield of North Dakota
BlueCross BlueShield of Oklahoma
Blue Cross and Blue Shield of Rhode Island
BlueCross BlueShield of South Carolina
BlueCross BlueShield of Tennessee
BlueCross BlueShield of Texas
BlueCross BlueShield of Vermont
BlueShield of Northeastern New York
Blue Cross of Idaho
Blue Cross of Northeastern Pennsylvania
Blue Shield of California
Bluegrass Family Health, Inc.
Boston Medical Center Healthnet Plan
Bravo Health
Capital Blue Cross
Capital District Physicians´ Health Plan
Capstone Health Plan, Inc.
Care 1st Health Plan
CareFirst BlueCross BlueShield
CareMore Health Plan
Celtic Insurance Company
Chartered Health Plan
Children's Mercy Family Health Partners
Chinese Community Health Plan
CIGNA Health Care
CNO Financial Group
Colorado Choice Health Plans/San Luis Valley HMO
Commercial Travelers Mutual Insurance Company
Community Care, Inc.
Community Health Network of Connecticut
Community Health Partnership
Community Health Plan of Washington
ConnectiCare, Inc.
Coventry Health Care, Inc.
Dean Health Plan, Inc.
Delta Dental Plans Association
Denver Health Medical Plan
Disability Management Services, Inc.
Empire Blue Cross and Blue Shield
ENCOMPASS Health Management Systems
Erickson Advantage
Essence, Inc
Excellus BlueCross BlueShield
Fallon Community Health Plan
Family Care, Inc.
Federated Insurance Companies
FirstCarolina Care, Inc.
First Choice Health Network
First Health
Florida Hospital Healthcare System
Fresenius Medical Care Health Plan
Geisinger Health Plans
Gen Re LifeHealth
Genworth Financial
Group Health Cooperative
Group Health Cooperative of Eau Claire
Group Health Cooperative of SC Wisconsin
Group Health Incorporated
Guarantee Trust Life Insurance Company
Guardian Life Insurance Company of America, The
Guildnet, Inc.
Gundersen Lutheran Health Plan Inc.
Harvard Pilgrim Health Care
Health Alliance Medical Plan
Health Alliance Plan
Health Dialog
Health First Health Plan, Inc.
Health Net
Health New England
Health Partners – Philadelphia
Health Plan of Michigan
Health Plan of Nevada
Health Plan of San Joaquin
Health Tradition Health Plan
Healthfirst, Inc.
HealthNow of New York, Inc.
HealthPartners, Inc.
HealthPlan Services
HealthPlus of Michigan
Healthways, Inc.
Highmark Blue Cross Blue Shield
HIP Health Plans
Hometown Health Plan
Horizon BC/BS of New Jersey
Humana, Inc.
Illinois Mutual Life Insurance Company
The i/mx* Companies
Independence Blue Cross, Philadelphia, PA
Independent Health
Insurance Administrative Solutions, L.L.C.
Integrated Health Plan
Inter Valley Health Plan
IU Health          JHA, Inc.
John Hancock Financial Services
Kaiser Permanente
KelseyCare Advantage
Kern Health Systems
Keystone Mercy Health Plan, Inc.
L.A. Care
LifeCare Assurance Company
LifePlans, Inc.
The Lifetime Healthcare Companies
Univita Health
Long Term Care Partners, LLC
Lovelace Sandia Health System/Lovelace Health Plan
Martin's Point Health Care
MedAmerica Insurance Company
Medica Health Plan
Medical Benefits Mutual Life Insurance Co.
Medical Mutual of Ohio
Mercy Health Plans
Metropolitan Health Plan
Mid Rogue Health Plan
Molina Healthcare
Mount Carmel Health Plan
MultiPlan, Inc.
Munich Re America HealthCare

Mutual of Omaha Insurance Company
MVP Health Care
National Teachers Associates Life Insurance Company
Nationwide Life Insurance Company
Neighborhood Health Plan
Neighborhood Health Plan of Rhode Island
Neighborhood Health Providers
Network Health Plan
New West Health Services
New York Life Insurance Company
The ODS Companies
Olympic Health Management Systems, Inc.
On Lok Senior Health Services
Optum Health
PacificSource Health Plans
Passport Health Plan
Penn Highlands Health Plan
Penn Treaty American Corporation
Peoples Health
Physicians' Benefits Trust Life Insurance Co.
Physicians Health Plan of Northern Indiana
Physicians Mutual Insurance Company
PHP Companies d/b/a Cariten Healthcare
Preferred Care Partners
Preferred Health Systems
Presbyterian Health Plan
PrimeWest Health Systems
Principal Financial Group
Providence Health Plans
Prudential Life Insurance Co. of America
Puget Sound Health Partners
QualCare, Inc.
QualChoice of Arkansas
Regence BC/BS of Oregon
Regence BlueCross BlueShield of Utah
Regence Blue Shield
Regence BlueShield of Idaho
Resolution Health
Rocky Mountain Health Plans
Samaritan Health Plans
San Francisco Health Plan
SCAN Health Plan
Scott & White Health Plan
Senior Health Insurance Company of Pennsylvania
Senior Whole Health, LLC
Sentara Healthcare
Sharp Health Plan
Silver Script Insurance Company
Southeastern Indiana Health Organization
State Farm Insurance Companies
Sterling Life Insurance Company
Stonebridge Life Insurance Company
Sun Health MediSun, Inc.
TakeCare Insurance Co.
Teachers Protective Mutual Life Insurance Company
Thrivent Financial for Lutherans
Touchstone Health Partnership, Inc.
Transamerica Life Insurance Company
Trillium Community Health Plan
TriWest Healthcare Alliance
Tufts Health Plan
Trustmark Insurance Company
UNICARE Life & Health Insurance Company
United HealthCare
United Teacher Associates Insurance Company
UnitedHealth Group
Unity Health Plans
Unison Administrative Services
Univera Healthcare
Universal American Corp
University Health Alliance
Universal Health Care
Unum Group
UPMC Health Plan
Upper Peninsula Health Plan
USAA Life Insurance Company
USHEALTH Group, Inc.
Virginia Premier
VNS Choice
Vytra Health Plans
Wakely and Associates
WellCare Health Plans
Wells Fargo
WellPoint, Inc.
Western Health Advantage
WINHealth Partners
World Insurance Company
XL Health
Yale University Health Services
Zurich North America

Courtesy of: HBMA

Share with your providers: Aetna Compassionate CareSM Program

Aetna Compassionate CareSM Program

Compassion. Caring. Support.
When you’re facing difficult decisions about a serious illness, our resources help you make choices that are best for your family.

Making decisions:
Discussing sensitive issues, such as treatment options and pain management, can be difficult. Here is a resource that can help you begin the discussion: The Conversation Project: View and explore the Starter Kit.

Advanced planning:Making your wishes known gives you peace of mind, and of spirit. You can protect yourself and your family. Start by making a record of instructions for care. These instructions should clearly describe the types of treatment you want to receive.

Advance directives/living will:
This legal document tells your doctor what kind of care you want or do not want. It will be used if you are too sick to make medical decisions on your own. It is sometimes also called a “living will.”  More information.
Hospice careHospice is a way of providing care for people with advanced illnesses. Hospice allows them to be comfortable (physically, emotionally and spiritually) at home, or at an inpatient facility. We can help you understand the value of hospice care. We can also help find the care that is right for you.
Some useful resources for Hospice information:
  • Aetna Case Manager – Call the toll-free Member Services phone number on your Aetna member ID card to request an Aetna nurse case manager.
  • Medicare Hospice Benefits 
Grief/bereavementGrief is a reaction to a major loss. It is most often an unhappy and painful emotion. It may be triggered by the death of a loved one. People also can experience grief if they have an illness for which there is no cure, or a chronic condition that affects their quality of life. For more information on grief:
Accelerated death benefit (ADB)  (PDF, 110 KB)
This is a provision in most life insurance policies. It allows a person to receive a portion of his or her life insurance money early.

Read this family's story.   (PDF, 85 KB)
Find out how one family benefitted from Aetna's Accelerated Death Benefit election.
Important paperworkThe following printable documents can help you and your loved ones keep track of the vital information needed to manage health care issues, such as health and finances. Fill out the forms, and then make three copies:
1. One for your records
2. One for a trusted family member or friend
3. One for your attorney, if you have one
List where your important papers and documents are stored. This will make it easy to locate your living will, life insurance policy, bank accounts, retirement information and more.
View My Important Papers  (PDF, 527 KB)
Important contacts List the names and contact numbers for the people who can assist you or your family members as you deal with serious illness. Include your doctor, clergy, attorney, accountant, etc.

View My Important Contacts  (PDF, 521 KB)
Useful websites:

Wednesday, July 24, 2013

HBMA ICD-10 Readiness Statement published in Wall Street Journal

The HBMA Government Relations Committee, through its spokesperson Holly Louie, took the stage at our nation's capitol to deliver your collective message to the National Committee on Vital and Health Statistics (NCVHS). Holly spoke on behalf of the HBMA ( to the NCVHS on ICD-10 Readiness - Learn from Past, Don't Repeat 5010 Mistakes.
HBMA testifies before NCVHS on ICD-10 Readiness
Learn from Past, Don't Repeat 5010 Mistakes
LAGUNA BEACH, Calif., June 28, 2013 /PRNewswire-USNewswire/ -- Because of its significant role in revenue cycle management, the Healthcare Billing and Management Association ( was invited recently to participate in discussions with the National Committee on Vital and Health Statistics (NCVHS) Subcommittee on Standards in Washington, D.C. to provide an update on the status of transitioning from ICD-9 CM to ICD-10 CM by the October 1, 2014 effective date.
In testimony before the NCVHS Subcommittee on Standards, Holly Louie, CHBME, Chair of HBMA's ICD-10/5010 Committee presented the association's views on "lessons learned" from the 5010 implementation and how those lessons can and should be applied to avoid problems with ICD-10 implementation. NCVHS is charged with advising the Secretary of Health and Human Services on all HIPAA related matters.
Louie was part of a panel of experts invited. In her testimony, she said, "HBMA believes that we MUST learn from the mistakes that were made in transitioning from 4010 to 5010, and undertake the transition from ICD-9 CM to ICD-10 CM in a way that demonstrates we learned those lessons."
Louie shared HBMA's concern that in order for there to be a successful transition from ICD-9 CM to ICD-10 CM "we must allow the 'lessons learned' from the 4010 to 5010 transition last year to materially inform the implementation of ICD-10 CM." Louie pointed out to the Subcommittee that "the economic stability of America's healthcare reimbursement system will be at risk and could be severely compromised, affecting provider financial viability and patients' access to care."
The Centers for Medicare and Medicaid has already delayed the effective date for ICD-10 CM implementation from October 1, 2013 to October 1, 2014. Speaking about this delay, Louie said, "it is imperative that the time gained by the delay be used wisely in order to ensure that the transition is successful. If we fail to learn the lessons we will merely be delaying the likelihood for payment disruptions and patient access to care problems from 2013 to 2014."
HBMA strongly recommends the following:
   1. While CMS has adopted a definition of "ready" and developed the tools and 
      checklists to assist every provider, organization, payor and vendor to 
      validate they are ready on October 1, 2014, a subsequent announcement by 
      CMS that they will not perform any external testing is extremely 
      problematic for the industry.  End-to-end testing by all payors, to meet 
      the definition of "ready" must occur to ensure a smooth ICD-10 CM 
      implementation.  Failure to engage in meaningful end-to-end testing is a 
      recipe for disaster. 
   2. CMS must establish period benchmarks that cannot be ignored to assess the 
      "readiness" status for all facts of the healthcare industry. 
   3. There must be clear pronouncement that there is no vendor, EHR, coding 
      assist tool, map, crosswalk or other product that will solve the problem 
      of excellent medical record documentation and accurate coding. 
      Physicians and staff must be fully prepared with adequate training to 
      operate compliantly and not rely on false proclamations of marketed 
   4. Payor policies will be critical to the appropriate adjudication of 
      claims.  Currently, there is a wide variance among payors in stated 
      policies.  It is imperative that policies are published by October 1, 
      2013 in order to allow adequate time for education and training, data 
      analysis and other preparations for ICD-10 CM. 
   5. Any payor that is currently only accepting claims by 4010 format must be 
      fully 5010 compliant by January 1, 2014 in order to be ICD-10CM ready. 
HBMA's expert remarks were made on behalf of the membership with the goal of making this transition as smooth as possible for the entire medical community. To learn more about ICD-10 transition, go to
Related Searches: NCVHS, ICD-9, ICD-10, HBMA, HIPAA, Holly Louie, 5010
SOURCE Healthcare Billing & Management Association
/Web site:

Billing Medicare for Non-Physician Providers

Become Fluent in the Federal Rules

An article by Richard R. Wier, Jr., Esq., taken from the May/June issue of HBMA Billing (
The Centers for Medicare and Medicaid Services (CMS) and federal law enforcement agencies have increased efforts to combat healthcare fraud. In order to help fund these efforts, the Patient Protection and Affordable Care Act (PPACA) has increased the Health Care Fraud and Abuse Control Program's funding by $350 million from fiscal year 2011 to fiscal year 2020. As a result of these increased efforts and funding, in October 2012, the Medicare Fraud Strike Force charged 91 individuals, including doctors, nurses, and other licensed medical professionals, for their participation in falsely billing the Medicare program, resulting in approximately $429.2 million in penalties.

According to the False Claims Act, fraudulent billing under Medicare includes, but is not limited to, billing for tests not performed, performing inappropriate or unnecessary procedures, upcoding by using more expensive billing codes when lower priced procedures were performed, and various other billing inflation practices. When billing, health care providers must remain vigilant of the ever-changing billing and coding laws and pertinent state regulations to ensure that they are not improperly submitting Medicare claims.

One billing issue that may arise is the improper billing of Non-Physician Providers (NPPs), such as physician's assistants, nurse practitioners, and clinical nurse specialists. NPPs are able to enroll and bill Medicare for services that they are licensed or certified to perform within the state. When NPPs work independently, they are recognized under Medicare for professional billing and are able to bill Medicare under their own Medicare provider numbers; however, the reimbursement by Medicare is only 85% of the Medicare Physician Fee Schedule (MPFS). The MPFS provides the billing codes and proper coding methods that are required when requesting reimbursement from Medicare for services provided. Conversely, NPPs who perform services that are incident to the physician's course of treatment, which are known as "incident-to services," can bill Medicare for the services provided by the NPP under the physician's Medicare provider number, and the health care provider would receive 100% reimbursement from Medicare under the MPFS. In order for NPPs to bill incident-to services, Medicare requires that the physician perform an initial visit with the patient in order to establish the physician-patient relationship. After the initial visit, the physician does not need to be involved in each patient visit, but must actively participate in the management of the course of treatment for the patient. Although not required by Medicare, some carriers require that the physician meet with the patient every third visit or when a new symptom or medical issue arises.

When determining whether to bill for services provided by the NPP independently or incident-to the physician's services, health care providers must verify the scope of practice for the NPP, the place of service, and physician supervision over the NPP. There are a variety of resources available for guidance, including Title 42 of the Code of Federal Regulations (CFR); coding and billing under the Medicare Physician Fee Schedules (MPFS), as previously mentioned; and state laws and regulations. The CFR is a federal law that provides minimal standards necessary for billing under Medicare. Health care providers must keep in mind, however, that it is imperative to look at state law first because it may be more stringent than the federal law. State law will specify the scope of practice, certification and licensing, and level of supervision required for each type of NPP, and these factors determine whether the NPP can bill incident-to services under the physician's Medicare provider number, which will result in 100% reimbursement under the Medicare Physician Fee Schedule for services performed. Therefore, the health care provider who employs NPPs must fully review state laws in order to ensure that proper billing is submitted to Medicare for reimbursement.

The most important state law regulation to consider when billing incident-to services is the level of supervision required by a physician when an NPP treats a patient. Some state laws allow NPPs to bill under the physician's Medicare provider number when conducting incident-to services that relate to the physician's course of treatment without requiring the physician to be physically present during the meeting. The incident-to services must be part of the physician's course of diagnosis or treatment of an injury or illness, and the physician must supervise the services provided to the patient by the NPP. State law will define "supervision" as it is to be applied to Medicare billing. For instance, some states do not require the supervisory physician to be present in the room, nor does the physician have to provide any care during a patient visit. However, a physician in a supervisory role must still be "present on the premises" and immediately available to assist the NPP in providing services if necessary. State law can also define the specific meaning of "present on the premises." Similarly, the location where the services are provided will affect the way in which billing is submitted to Medicare, because incident-to services performed by an NPP in a hospital are directly paid to the hospital, and hospitals are reimbursed differently under Medicare. With these factors in mind, it is imperative for the health care providers who employ NPPs to verify state law for regulations regarding the location, scope of practice, and level of supervision required for an NPP when billing Medicare – especially since these laws are constantly changing.

Preparing your clients practices' for the government's increased scrutiny of fraudulent billing and overpayments are crucial. Therefore, it is important to meet with your legal counsel to identify risks and discuss preventive measures to ensure your doctors are in compliance with state and federal laws and regulations.

Courtesy of HBMA
Billing Medicare for Non-Physician Providers - HBMA - Healthcare Billing and Management Association for 1st and 3rd Party Billers - Medical Billing, Practice Management