Tuesday, August 27, 2013

EHR Data Interface Issues for the Third Party Biller


Is the Industry Moving Away From Your Billing Model?

An article by Ron Sterling taken from the May/June issue of HBMA Billing.

Third party billers face a variety of business and technical challenges in interfacing with electronic health records (EHR) and other systems. Indeed, some of the initiatives in the healthcare industry will continue to complicate the establishment and maintenance of data interfaces for the foreseeable future.

Business Challenges

If you go back a few years before Meaningful Use, there were over 1,200 practice management system (PMS) vendors and a couple of hundred EHR vendors. During that time, the third party billers and/or practice management system vendors had the access to, and the attention of, physicians who needed to get their claims out of the door and paid. Consequently, it was the EHR vendors that would offer to accommodate interfaces with medical billing systems. Indeed, a variety of PMS vendors touted their systems as a gateway to a variety of EHR options for their physician clients.
Today, newly introduced integrated PMS/EHR products and EHR acquisitions by PMS vendors and vice versa have led to fewer, if any, billing system options for many EHR buyers. From integrated systems (that by design and business model do not interface with other products), to vendors that will not interface with other options, many vendors have established themselves as one stop shops for medical billing, EHR solutions, and, in some cases, RCM services. Indeed, some vendors have exclusive or "preferred" clearinghouse relationships for the handling of standard HIPAA transactions. In essence, more and more vendors want to position themselves as the only source for healthcare software solutions and services.

That is not to say that there are not EHR vendors who are eager to interface with a variety of practice management systems. However, the industry is moving to fewer interfaced solutions and more integrated offerings. Indeed, the majority of "new" solutions are integrated PMS/EHR offerings.

Healthcare Industry Changes

Related to the business challenges, the Meaningful Use initiative will affect interface strategies for all PMS and EHR products. For example, Stage 2 Meaningful Use core (required) measures include secure messaging with patients and providing electronic access to patient medical information. In most cases, this requires the use of a patient portal.

Patient portals can provide both medical billing and clinical interactions with patients. As importantly, most patient portals are designed to interface with one product line of medical billing and EHR products (such as Centricity PMS/EHR or NextGen EPM/EHR). Patient portals are not typically designed to interface with one vendor's practice management software containing billing data and a different vendor's EHR that houses clinical information. If the patient portal is separately interfaced with a PMS from one vendor and an EHR from a different vendor, the patient portal may not "know" how to properly route the message. In practice, however, patients may exchange secured messages with the practice on both billing and clinical issues.

A strategy that may include a separate patient portal for clinical issues and one for medical billing purposes presents a variety of operational challenges, including coordinating patient access and even accurately routing information. As importantly, separate patient portals will undermine support for the Patient Centered Medical Home and Accountable Care Organizations. For example, a patient who accesses the medical billing patient portal may not be reminded about a clinically-driven patient service issue.

Technical Challenges

Most interfaces are based on the Health Level 7 (HL7) structure. However, various aspects of HL7 are open to interpretation by vendors. Indeed, a variety of PMS and EHR vendors do not strictly support the HL7 standard. For example, some vendors use general HL7 messages instead of designated HL7 messages to send information. In other instances, the information in a message is not placed in the expected place but in a comment or supplemental area. Indeed, some vendors do not use the standard code sets, and instead use text fragments. In each case, the effort to establish the interface may require a painstaking evaluation of the vendor's "HL7" implementation.

Even after achieving success, the interface may have to change to address evolving coordination of information requirements between the medical billing and clinical record functions. For example:
  • The Meaningful Use Stage 1 measures require ethnicity and race information that is commonly captured in the PM systems but is needed by the EHR to track provider performance and qualify for the EHR incentive payments from Medicare or Medicaid.
  • Meaningful Use Stage 2 will require sharing of contact information and email addresses.
  • The HIPAA omnibus rules will affect the information needed to track HIPAA Privacy and Disclosure as well as support exchanges with patients. As a practical matter, most medical billing and EHR interfaces do a poor job of coordinating HIPAA privacy and disclosure status for patients.
In light of these increasingly complex business and technical challenges to interfacing medical billing and EHR products, third party billers may need to establish their own preferred relationships with EHR vendors. However, such relationships will be under increasing competitive pressure and user demands to provide a more coordinated approach to patient service and provider relationships.

Right, wrong, or indifferent, the healthcare industry is moving towards comprehensive solutions to meet patient service challenges and optimize provider performance. Consequentially, the PMS/EHR vendors are addressing those needs. A myriad of changes that affect physician relationships with patients and the expectations of patients and payors will complicate the use of interfaces with EHR products and inhibit the efficiencies needed to manage patient care and service. As importantly, interfaced systems may complicate reporting for quality, operational, and management purposes.

Therefore, interfacing between PMS and EHR systems may present a tactical solution to meet physician needs in these relatively early stages of the transition to EHRs, but present a strategic challenge to address evolving healthcare business and patient service models. Third party billing organizations need to recognize these business and service issues in order to provide a clear strategic path for how your services and products will evolve to meet the new demands that your clients are facing.

Courtesy of: http://www.hbma.org/news/public-news/n_ehr-data-interface-issues-for-the-third-party-biller

Three Mindsets for Growing Your Business and Sales

(An article by Ron Karr, taken from the July/August issue of HBMA Billing)

If I ask you not to think about pink elephants, what will you think about? Be honest! You're thinking about pink elephants! But why would you, when I asked you not to?

The answer is simple: the mind cannot process the negative. If you are about to go into an account hoping to not lose the sale, what do you think is going to happen? You will lose the sale. The opposite is thinking about the deal you are going to close. Thinking about what you want to achieve, instead of what you don't want to have happen, makes all the difference in the world when it comes to your success in sales. Thinking about closing the deal puts you in an entirely different mindset that allows you to have the right conversation to make it happen.

Your mindset is the difference between closing more business and losing it. We have identified three critical mindsets that top producers use to grow their business. They are:
  1. Creation vs. competition
  2. Openings vs. closings
  3. Alliances vs. lone ranger

Creation vs. Competition

Too many sales executives go into sales calls trying to beat their competition instead of creating better results for their customers. To build a value proposition that is second to none, you must concentrate on generating better results rather than competing against the processes already employed by the client. This is what Scott Nadell, Director of Sales for a third party billing company in New York, does.

Scott called me and wanted to know how he could close more deals. It seemed as though every time he walked into a practice, the walls would go up and office managers and doctors would be rude and unwilling to listen. Scott was going in to tell them how great his system was and how he could save them time and money. He was a threat to peoples' jobs and nobody wanted to deal with him. Sound familiar?

Scott changed his approach from competing against what they are currently doing to having conversations on how partnerships with his company can produce better results. He created different mindsets that enabled his audience to want to hear what he had to say without feeling threatened.

Openings vs. Closings

After switching his mindset to one of creation, Scott then looked at how he presented his position when introducing himself to prospects. Instead of telling them how great he was, he provided actual statistics on how much money his company had successfully billed and collected for its clients. He positioned his company as a valued resource that helps practices increase their profits and revenues through an efficient billing and collection system.
But here is the catch! Scott did not do this in a one-sided conversation. He got the doctors and practice managers to talk first about where they wanted to take their practices and what goals they had identified for their billing systems. Once he figured out where their struggles were, he then presented his systems and results in the context of what was important to each particular practice. When the managers and doctors heard his pitch, they felt like it was fully customized to address their issues.

Alliances vs. Lone Rangers

Scott then decided to take the same approach when it came time to creating alliances with other parties, such as attorneys and accountants. He realized that being introduced to a new prospect by one of their trusted advisors greatly reduced the amount of time it took to gain his prospect's attention and interest. If your attorney says that you need to speak to a service provider who is going to help your business, you are going to have that conversation.

Scott always knew that this was important. What he did not realize is that you need to treat each alliance as a client. In other words, don't just ask them for referrals. Do what you do with the doctors: ask about where they are trying to take their businesses, then discuss how partnering with you can help them get there.

Today, Scott and his company are enjoying great results from operating with these three mindsets. They are closing new accounts and creating alliances with influencers in their industry who are opening a lot of doors for them.

Scott started seeing results initially in the quality of the conversations he was having, which led to more opportunities and eventually more business.

What mindsets do you operate from? For doctors to switch third party billing companies or to go to a third party biller, they need to hear a compelling reason. That only comes when you operate from the right mindset. 

Courtesy of: http://www.hbma.org/news/public-news/n_three-mindsets-for-growing-your-business-and-sales

Choosing the Right Clearinghouse - Five Essential Qualities

An article by Bill Marvin from the July/August issue of HBMA Billing (www.hbma.org).
In the healthcare billing industry, the clearinghouse you work with has a huge impact on your business. The more efficiently your clearinghouse processes and returns your information, the faster you and your clients will get paid and the more payments you will collect. Therefore, knowing the right qualities to look for in a clearinghouse is crucial to the success of your business.

To gain insight into what billing services need from a clearinghouse, I interviewed Kevin Milam, owner of a company that does billing, consulting, and accrediting for clients across several states. We came up with five essential qualities to look for when researching clearinghouses to ensure that you are making the best decision for your business and your clients.

1. Knowledgeable and Immediate Customer Support

Having access to a knowledgeable, responsive customer service team is critical in any industry. For a billing service, waiting multiple days for an issue to be resolved can result in delayed payment, so choose a clearinghouse that allows you to log an inquiry 24/7 and that will respond to you within 24 hours. How can you tell for sure if a clearinghouse offers high-quality customer support? "Generally, if you receive immediate acknowledgement and responses to inquiries while you're researching a clearinghouse, you likely will receive the same treatment as a customer," says Kevin. Also, review the clearinghouse's commitment to customer service hours and responses in its contract. In most contracts, these performance elements are known as Service Level Agreements (SLAs) and are contractual commitments, sometimes with penalties.

2. Quick Claim Responses (Claim Status)

Once you submit claims to your clearinghouse, you should know within minutes which claims went through and which claims need to be corrected and resubmitted. "The longer you have to wait for claim responses, the longer it takes before you can correct any errors," says Kevin. "This delays cash flow for you and your clients and potentially leaves money on the table." Clearinghouses that tie claim status back to individual claims will save you time in the submission process.

3. Consistency and Accountability with 835s

You should receive an 835 and payment within a consistent timeframe so that you can post and reconcile your payments quickly. "With clearinghouses I've used in the past, I have received 835s weeks or even months after receiving the payments," says Kevin. "There was no consistency." When you can count on receiving 835s and payments within a day or two of each other, you and your staff won't waste time tracking down delayed 835s or payments for posting and reconciliation. Furthermore, the payment trace numbers or check numbers should re-associate with the 835s so that you can reconcile the payments more efficiently.

4. Efficient Claim Information

"It's not enough to have all of the claim information in your system," says Kevin. "You need to be able to use that information efficiently across multiple staff members at the same time." For example, if you can view a summary of all claim statuses on an 835, your staff can immediately identify which payments to post and which claims to reprocess. Additionally, your staff should have the ability to update the claim statuses as they reprocess claims or post payments, so that they don't duplicate any work done on the 835. This enables you to track all claim activity from a summary report or dashboard without wasting time looking at each individual claim.

5. Usability

For a billing service, it's key to be able to train your staff to use your system, especially as your staff changes or expands. Choose a clearinghouse with easy-to-use features like human readable claim responses and 835s; detailed and customizable reports hosted in a secure, private cloud; and a minimal number of clicks required to complete your workflow. "The steps required to process claims should make sense," says Kevin. "If you can't easily train your staff to use your system, it won't benefit you."

In addition, it is important to choose a clearinghouse that is accredited by the Electronic HealthCare Network Accreditation Commission (EHNAC). Some states and many payers will require you to use an EHNAC-accredited clearinghouse.

When you research clearinghouses, be sure to speak with existing customers, whom you can ask about each of these qualities. As the industry pushes for greater efficiency, it becomes even more important for your business to save time and money. Working with a clearinghouse that has all five of these qualities will help you to simplify your day-to-day processes, increase your cash flow, and help your business and your clients' businesses thrive.

Opportunities to Expand and Keep Your Business

By Steven Peltz, from the Jan/Feb issue of HBMA Billing

As a medical practice consultant, one the first areas of a medical practice that I evaluate is the billing department or billing company of a practice that has hired me. In my capacity as the president-elect of the National Society of Certified Healthcare Business Consultants (NSCHBC), I have had informal discussions with HBMA President Don Rodden, CHBME, about the consulting services that billing companies provide to practices, sometimes without understanding how important their role is to the practice.

I was introduced to HBMA by Government Relations Committee Chairman, Barry Reiter, CHBME. He and I have discussed the constant chaos that the healthcare delivery system is in and identified some of the opportunities that arise from that state. You may not know it, but many of you are already consulting, and if you have not set up your engagement contracts wisely, you are missing out both on revenue and having your client understand and appreciate all the value you bring to the practice. As practices merge and are acquired by hospitals, it is a good idea for your company to offer more than one line of service. Here are a few examples of what I do; you may want to consider adding these services to your company if you do not already offer them.

Over the years, I have established a benchmark of what a practice's accounts receivable (A/R) should look like. It is not cast in stone and is not fail proof, but it is a simple measuring tool that I use. I take the A/R temperature of all new clients and put it on a bar graph, then compare it to my benchmarks (see page 24). I then demonstrate to the potential client that by using the graph, their money is worth less the longer it is owed to the practice. I point out that either their billing company or billing department is not meeting the standard. I also break down the front end of the billing process and identify disconnects in the data collection process, such as: poorly trained staff, lack of reconciliation, monitoring, and the final decision with respect to collections.

Reducing the lifetime of debts that your company must collect begins at the point of service. Collecting co-pays at the time of each practice visit reduces postage, cuts billing staff time, and increases cash flow. Increasing the consistency of this front end collection means training the practice's staff to train the patients. For example, the front end staff may say to the patient, "Your co-pay today is $20" and then stop and wait. A more effective script for collecting co-pays may be, "Your co-pay today is $20, and we accept cash, checks, and credit cards. How would you like to pay?" A subtle but important difference, and while it will not work 100% of the time, it will result in increased revenue. Then, tell your client that you will monitor the success of their front office staff in collecting co-pays and refresh the front staff's training a few times a year. Finally, track the front staff collections on a monthly (or less frequent, but consistent) schedule and meet with your client enough times for your client to develop trust in you as a part of the management team.

When patients call to schedule appointments, do the front desk staff members ask for enough information to check insurance eligibility and acquire authorizations, when appropriate, before the visit?

Is there a daily, weekly, or monthly close that reconciles the cash, personal checks, credit card receipts, and insurance checks with the end-of day and end-of-week computer report and the bank statement? This is a simple way to make sure all the funds go into the bank and not into someone's pocket.

Does the office manager or billing department / company supervisor produce a monthly report that compares the charges and collections of the past month with the same month last year and two months before? This will spot and identify trends before they become problems.
During the first few meetings with your client, be prepared to bring something to the discussion that demonstrates the depth and scope of your knowledge and how your expertise will add to the success of the practice. For example, each year Medicare changes their codes; you could explain which, if any, impact the practice. If it is a primary care practice, establish a referral-based report. Identify how many dollars are sent out of the practice and to what specialties. Are there ways to recapture some of those dollars? Is the PCP or the specialist asking enough questions and documenting enough to code one level higher, if appropriate? I usually tell the owners(s) that the practice needs a preventative audit at least once every year and especially after a new provider is hired. When they ask why, I give them examples of other practices that have had to write checks back to payers.

When your client brings in a new provider, do you offer to credential the provider or bring in someone who can? Do you discuss ancillary sources of revenue that other practitioners use that can also be applied to that practice?

You probably already do between 80% and 100% of the above suggestions, but does the client understand how these services impact their practice? The point is whether your client knows that you provide these services. Yes, I know that they do not want to pay more for services that they think should be included, but that is not a reason to forgo informing them of all you do. Enhancing the services that you offer discourages clients from shopping for competing providers – it is much less expensive to keep a client than it is to get a client. Also importantly, by enhancing your services, you become more appealing to potential new clients when you make sales calls and offer to analyze their operational efficiency.

As a consultant, I either know the answer to the question or where to get it. You should be no different. With the constant change in the healthcare delivery system, you need to be constantly enhancing your product and empowering your clients with more opportunities.

 Courtesy of: http://www.hbma.org/news/public-news/n_a-reminder-opportunities-to-expand-and-keep-your-business

What to Do When Services are Not Paid by a Commercial Payer

If a practice is contracted as a participating provider with commercial insurers and networks, it must pay close attention to the patient "Hold Harmless" sections of the agreements. Many agreements prohibit billing the patient for services that are unpaid due to the insolvency of a payer (which may be the insurer or a self-funded employer), when the payer deems a service not medically necessary, for lack of compliance with utilization programs, or for failure to file a claim in a timely manner. Some agreements even go so far as to prohibit a practice from having a waiver signed by the patient in which the patient agrees to be responsible in these circumstances.

The best way to protect a practice so that it can bill the patient for services not paid for by the plan is twofold:
  1. Re-negotiate the language in agreements in the Member Hold Harmless provision, sometimes called "Billing the Patient," or the like, to more favorable language.
  2. Implement a patient financial responsibility statement / waiver* and signature process so that your patients acknowledge their responsibility to pay during these circumstances.
In re-negotiating the contract language, be sure the terms reflect that it is "only when required by applicable law" that you will not bill the patient / member under the circumstances that the plan is insolvent or has determined that the billed services are not medically necessary. In many states, practices are bound by such provisions by state regulations, but only with respect to state regulated HMOs and certain fully insured or government plans. These plans are generally required by law to retain reserves that will pay claims for a matter of months should the plans become financially unstable.

The majority of the members / patients that practices see under most agreements are in self-funded plans that operate under the federal Employee Retirement Income Security Act (ERISA). These plans do not have the same regulatory reserve requirements as the plans discussed above, and the contract should reflect that a patient waiver for such plans can be used to hold patients financially responsible if a self-funded plan does not pay for any service. The risk of a self-funded plan going belly up overnight and not having funds reserved to pay recent claims is therefore much greater. If a practice signs a network agreement that says that it can never bill the member for services not paid for by the self-funded plan, even in the case of insolvency or when the plan determines the service to be medically unnecessary, then billing the patient is technically prohibited even when there is a waiver signed by the patient agreeing to pay for claims in these cases.

In revising your patient responsibility statement or waiver for patients covered under private payer plans, be sure to specifically include the patient's promise that he or she will be financially responsible, as allowed by applicable law, in the event that:
  • His or her insurer or self-funded employer does not pay the claim in a timely and accurate manner
  • The insurer or payer deems the service to be either not medically necessary or to be an excluded or non-covered service
  • The payer or insurer denies the claim for lack of timely filing or adherence to utilization or payment policies
  • A claim is prospectively or retroactively denied due to lack of eligibility or benefits
Although the practice is obliged to adhere to utilization management programs and payment policies in most agreements, many payers' programs and policies are not readily accessible, especially when leased networks are involved. The patient needs to be financially responsible and compliant with program requirements. When a multitude of claim administrators and employers are renting a network such as Multiplan, Galaxy, or Three Rivers Provider Network, each party leasing the network may have unique programs and policies that are not found on a central web site or portal. There can be some very good reasons to contract with leased networks, but these varying policies can make monitoring those who rent the networks more challenging. Sometimes these networks are less likely to modify the hold harmless language so as to appease all of their renting parties.

In addition to the hints provided above, when defining and administering the terms of the patient responsibility statement / waiver, the practice should be prepared to advise the patient in advance of denial, if it is aware that a service may not be covered. Provide the patient with the likely cost and payment terms that will be accepted, preferably in writing, including any prompt pay or hardship discounts that might apply. This type of communication can assist you in managing the patient's expectations and his or her commitment to timely payment. These extra steps can also add to the practice's compliance with the newly negotiated and more favorable hold harmless terms.

Compliance FAQs... How Much is Too Much?

How much information can a biller leave on an answering machine when calling for address or insurance updates?

Answer: Because the biller cannot know for sure who will listen to a message, even when calling a telephone number provided by the patient, it is wise to leave the minimum amount of information necessary to accomplish the reason for the call. Various legal concerns, including the HIPAA Privacy and Security rules, state that confidentiality and privacy laws and debt collection statutes and regulations can be implicated and should be taken into account.

A bare bones message may contain little or no revealing information while still accomplishing the task.

EXAMPLE 1: "This message is for [patient]. We are calling to verify your current mailing address (or insurance information) in order to bill for recent medical services you received. Please contact us at xxx-xxxx during office hours."
Here is another message scenario that gives minimal information.

EXAMPLE 2: "This is Medical Billing Office calling for [patient]. We need to contact you for an updated / corrected mailing address (or insurance information). Please call us at xxx-xxxx at your earliest convenience."
Various factors should be considered in deciding how to draft scripts or instructions for your staff regarding outbound messages.
  • What is the purpose of the call / message?
  • Who is the provider / client? Are they well known in the community?
  • Do they practice in a sensitive specialty, such as family planning, mental health, etc.?
  • Is there a reason you would need to disclose the client's identity or other detailed information at all?
  • What would be the risk if someone other than the patient or a close family member heard the message?
If additional information would be helpful and would not unnecessarily reveal personal health information (PHI) or sensitive information, it can also be included in the message.

EXAMPLE 3: "This message is for [patient]. I am calling for the billing office at [General Hospital Radiology Group]. Please contact our office to update your mailing address (or insurance information)."
CMS has published FAQs that are generally related to this question. By analogy, they support the conclusion that a biller may leave a minimum amount of information on an answering machine to solicit a response and gather information to enable proper billing.
The official HIPAA FAQs can be found on the website of the DHHS Office of Civil Rights at www.hhs.gov/ocr/privacy/hipaa/faq/index.html.
From the Office of Civil Rights HIPAA website:

May physician offices or pharmacists leave messages for patients at their homes, either on an answering machine or with a family member, to remind them of appointments or to inform them that a prescription is ready? May providers continue to mail appointment or prescription refill reminders to patients' homes?

Answer: Yes. The HIPAA Privacy Rule permits health care providers to communicate with patients regarding their health care. This includes communicating with patients at their homes – either through mail, phone, or in some other manner. In addition, the Rule does not prohibit covered entities from leaving messages for patients on their answering machines. However, to reasonably safeguard the individual's privacy, covered entities should take care to limit the amount of information disclosed on the answering machine. For example, a covered entity might want to consider leaving only its name, number, and other information necessary to confirm an appointment, or ask the individual to call back.

A covered entity also may leave a message with a family member or other person who answers the phone when the patient is not home. The Privacy Rule permits covered entities to disclose limited information to family members, friends, or other persons regarding an individual's care, even when the individual is not present. However, covered entities should use professional judgment to assure that such disclosures are in the best interest of the individual and limit the information disclosed. See 45 CFR 164.510(b)(3).

In situations where a patient has requested that the covered entity communicate with him or her in a confidential manner, such as by alternative means or at an alternative location, the covered entity must accommodate those requests, if reasonable. For example, the Department considers a request to receive mailings from the covered entity in a closed envelope rather than by postcard to be a reasonable request that should be accommodated. Similarly, a request to receive mail from the covered entity at a post office box rather than at home, or to receive calls at the office rather than at home are also considered to be reasonable requests, absent extenuating circumstances. See 45 CFR 164.522(b).

ICD-10 Physician Training Tips: Podcast

Podcast: http://www.physicianspractice.com/medical-billing-collections/icd-10-physician-training-tips

ICD-10 is just around the corner and your practice needs to start preparing. Part of that preparation must include physician training and efforts to increase physician engagement.

During her presentation at the AHIMA 2013 ICD-10-CM/PCS summit in Baltimore, Cindy Seel, director of education and training at HRS, shared seven steps health systems can take to get physicians prepared for the transition.

Later, she spoke with Physicians Practice about some of her key ICD-10 preparation and training recommendations for physicians.

Four Steps to Healthier Accounts Receivable at Your Medical Practice

It happens in most all practices — the time of the month when cash flow becomes an issue. Instead of panicking and finding short-term solutions for long-standing problems, take a minute to consider the bigger picture.

How would you like your 0-30 days accounts receivable (A/R) to be 80 percent of your total A/R. Yes, it is possible, and the healthiest practices operate with this percent as a long-term goal. Here are some areas you can look at right now that can quickly boost your dwindling cash flow issue:

• Bill your claims out daily. Yes, daily. This will immediately result in your claim being processed within 30 days, and not automatically push it to the 30-60 day category. You're already in trouble if you are not billing out daily. If your billing company or department does not do this now, have a sit-down meeting with them, and ask them to start this process with your claims. You will see immediate results.

• Handle documentation requests from your billing department immediately. This is such a quick and easy solution, that you will see results within a month or two months. When your billing department requests additional documentation either to process an original claim or fulfill a denial or delay in payment from the insurance company, is your staff getting back to them within 24 hours? They should be. Thinking about the lifecycle of a single claim, it's no wonder a majority of you’re A/R is in the 90+ category. If you are billing out on a monthly basis, your claims are already in the 30-60 day category. On top of that, you now have to wait to hear back from the insurance company, so your claims are now in the 45-60 day category. If your billing department has requested documentation, and your staff is sitting on those requests because they're too busy processing patients, now you've pushed the claim out to the 75-90 day category. See how quickly this can happen? Filling your lobby and rooms with more patients is not the long-term solution.

• Follow up with your billing department. Whether it is an internal billing department or an outsourced company, following up with them in critical. Some companies don't want to bother with secondary claims because the yield is low. Denials are also more work and require more time with sometimes poor results. Following up with them as frequently as possible — a minimum once a month — is a critical step in lowering you’re a/R.

• Are all of your practitioners on your insurance contracts? Many plans have applications the physician, nurse practitioner, or physician assistant must fill out that include their license number and NPI. If your staff have not filled these out, then you need to check to see if your adjustments (write-offs) are due to a physician not being on a particular contract. Blue Cross, Blue Shield, United Health Care, TriCare, and Medicare, are just a few that require this certification. Some workers' compensation companies pay differently (up to $10/ visit to $15/visit) for therapists who are considered in-network versus out-of-network. It's really worth your time to ask.

By following these four tips today, you can shorten the time between seeing a patient and being paid for your services. They are easy, quick and will yield you the highest result in the shortest amount of time.

Article By P.j. Cloud-moulds  http://www.physicianspractice.com/medical-billing-collections/four-steps-healthier-accounts-receivable-your-medical-practice

Health Insurance Exchanges: Good News, Bad News for Physicians

USA Today recently reported that people have been signing up for health insurance exchanges for in excess of expected levels.

Staff writer Kelly Kennedy reports that a survey of each of the 50 states yielded 19 states reporting estimates for how many of their uninsured residents they expect will buy through the exchanges. The reported 8.5 million would far outstrip the federal government's estimate of 7 million new customers for all 50 states under the Affordable Care Act (ACA).

In the short term, this is great news for physicians' practices. This statistic means there will be 8.5 million new paying customers. This is even better news for physicians in states which have refused to expand Medicaid to the level mandated by the reform law, commonly termed "Obamacare."

Prior to the law, many states were permitted to set their own limits for Medicaid eligibility. Alabama, for example, reportedly disqualified a family from Medicaid eligibility if the family earned 25 percent of the federal poverty level (about $6,000 per year for a family of four). Under the reform law, states would have been required to expand Medicaid roles to conform to a new national standard of 133 percent of the federal poverty level (about $31,300 per year for a family of four). On June 28, 2012, the U.S. Supreme Court upheld the constitutionality of most of the ACA in the case National Federation of Independent Business v. Sebelius. However, the Court held that states cannot be forced to participate in the law's Medicaid expansion under penalty of losing their current Medicaid funding. Therefore, patients in states which did not expand Medicaid roles to include these "newly eligible" patients are able to purchase federally subsidized private plans through health insurance exchanges, which is the subject of the USA Today article.

This is good news for physicians’ practices, because Medicaid simply doesn’t pay very well (so low in fact, about one-half of all physicians would refuse to accept a new Medicaid patient).) Private plans which are subsidized by the government would almost certainly provide reimbursement rates which are above the rock-bottom rates for Medicaid patients. Open enrollment begins October 1, 2013, and coverage is set to begin January 1, 2014.

Before we all get too drunk on all this free government Kool-Aid, recall that the Kool-Aid isn’t "free." The reform law was enacted because the Medicare trust fund could not afford to pay for all the aging baby boomers set to turn 65 in the next few years.

The idea behind the law was to save Medicare by forcing more healthy Americans into the system through individual mandates, employer mandates, expansion of Medicaid for the poorest Americans, and providing health insurance exchanges for those who are just above the level needed to qualify for Medicaid. But how is this supposed to help save the Medicare trust fund? Obviously, by cutting future Medicare reimbursement rates.  But on what part of "planet crazy" does it make sense for the government to pick up the tab of the cost for all the newly insured, (which was supposed to save the system from failing, because the government is broke)?

In her book, "Your Doctor is Not In," Jane Orient draws the analogy between our nation’s healthcare model and the one created by Ptolemy, which contained multi-layered epicycles to explain the universe. "Wheeling and whirring, the Ptolemaic universe could be turned to predict almost any observed planetary motion — and when it failed, Ptolemy fudged the data to make it fit," Orient writes.

Here, the Obama Administration is so desperate to make the healthcare reform law work, any solution that will keep the wheels whirring, is perfectly acceptable. By the time anyone figures out it is a bad model, the president will be working on a location for his presidential library, and paying for healthcare will be the next administration’s problem.

Article By Martin Merritt http://www.physicianspractice.com/blog/health-insurance-exchanges-good-news-bad-news-physicians

Saturday, August 24, 2013

What Health Insurance Exchanges Mean for Physicians

Congress enacted the Affordable Care Act (ACA) to provide the means for uninsured Americans to purchase healthcare coverage.  Despite many legal battles and slipped deadlines, the new healthcare insurance exchanges — also known as marketplaces — will begin open enrollment on Oct. 1, 2013. The law provides for three options: one, where states will create and run their own exchanges; two, where they will create a hybrid exchange run by both the state and federal government; and three, where the federal government creates and runs the exchanges for states that have opted out. Coverage through the plans begins on Jan. 1, 2014.

Aside from great reservations expressed by many states, there are a number of unanswered questions where physicians and their practices are concerned. In part because so many states were reticent to fund and undertake the creation of a state-based exchange, progress to date varies widely. As of May 10, 2013, 25 states have been conditionally approved to operate some type of state-based exchange, according to The Center for Consumer Information & Insurance Oversight (CCIO).

And, because each state exchange is unique, the number and type of insurance companies that participate in the exchanges will be singular to each state.

So, what does this mean for physicians and their practices?

Sarah Dash, a faculty member at the Health Policy Institute at Georgetown University, says "fundamentally the exchange plans are just insurance plans. …The market is organized for the purpose of the consumer gaining easier access to those insurance plans. So, to some extent, it is the same thing." Since many people put off seeing the doctor because they are uninsured and can't afford the cost, experts have suggested that there will be a flood of sicker patients once the exchanges provide health insurance. Dash calls it "pent up demand." However, she is not convinced that this will be the case. She points out that the premise of the reform law's "insurance mandate" was to provide a good mix of healthy younger patients with older, potentially sicker patients. Owen Dahl, a practice management consultant based in The Woodlands, Texas, also believes that practices won't be deluged with new patients — but for a different reason. He says people who don't have insurance now are generally those who don't understand how it works and can't afford to pay for it.  "If I've been going to the emergency room for 15 years to get my care, [patients will say] 'Oh look, I've got this insurance, well I'm still going to go to the emergency room,'" says Dahl. He thinks that it will take time for people to change their behavior, which means practices will have plenty of time to prepare for newly insured patients. There is also trepidation among physicians that plans offered on the insurance exchanges will not pay well. As it is nearly impossible to predict reimbursement rates until the exchanges are fully established and patients are enrolled, it is perhaps a wasted effort for practices to dwell on this aspect. Dahl feels that plans offered on the exchanges may behave like managed-care plans. He says that it is likely that exchange plans will be offered by the major payers such as Blue Cross. "As far as the rates are going to be concerned, I think the best-case situation we could expect would be Medicare rates," he says. While that could mean lower revenues for practices, there are other aspects of the reform law which may be to their advantage. Dash says that "the point of the ACA is not to just give people an insurance card. It's to give people an insurance card that they can use. By that I mean, if the cost sharing is too high [in the forms of copays and deductibles], certainly that could be a deterrent."  She argues that through the law, patients will have access to tax subsidies and cost-sharing subsidies that should make it easier for patients to pay their bills. Certainly these changes will bring added administrative burdens to practices, but in many cases, they have already begun to implement new processes and quality improvements required by programs like Patient-Centered Medical Homes. Dahl advises practices "Do not panic." He says that while the business of medicine is most certainly changing, it won't happen overnight. "The important thing is for doctors to think about [the law] and to be prepared for that, but not react," he says.

Article By Erica Sprey - See more at: http://www.physicianspractice.com/blog/what-health-insurance-exchanges-mean-physicians#sthash.oenrJwFk.dpuf

Four Areas to Review to Reduce Denied Medical Claims

Tracking your practice's denials is a fantastic idea. It helps you identify where your mistakes are occurring, so that you can update your internal policies and procedures accordingly. But, more importantly, there are several other areas that you can track to ensure that your denials continue to decrease. This shows that you are managing this area of your practice effectively.

There are at least four areas that you can review on a monthly basis that will ensure your denials will continue to decrease, they are:

1. Your charges out, your payments in, your adjustments and your percent collections.
It's not just the charges out and payments in. If your billing staff is making decisions to write off accounts without your knowledge, your adjustments percent will be higher than contractually necessary. Track this on a monthly basis and see how this will change.

2. Your billing register should tell you lots of information about your billing department. You will have your monthly charges, and the amount you actually billed out. The difference will be the number of re-bills completed. Your billing department rebills a claim when a correction has been made. A correction is driven from a denial. The number of rebills is a direct correlation to the number of denials.
You'll take the dollars billed out minus your monthly charges, and get your dollars rebilled.

3. Your paper denials are the next area to review. Conduct a physical count each month on how many of these paper denials come into your practice. This is complete transparency of your billing department.
Contractual adjustments are not denials, but if a therapist cannot code correctly, this is an area to review.

4. Electronic Explanation of Benefits (E-EOBs) is the next area. These are very similar in context to the paper denials, the E-EOBs reveal a lot of information that can help you review your systems and processes.
E-EOBs can be easily tracked by your billing department. An accurate hand count should be completed monthly.

The key to reviewing all of this information is to utilize the results in an effective manner. If you find that you are seeing a workers' compensation patient that has an out-of-state plan, they may not use the workers' compensation codes for your state. The best thing to do is to call the nurse-case manager and ask! Don't just write those off as un-collectable. Make a five-minute phone call and find out.

If you are managing an insurance contract that places a monetary cap on how much a patient can use for their medical treatment, adhere to that cap. When you exceed it, it is much less likely that you will be able to recover those claims. If there is any other visit limit, or number of times you can code a procedure within a year's time, find out when the front office performs the insurance verification.

There is a reason why insurance companies dominate the healthcare market, and small practices are going out of business. They bank on the fact you won't follow up. Make this a priority of yours, today.

Article By P.j. Cloud-moulds - See more at: http://www.physicianspractice.com/blog/four-areas-review-reduce-denied-medical-claims#sthash.8t9HvDwD.dpuf


When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer. The volume of documentation should not be used to determine which specific level of service is billed.

In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from Medicare for a service, the service must also be considered reasonable and necessary. Therefore, the service must be:

  • Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and
  • Compliant with the standards of good medical practice
The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes.

Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to identify procedures furnished in an encounter. CPT codes are used to bill for services furnished to patients other than inpatients and for services being billed on claims other than inpatient claims. Therefore, CPT codes should be used to bill for E/M services provided in the outpatient facility setting and in the office setting.

The use of ICD-9-Clinical Modification (CM) diagnosis and procedure codes is limited to billing for inpatient E/M services on inpatient claims. All other provider types should continue to use CPT codes to bill for E/M services.

The compliance date for implementation of the International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/ PCS) is for services provided on or after October 1, 2014, for all Health Insurance Portability and Accountability Act covered entities. ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes. The implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.

All providers billing for inpatient services provided to inpatient beneficiaries will use ICD-10-CM diagnosis codes instead of ICD-9-CM diagnosis codes for services furnished on or after October 1, 2014.

 ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes. The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine. 

ICD-10-CM/PCS consists of two parts: 
  • ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
  • ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services for use in the U.S. for billing inpatient hospital claims for inpatient services ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.
Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html


“If it isn’t documented, it hasn’t been done” is an adage that is frequently heard in the health care setting.

Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and are used to record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s health care over time.

Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:
  • The site of service;
  • The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided;    and/or
  • That services furnished have been accurately reported.

There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general principles help ensure that medical record documentation for all E/M services  is appropriate:
  • The medical record should be complete and legible;
  • The documentation of each patient encounter should include:
    •  Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
    • Assessment, clinical impression, or diagnosis;
    • Medical plan of care; and
    • Date and legible identity of the observer.
  • If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred;
  • Past and present diagnoses should be accessible to the treating and/or consulting physician; Appropriate health risk factors should be identified;
  • The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented; and
  • The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

Wednesday, August 21, 2013

Answering Insurance Questions from Your Patients

A majority of patients are in the dark about what is and is not covered on their healthcare plan. You really can't blame them since their plans most likely change on an annual basis. With the conversion of healthcare upon us, there are even more opportunities for confusion.                   

What is the best way to calm your patients, while providing the most updated information to them? There are a couple of different schools of thought with this question. You can tell the patient that they are solely responsible for their benefits and that they should know what is covered prior to coming to see you. However true this statement is, it's not very realistic for you or your patient. I think a better approach would be to call about patient benefits prior to their appointment, ask very specific questions about the benefits, how they are paid, what codes are covered and what is not. Ask if there is a timeframe on these benefits, or if they can only be seen for this diagnosis once or twice or more per year. Is that a calendar year, or is it a benefit year, etc? Get specific.

All of these questions need to be asked prior to the patient arriving for their visit. Once they are there for the visit, spending a few extra minutes with the patient and explaining their benefits is critical.

This should especially be done with Medicare patients and everything shifting with their plans. Most patients do not understand when they sign their Medicare benefits over to a Medicare Advantage plan. They think they have Medicare as a primary insurance and Blue Shield as a secondary, when in fact, Blue Shield is the Medicare Replacement Plan. Benefits under these replacement plans differ greatly even within an insurance company. Some have a $10 copay, and others have a $50 copay. Explaining this to the patient is so important. Healthcare costs are on the minds of many, and being up front and forthcoming alleviates an unneeded stress that goes along with an appointment.

There are several resources available for the patient to become well educated in their personal insurance plan. My first suggestion would be for the patient to sign up with their insurance company through the personal website portal. Most all plans have this available to patients so that they can review pertinent information like: copay, coinsurance, deductible (what has been met, what is still pending to be met), how much of a certain benefit is still available such as number of visits with physical therapy, speech or occupational therapy benefits, etc.

The websites are also becoming more dynamic and "smarter," allowing the patient to figure out what the cost of a test or procedure will be prior to having that done. Involving the patient in their overall health, and empowering them to make decisions will take a burden off of you and educate them. Many insurance companies offer programs at a discount even if they do not cover a specific benefit under the patients plan. There is a weight loss company that provides Aetna patients a nice discount for signing up with them. There are seminars that companies and other healthcare professionals put on, that can also benefit the patient.

With so many options available for patients to learn about their healthcare plans and benefits, it can be as simple as steering them in the right direction. Again, you are not required to educate patients on their health plans or benefits, but what you would be providing is a level of customer service that is becoming near non-existent in this era. You are also working with the patient and not talking at them. People respect that.

Article By P.j. Cloud-moulds
- See more at: http://www.physicianspractice.com/medical-billing-collections/answering-insurance-questions-your-patients#sthash.cYzq9QHo.dpuf

Ten Things That Would Make Medical Billers Happy

By Marsha Sosebee
I have a friend who starts reminded everyone in the middle of summer just how many days there are until Christmas.  Every year about this time, I take the solemn oath that this will be the year I get all my shopping and wrapping done before Thanksgiving so that I can really enjoy the holidays. With sugarplums already dancing in my head, I thought about what billers would really like for Christmas. What would really make a biller really happy to find under his or her tree? Here are the top 10 things on my “Billers’ Wish List.”1. A standardized explanation of benefits (EOB). For years I have been perplexed as to why every medical provider in the United States must submit claims to hundreds of different insurance companies on a standardized claim form or electronic format, yet the hundreds of insurance companies do not have to use a standardized EOB?2. One fee schedule. Having just one fee schedule to keep up with would make my job so much easier. Evaluating claim payments would take much less time and so would updating the fee schedule module in my system.3. A shock collar functionality built into the practice-management system. When the same mistake is made by the same user more than three times, when the doctor doesn’t complete the electronic medical record before the patient checks out, or when the front desk “forgets” to ask for a payment, they would get a little jolt to remind them.4. Electronic statements. Some billers out there are still in the dark ages when it comes to monthly patient billing and I am currently one of them, not by my choice at all though. Sending a file of statements takes only a few minutes whereas printing, folding, stuffing, and mailing paper statements can take a few hours. The cost per e-statement is very low compared to the money offices spend on printing, paper, envelopes, and staff wages to do the statements in house.5. Co-workers who really understand how their job affects my job. Some days half of my time is spent fixing what someone else has messed up or doing what someone failed to do.6. Truth serum for insurance customer service representatives. Wouldn’t it be so nice to know when they tell you “that claim will be reprocessed in 10 to 14 days” what they really mean is “that claim will be processed in 10 to 14 days IF I actually send it to the claims department and don’t need to deny it to meet my quota of denied claims for the week?”7. Return phone calls when promised. If people would always return phone calls when promised, I wouldn’t have so many things on my to-do list.8. Seminars that are actually helpful. I would love to attend a billing seminar that gives me practical how-to advice for the real world. And not so boring that I need four cups of coffee to keep myself from snoring louder than the monotone drone of the speaker.9. A boss who shows sincere appreciation for my hard work. That should probably be number one on the list.10. Cancellation of the ICD-10 code set. Billers have enough to do already without having to learn a new diagnosis code system.
Article By: Marsha Sosebee
Courtesy of: http://www.physicianspractice.com/blog/ten-things-would-make-medical-billers-happy#sthash.H1RAzZsW.dpuf

Tracking Patient Collections a Necessity at Your Medical Practice

As a physician, do you know how many patient collections (copay, coinsurance, deductible, etc.) are paid by credit card, check, or cash? You might be surprised to know that cash is still a very viable form of payment by a lot of people. With so many people out of work, they have to budget their money very carefully. One way they are doing this is really buckling down on expenses and using cash as often as feasibly possible. It makes sense, really, to those who are disciplined enough to not impulse buy.                   

This said, do you have a way of tracking the money coming in and the money going out of your practice? I really hate to be the person who points this out, but under certain circumstances, even your most trusted front-desk person might "misplace" some of the cash that should be deposited into your bank account. Many employees don't understand and don't have all of the information about the financial health of your practice; nor should they. Their mindset might be, "They have enough and I'm barely scraping by (because I just bought that third pair of really cute shoes)." For whatever reason, money may be leaving your facility without your knowledge.
Here are some ideas to stop this now and prevent this temptation in the future.

  • Create a simple spreadsheet that can be placed in the desk of the front-office staff collecting the copays. This should include the patient name, description of the money in, or money out, the amount that was paid, and today's date.
  • At the beginning of each day, the front-office person counts the money in the cash box. Any money over a set amount (by you – say $100) should be "deposited" to you or your practice administrator. Those monies then need to be tracked and deposited in the bank with a deposit slip showing this same amount.
  • Throughout the day, the front-office person will write down every single payment (cash or not) on the spreadsheet. This can also be a digital document, programmed to record all calculations. The reason you need to write down every single payment is because this will ensure that each patient who owes has been collected on.
  • If someone in the office borrows money for an employee lunch, office supplies, etc., that needs to be recorded and calculated in a cash-out area at the end of the day.
  • At the end of the day, all the money in and out should balance. The front-office staff is required to manage the cash flow of the practice. The practice administrator or manager needs to sign off on a weekly basis, how the week's in and out activity has occurred.

By following these simple steps, it will insure your practice collects what is necessary, patients do not receive a bill, money get deposited into your bank account, and there are no questions of where the funds have gone.

Article By P.j. Cloud-moulds
- See more at: http://www.physicianspractice.com/blog/tracking-patient-collections-necessity-your-medical-practice?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=20082013#sthash.jv2859XU.dpuf

From Volume to Value: Minimizing a Major Healthcare Shift

Nearly everyone, including me, has written on the fact that reimbursement for medical care will move from "volume" (do more, get more) to "value" (do less, keep more). The assumption is that this shift is an irresistible force and, over the years ahead, population management including substantial incentives tied to quality metrics will replace the classic fee-for-service environment. Large health systems are investing heavily in data systems that can track patients across the continuum of care and have begun to add clinical staff providing the needed care coordination. Essentially they are placing fairly expensive bets on the inevitability of the value evolution.
So, what should private physicians do? Should they add staff that can track patients to see if they showed up at the specialist, took their medications, and received the diagnostic study? Should practices begin to rethink how they pay providers? Should you expect a visit from the dominant insurance carriers with a "take it or leave it" imperative to move to value? Maybe not.While I still have confidence that there will be significant financial incentives tied to better management of chronic diseases, avoidance of high-end diagnostics when alternatives are appropriate, providing care in the least costly settings, and reporting quality indicators, I believe that many practices can benefit from these incentives without reinventing what they do.  What then should a practice do? • Medications: Many insurance plans provide incentives to practices that utilize generic medications when appropriate and the government already has bonuses for e-prescribing. This may change the way that physicians select therapeutics but the shift will not have any additional cost or require more staff.• Site of Service: Using an freestanding imaging center, an ambulatory surgery center, or a post-acute care environment may result in bonus payments from some carriers. While there is discussion about the elimination of the reimbursement differences between performing these services in a freestanding setting versus a hospital, this isn’t going to change quickly.• Patient Management: Practices that using an EHR may already have the capability to monitor chronic patients against care protocols that are developed within the practice or adopted from organizations such as the Centers for Disease Control or specialty academies. EHRs can highlight children that are overdue for immunizations, diabetics due for routine lab work, and patients that have skipped preventive care. All of these can ultimately result in cost reductions but add little effort to the practice. In many cases, care recalls can actually increase practice revenue. I recently discussed the lack of dramatic cost savings from the early population management efforts. CMS reported in July that during the first year of operations the Pioneer accountable care organizations (ACOs) were able to reduce costs by 0.5 percent when compared against non-ACO patients. There was still a 0.3 percent increase in overall costs but better than the 0.8 percent in unmanaged care. Only 13 of the 32 Pioneer programs actually reduced costs. Results like this may provide support for more focused programs. Some cost management efforts have produced reliable successes. Co-management arrangements where physicians and hospitals partner around high-cost procedures with the goal of assuring good outcomes while making the care process more efficient are good example. Physicians continue to do what they have but have financial incentives for standardizing care. Generic prescription initiatives produce millions in savings. These programs may be more likely to be the kind of initiatives that will be experienced by the bulk of physicians. The shift from volume to value isn’t going to go away but it might take a much more conservative pathway than the model reflected in ACOs and other population management initiatives. Starting to examine prescriptive patterns, develop care protocols, identify your referral patterns and see if less expensive options are available, and reaching out to your two or three major payers and see if they have an incentive program that might match the steps that you can accomplish.If none are available, then it’s business as usual for your medical practice.

 Article By: Greg Mertz- See more at: http://www.physicianspractice.com/blog/volume-value-minimizing-major-healthcare-shift?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=20082013#sthash.toH5dZCs.dpuf

E/M Tip: CPT Modifier 25 (Critical Care)

Services, such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter, e.g., Swan-Ganz (CPT code 93503), are not bundled into the critical care codes. Separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with CPT modifier 25. The time spent performing the pre, intra and post procedure work of these unbundled services, e.g., endotracheal intubation, shall be excluded from the determination of the time spent providing critical care. This policy applies to any procedure with a 0, 10 or 90 day global period, including cardiopulmonary resuscitation (CPT code 92950). CPR has a global period of 0 days and is not bundled into critical care codes. Therefore, critical care may be billed in addition to CPR if critical care was a significant, separately identifiable service and it was reported with CPT modifier 25. The time spent performing CPR shall be excluded from the determination of the time spent providing critical care. In this instance, it must be the physician who performs the resuscitation who bills for this service. Members of a code team must not each bill Medicare Part B for this service.
For more information, please visit the Medicare Claims Processing Manual, 100-04, chapter 12, Section 30.6.12. K at CMS website (PDF, 1 MB).

Thursday, August 15, 2013

Complaints and Disputes Against Insurers

When an insurer or payer denies a claim unfairly or otherwise conducts business in an inappropriate manner, a physician practice can and should take action. Use the information on this page to better understand and navigate the complaint process.

Complaint proceduresPhysicians should first try to resolve the issue through the third-party payer’s internal complaint submission process. If you feel that your issue was not properly addressed in the internal process, consider seeking an impartial review by a state insurance regulatory agency, your state medical association or the AMA. Understand what to expect during the complaint process.

Filing a complaint against an insurer – mapTo assist you with the process of filing a complaint with the AMA, your state medical association or state insurance regulatory agency, the AMA has compiled the complaint process procedures for every state. Information is available through an easy-to-use interactive map.

Health plan complaint formUse the AMA Health Plan Complaint Form to let the AMA know about the hassles and unfair business practices you experience in your day-to-day interactions with health insurers.

File a HIPAA-related complaint
Physicians are encouraged to file a complaint with the AMA when an insurer is out of compliance with Health Insurance Portability and Accountability Act (HIPAA) transaction and code set standards. Also learn how to file a complaint with the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS).

Courtesy of : AMA http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/complaints-disputes.page?

Overpayment Recovery

Physician practices frequently have to deal with allegations that they have received overpayments from commercial and governmental payers. Attempting to determine the validity of alleged overpayments can divert significant time from direct patient care, which results in lost practice revenue. All too frequently, overpayment demands are made in the most general terms; the practice is not given the specific information—such as dates of service, patient names, or individual claims—which would enable the practice to determine independently the validity of the demand. Overpayment demands may also be intimidating, particularly when the amounts alleged are significant. Such amounts are frequently the result of "extrapolated" audits. Sizable demands may also reflect a payer’s contention that alleged overpayments have been occurring over many years.

The AMA has created "Questions to consider when addressing payer overpayment recovery requests on individual claimsPDF FIle" to help you handle overpayment recovery issues.

Challenging overpayment allegations
Overpayment allegations can frequently be successfully challenged. Insurers may, for example, request overpayments of dubious legitimacy, hoping that the practice will simply concede. Although this may resolve a particular set of allegations, ready acquiescence may fix the practice as an "easy mark" to which an insurer may return with further demands. Informed opposition, even if not always entirely successful, may lead the practice to develop a better process for identifying overpayments,, as well as confirm for the insurer that the practice is not an "easy mark."
Federal and state regulations may help practices oppose or otherwise limit the effectiveness of overpayment demands. For example, a number of states limit the "look back" period over which insurers may claim overpayments. Many states also require insurers to provide specific information enabling physicians to determine independently the validity of demands prior to recoupment. The AMA has also successfully lobbied for significant limitations on the authority that certain government contractors (for instance, Medicare and Medicaid Recovery Audit Contractors) may exercise when pursing physician practices for alleged overpayments.

Read more about the AMA’s advocacy with respect to the Medicare and Medicaid Recovery Audit Contractor Programs.
New Medicare overpayment obligations under the Patient Protection & Affordable Care Act
Repayment is even more important now, since the Patient Protection and Affordable Care Act (ACA) imposed a new Medicare repayment obligation on physicians and providers. Under the ACA, a physician practice must report and repay a Medicare overpayment no later than sixty (60) days after the date on which the practice identified the overpayment. Failure to report and repay the overpayment within this deadline may result in significant monetary and administrative penalties. Physician practices should have in place procedures for repaying identified overpayments to all payers as a matter of good business practice.
For more information on AMA’s advocacy with respect to the 60-day repayment obligation, refer to the Fraud and Abuse section on the Advocacy with the Administration webpage.

Article Courtesy of: AMA- http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/claims-revenue-cycle/overpayment-recovery.page

Medicare Preventative Services National Provider Call

JE Medicare Part B Processing Changes Using CPT Modifier 52-Reduced Services - Effective September 16, 2013

Noridian has identified a claim processing difference between contractors .This notification is to make all Part B providers served by Jurisdiction E (JE) aware of this difference. 
Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. A concise statement that explains the nature of the reduced service along with any other supporting documentation the provider deems relevant. The concise statement may appear on the operative report but, it must be clearly identified. This statement may be entered in the electronic documentation field or submitted via the fax attachment process. For paper claims, this documentation must be submitted as an attachment to the CMS-1500 claim form. Services that are submitted with CPT modifier 52 that do not include a concise statement will be rejected as 'unprocessable' and must be resubmitted as new claims
Noridian requires the provider to determine the charge amount, reduce normal fee by percentage of service not provided e.g., if 75% of normal service provided, reduce amount billed by 25% Medicare reimburses lower of actual charge or fee schedule allowance.

Example: Provider performs 75% of service and appends modifier 52
Medicare Physician Fee Schedule (MPFS) allowed amount $300
Reduced Billed Amount ($300 x 75%)$225
  • Reflect statement “reduced services” in Item 19 (narrative or electronic equivalent)
  • Documentation reflecting “reduction” reason retained in patient’s medical record
  • Do not confuse with “terminated procedure” modifier 53
  • Never use with evaluation and management or anesthesia codes
  • When submitting the Redetermination request include:
    •  A separate, concise statement explaining the necessity for allowable reduction
    •  An operative report or chart notes
  • Performed on one eye; unilateral
  • Do not use RT or LT
Treatment DescriptionCPT/Modifier
Fundus photography with interpretation/report; bilateral92250 52

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JE Medicare Part B Processing Changes for Use of CPT Modifier 22 - Effective September 16, 2013

Noridian has identified a claim processing difference between contractors. This notification is to make all Part B providers served by Jurisdiction E (JE) aware of this difference. 
Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. Documentation required with the claim is a concise statement and operative report which is either entered in Item 19 of the CMS-1500 claim form for paper claims or submitted with an electronic claim via the fax attachment process. Failure to submit the appropriate information results in a denial of the claim. Claims submitted with CPT modifier 22 are reviewed on an individual basis. Additional reimbursement allowance will be dependent on the documentation.
Noridian pays claims with the CPT modifier 22 at the established fee schedule rate. Providers may appeal for additional payment with sufficient documentation demonstrating the work performed was substantially greater than typically required and explains why the surgery was unusual.

When appealing:
  • Redetermination requests require a separate, concise statement explaining the necessity for additional reimbursement be included.
    • Need operative report or separate letter
  • Medical Review addresses each request individually with no assurance of additional payment 
Treatment DescriptionCPT/Modifier
Pharyngolaryngectomy, with radical neck dissection; with reconstruction31395 22             

Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.2 “Billing Requirements for Global Surgeries” – Unusual Circumstances at  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/bp104c12.pdf This link takes you to an external website.

Wednesday, August 14, 2013

In Medical Coding, Apply the Right Rules at the Right Time

When submitting medical claims, not only do you need to get the codes right but you have to apply the right rules. Coding guidelines are found in the CPT® code book and payer policies. HIPAA mandates that providers and payers use the same codes but payers can vary the payment policies and coding requirements. For example, bilateral procedures can be reported in different ways. The "right" way is to follow payer preference which can vary from payer to payer.
Some of the options for reporting bilateral knee arthrocentesis include:
  • 20610-50 with two units 
  • 20610-LT, 20610-RT with one unit each
  • 20610, 20610-50 with one unit each

In the CPT® code book, there are coding guidelines throughout the sections and subsections that provide valuable information for proper code selection. Often the coding guidelines include a description of the procedures and additional procedures that can be billed when performed. For example, the coding guidelines preceding malignant excisions codes (11601-11646) state that a simple closure is included in the procedure. If the excision site requires an intermediate or complex closure, the closure can also be reported if performed. If you did not pay attention to this guideline, you could be losing money if you did not code the intermediate or complex closure.

The parenthetical notes found in the CPT® code book are also valuable. The intent is to assist in proper coding. These instructions are often overlooked which leads to coding errors. For example, following code 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure). CPT® states "Do not report 64492 more than once per day." This instruction informs you it would not be appropriate to submit multiple units of the code on the same date of service.

One of the biggest mistakes a practice can make is applying Medicare rules to all payers. This can cause improper reimbursement. There are some procedures Medicare does not cover that private payers will and vice versa. For example, Medicare allows for a Pap smear every two years for a female who is not considered high risk or of childbearing age. Private payers may cover the Pap smear once per year. If you applied the Medicare frequency limitation, you would lose out on the reimbursement from the private payers.

The good news is the information for private payers can be found in the provider-payer contract, payment policies, and provider manuals. Most payers provide payment polices and provider manuals on their website. Coding requirements for Medicare can also be found on the CMS website in the Medicare Claims Processing Manual, Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). There is a lot of information available that provides guidance for submitting the codes correctly.

You need to make the time to read and understand the rules and remain up to date. Keep in mind, policies periodically change, which requires you to stay updated on those changes.

Article By Raemarie Jimenez, CPC - : http://www.physicianspractice.com/blog/medical-coding-apply-right-rules-right-time#sthash.f6W2pbDx.dpuf

Proper Coding Can Help Prove Medical Necessity

For a service to be considered medically necessary, it must be reasonable and necessary to diagnosis or treat a patient’s medical condition. When submitting claims for payment, the diagnosis codes reported with the service tells the payer "why" a service was performed. The diagnosis reported helps support the medical necessity of the procedure.             

For example, a patient presents to the office with chest pain and the physician orders an electrocardiogram (ECG). A 12-lead ECG performed in the office and interpreted by a physician is reported with CPT® code 93000. The reason the physician orders the ECG is because the patient is complaining of chest pain. The diagnosis code for unspecified chest pain is 786.59.

The provider must document the diagnosis for all procedures that are performed. The provider also must include the diagnosis for each diagnostic test ordered. A common error seen when reviewing medical documentation is that the provider will document a diagnosis and indicate tests ordered, but it is unclear that all the tests ordered are for the diagnosis documented in the assessment. For example, the patient presents with right knee pain and the physician performs an arthrocentesis. He also orders a chest X-ray. The only diagnosis documented is knee pain. The knee pain supports the medical necessity for performing the arthrocentesis, but it does not support the medical necessity for the chest X-ray.

In this case, the provider should be queried why the chest X-ray was ordered so the proper diagnosis can be reported. The provider may have wanted a knee X-ray and made a mistake when writing his orders. By asking the provider for clarification, you have prevented the performance of an unnecessary test because the provider really intended to order a knee X-ray. In this case, the knee pain would support the order of the knee X-ray. If the provider intended to order a chest X-ray, by asking for clarification you can report the service with a more appropriate ICD-9-CM code and eliminate a claim denial. In this example, the arthrocentesis is reported with procedure code 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) and diagnosis code 719.46 Pain in joint; lower leg. The code for the X-ray is selected based on the anatomic site and number of views obtained.

Not all diagnoses for all procedures are considered medically necessary. Medicare and commercial payers have coverage policies that specify the diagnosis codes that support medical necessity for certain procedures. Also included in the coverage policies are documentation requirements. The documentation requirements can include diagnostic test values that must be met, that less invasive treatments be attempted before the service is determined to be medically necessary, or — for a repeat procedure — a statement of the outcome of the previous procedure of the same type. Knowing the coverage polices for the services provided in your office can help eliminate denied claims later.

The coverage policies are available for providers to review and adhere to when submitting claims. The coverage policies for Medicare are found at the Medicare Coverage Database. This database includes NCDs (National Coverage Determination), which are nationwide determinations for Medicare covered services; and LCDs (Local Coverage Determination), which are determinations if a service is covered carrier-wide by a MAC (Medicare Administrative Contractor). Using this database, you can search for coverage determination by CPT® or HCPCS Level II codes, and by your geographic region.

Private payers (e.g. Cigna, United Healthcare, etc.) have coverage policies as well. Most private payers have their coverage polices available on their website. Provider contracts with payers also include coverage policies. Review the coverage polices for the private payers you contract with, as well as Medicare if your provider participates in the Medicare program.

Word of caution: Do not alter the diagnosis code for a patient to match one of the diagnosis codes listed in the coverage policy as supporting medical necessity. The diagnosis code submitted must be supported by the medical record. It is inappropriate to report a diagnosis solely because it is on the approved list of diagnosis codes that meet medical necessity. Reporting a diagnosis that the patient does not have to receive payment for the service is fraud, which may result in fines and, in some cases, criminal prosecution.

When submitting claims, you must report the diagnosis that is indicated in the medical record for the procedures performed and ordered. Knowledge of coverage policies will help you to be proactive in avoiding claim denials and to educate your providers on the documentation required to support the services rendered. This is not to say that the provider should not perform the service if the circumstances may deem the service not medically necessary. If the physician determines the procedure is medically necessary even though the coverage policy does not approve it, this gives you the opportunity to educate your patients that the service may be denied by their insurance carrier. The patient then has the choice whether to have the procedure.

Article by Raemarie Jimenez, CPC  - See more at: http://www.physicianspractice.com/blog/proper-coding-can-help-prove-medical-necessity#sthash.gaQDAPLq.dpuf