Participating in New Healthcare Exchange Plans

By Susanne Madden from Physicians Practice

It is early with regard to the healthcare exchange plans and yet practices across the country are already feeling the impact. It's not just consumers who have experienced problems while attempting to sign up for the exchange plans on the healthcare.gov website; providers too are dealing with major headaches as they navigate through the first couple of months of this new system.

Let me explain. The insurance companies created something called "narrow networks" within their full network of providers. What that means is that only a subset of physicians within any given insurance company's network "qualified" for participation in the exchange plans. The result is that while some physicians got rolled into these plans, others were excluded, even though they participate in some of the other products with that particular insurance company. For example, a physician could be participating with an HMO and a PPO-type product, but be excluded from the exchange product. This has created a dilemma for many practices. On the one hand, it means no new business coming in from new exchange members. On the other hand, it also means scrambling to hold onto existing patients that have switched to these new, lower-priced health insurance products.

The physicians that were rolled in (or opted in, in many cases) to the new exchange networks are struggling to determine new patients' eligibility under these plans. Many patients have not yet received insurance cards, and those that have are sometimes finding that their physician was mistakenly listed on the website as a "participating" provider.

In addition, those physicians who are participating with the exchange plans are finding that they are getting paid less for doing more. That is, not only are the rates less in these plans, but many patients who previously did not have health insurance may have gone without care for prolonged periods of time. As a result, they are typically sicker than patients who have been under care over time.

Also, signing up for participation in these plans means accepting a lower payment rate because the insurance companies are offering these as "budget" plans with low premiums. Naturally, the discounts have to come from somewhere and this is in the form of lower payments to physicians who participate with these plans.

So where does that leave things for physicians?

Here are four points to consider:

1. Physicians need to know whether they are participating with an exchange plan.

This can usually be readily discovered by looking yourself up on an insurance company's online directory. But don't just trust the data that you find there; double-check by calling the insurance company and verify that you are in fact participating with an exchange plan (there have been many errors on these sites so far).

2. Physicians need to determine what their fee schedule is going to be.

Ask the insurance plan to send you a sample for your specialty or send them your highest utilized codes for pricing.

3. Physicians need to communicate very clearly with patients if they are not in the exchange plans.

Hang posters on your waiting-room walls and get communications out to patients to explain that the insurance company (if this is the case) has decided to exclude you from the exchange product. Many patients wrongly assume that their physician is automatically in the network, so do your best to educate them as soon as possible.

4. Physicians need to quantify the damage.

Take note of the number of patients that you may lose due to their choice of plan and appeal to the insurance company to see if there is a way that you can retain them. If you purposefully opted out of the exchange network then it is unlikely that you can hold onto these patients. But if you were excluded from the network, you may be able to appeal ― in doing so the plan might make an exception and add you in.

If you are participating with an exchange product and you find that you are receiving an influx of these patients, my best advice to you is to set up some very good patient education materials and tools around the most frequently seen chronic conditions, in order to help manage what may be a sicker population of patients. Don't be afraid to look at what the insurance company is offering in terms of chronic-care support. Many have teams of nurses that help to manage the patient's care and do a relatively good job of feeding that information back to the primary-care physician.

Lastly, remember that it is still early. There are going to be a lot of missteps under this new system, on all sides. So I suggest hanging in there to see how things shake out. Like any new program it will take a while to work out the kinks.

Article by: Susanne Madden, MBA, is founder and CEO of The Verden Group, a consulting and business intelligence firm that specializes in practice management, physician education, and healthcare policy. She is also COO, National Breastfeeding Center, and cofounder, Patient Centered Solutions. She can be reached at madden@theverdengroup.com or by visiting www.theverdengroup.com.

From Physicains Practice http://www.physicianspractice.com/healthcare-reform/participating-new-healthcare-exchange-plans?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=27022014

Forgiving Patient Copays Can Lead to Unforgiving Consequences

At one time in America, there was no such thing as "health insurance." Patients negotiated directly with hospitals and doctors, and paid what they could, often on a sliding scale, according to ability. Eventually, health insurance entered the market, easing the burden of healthcare costs.

It didn't take long to realize the ordinary rules of supply and demand would not apply, if the insurance company, not the patient, was responsible for the bill. Copayments, deductibles, and coinsurance developed as a check against overutilization. If the patient had some "skin" in the game, this would provide some disincentive, though not absolute, but some hedge against over-use. This protective requirement, though necessary, is at times at odds with AMA Code of Ethics Opinion 8.03, which holds: "The primary objective of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration.

"In the current economy, as available dollars are becoming scarce, insurance carriers have begun checking up on the collection of copayments, deductibles, and coinsurance. With greater regularity, physicians and hospitals are receiving letters requesting proof, in perhaps five randomly selected cases, that the provider has collected, or sufficiently attempted to collect the portion of fees which is the patient's responsibility. This comes as a shock to many providers, who in keeping with Opinion 8.03, and the historical tradition of sliding scales, based upon ability to pay, have subordinated financial ability to pay in favor of the higher duty to care for the patient's need.

It is important to understand, however, forgiveness of copayments could land you in hot water. Therefore, doctors must understand the rules regarding waiver of copayments. AMA Opinion 6.12 addresses the ethical considerations:

Opinion 6.12 - Forgiveness or Waiver of Insurance Copayments

Under the terms of many health insurance policies or programs, patients are made more conscious of the cost of their medical care through copayments. By imposing copayments for office visits and other medical services, insurers hope to discourage unnecessary healthcare. In some cases, financial hardship may deter patients from seeking necessary care if they would be responsible for a copayment for the care. Physicians commonly forgive or waive copayments to facilitate patient access to needed medical care. When a copayment is a barrier to needed care because of financial hardship, physicians should forgive or waive the copayment.

A number of clinics have advertised their willingness to provide detailed medical evaluations and accept the insurer's payment but waive the copayment for all patients.

Physicians should be aware that forgiveness or waiver of copayments may violate the policies of some insurers, both public and private; other insurers may permit forgiveness or waiver if they are aware of the reasons for the forgiveness or waiver. Routine forgiveness or waiver of copayments may constitute fraud under state and federal law. Physicians should ensure that their policies on copayments are consistent with applicable law and with the requirements of their agreements with insurers.

Where the insurance contract requires a doctor to make reasonable attempts to collect the patient's portion, an open question surrounds the definition of "reasonable attempts to collect the debt." Historically, doctors could satisfy the requirement by sending at least three letters attempting to collect the debt. However, the Office of Inspector General (OIG) has taken the position that the routine waiver of copayments could constitute a criminal kickback in Medicare cases.

This has emboldened private insurers, who are relying upon this contractual provision as a basis for a post-payment recoupment audit. If a provider cannot demonstrate efforts to collect from the patient, the carrier may demand a refund for any benefits paid across a large patient population.

Providers should be aware of this new emphasis upon patient responsibility. My advice would be to proactively get ahead of the problem. Contact your insurance representative to find out what is expected of you and document the response. By all means, if you are a physician and you receive a letter from an insurance carrier requesting proof of attempts to collect, do not ignore it. A failure to cooperate could constitute grounds for termination of the contract with the payer.

Because this emphasis upon collection of copayments is a fairly recent phenomenon, even if you have been deficient in the past, you may be able to satisfy the carrier by demonstrating a corrective plan of action going forward.

Courtesy of Physicians Practice, By Martin Merritt http://www.physicianspractice.com/blog/forgiving-patient-copays-can-lead-unforgiving-consequences?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=17122013

Medical Practices: Think Twice Before Waiving Copays

Historically, family practices and many other physicians groups have routinely waived insurance copays as a gesture of goodwill to patients in a tight economy. After all, who wants to hound sick patients for their portion of the charges?

There was a time when insurance companies turned a blind eye to these routine waivers of copays. Not anymore.

The AMA's Code of Medical Ethics Opinion 6.12 explains why routine waivers are unethical, particularly when a clinic advertises a willingness to waive copayments.

Further, the Office of Inspector General (OIG) has long taken the position that routine waiver of copayments constitutes an illegal kickback, which is a felony. 

The routine waiver of copayments also constitutes a violation of the terms of private insurance company plans. This contractual violation serves as a basis for a recoupment audit, during which insurance companies request proof of collection of copayments for five randomly selected patients. If the clinic cannot prove it collected, or at least exhausted all reasonable means of collection, then the carrier may demand a refund for any benefits paid across a large patient population.

Perhaps most frighteningly, routine copay waivers constitute ordinary financial fraud. If a patient is charged $100 and the insurance carrier is billed $80, the patient is supposed to pay $20. If you never attempt to collect the $20, this means the actual charge is $80, not $100.  Therefore, the insurance company should only pay $64 (80 percent of the $80
Fraud or dishonesty is a primary way to get in trouble with state medical boards.

There are provisions for waiving copayments in cases of financial hardship. At a minimum, you should document the financial hardship, and obtain a release from the patient to turn the financial document over to the insurance company, if requested.

The OIG states the following criteria for waiver on the basis of financial hardship:

• The waiver must be based on a good faith determination of the patient’s financial need. In other words, waivers must not be applied routinely. The government does not specify the financial status that would justify a waiver, so you should develop your own approach, apply it consistently, and document your efforts. For example, if your efforts to collect on a patient’s bill fail, or if it’s obvious that a patient is struggling to pay the amount owed, ask the beneficiary to fill out a form noting their employment status and average household income and expenses. Then make your determination based on the information provided.

• The waiver must not be based on the amount of the charges. Your decision about whether to waive what a patient owes should be based on the patient’s ability to pay without regard to what Medicare may have paid or the total charges for the service.

• The waiver must not be offered as part of an advertisement or solicitation.

State laws vary regarding waivers. Therefore, seek the advice of an experienced health lawyer in your state if you have questions about your practices.

Article By Martin Merritt from Physicians Practice
http://www.physicianspractice.com/blog/medical-practices-think-twice-before-waiving-copays?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19112013

Boost Medical Practice Collections by Cutting Down Patient Statements

By P.j. Cloud-moulds from Physicians Practice

Do you know how many patient statements are sent out at your practice? Do you know how high that A/R class is? These are two very important questions you need to ask yourself today. The numbers might shock you.

If you do find that the number of patient statements is too high, you can then start asking why this is the case. Here are some of the common reasons:

Your front office staff did not collect the patient copay, coinsurance, or deductible. If you have an up-to-date fee schedule, calculating the patient coinsurance and deductible is easy, and should be done at the end of the appointment prior to the patient walking out the door. Copays are easy to collect and should be collected at the beginning of the appointment.

Your front-office staff did not collect according to plan details. When verifying an insurance plan, sometimes the insurance company will provide incorrect information. Your staff may also be calculating the patient portion incorrectly. Be sure your staff is well trained in this area. It's costing you a lot of money if they are not.


 Patients are paying at the time of service, but those payments are not getting posted properly. This results in a nasty call from the patient stating that, “I paid, and will not pay again!” This is the epitome of poor customer service. Institute checks and balances at the end of each day to ensure payments are posted.

Patient “forgot their checkbook or credit card.” This is a line that you hear too often, and it's full of hot air. If the patient “forgets,” let him know that he can call in his payment by the end of the day, or he will incur a late payment fee. Yes, this is legal. If the patient can't pay now, he certainly won't pay in a month when he gets the bill.

Staff adjusts off a patient deductible. Your front-office staff performs the insurance verification, and sees that the patient has a $5,000 deductible of which only $352 has been met. Once the deductible is met, the patient is responsible for 20 percent of the allowed charges. Your front-office staff is reluctant to charge the patient the deductible amount for fear of being yelled at by the patient (who should already know her plan limitations, but most often does not) so staff charges her the co-insurance instead. This results in the patient getting a bill for the remaining amount. The angry patient then calls and yells at the staff stating, “I paid at the time of service!” Another example of poor customer service. Remember, you cannot adjust off a patient deductible.

The patient has Medicare and a secondary insurance. Since we are not allowed to collect monies from Medicare patients until Medicare pays its portion, we bill the secondary. If the secondary does not pick up all of Medicare's 20 percent, then the patient gets a bill. It's really difficult when some Medicare patients do not understand their secondary insurance has a deductible, or will not cover the entire 20 percent.

Just sending out statement after statement is a very poor way of running a business. Have a time limit of how many statements you will allow a patient to receive. Three months is a good rule of thumb. If patients need to be put on a payment plan, that's great, but put a time limit on that, as well. Your practice is not a bank, credit union, or credit card. It is a business, and no other business would allow goods and services to walk out the door before payment. Stop allowing patients to take advantage of your good nature.

Article taken from Physicians Practice http://www.physicianspractice.com/blog/boost-medical-practice-collections-cutting-down-patient-statements?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=22102013

The Evolution of Government Intrusion on the Medical Profession

By Martin Merritt from Physicians Practice

This week found me sitting alone in our law firm library, preparing to defend a physician before the Texas Medical Board. In an era of electronic research, both legal and medical, it is rare to find anyone, (other than me), in the library. I not only enjoy flipping through real pages; some of which were bound and placed on these shelves 70 years ago, I enjoy getting momentarily sidetracked from my original mission.

I picked up this habit as kid reading the World Book Encyclopedia. Regardless of what I might be looking for, I would always stop and absorb eight to ten articles, just to learn about some historical fact I didn’t know existed.  

This week, flipping through historical reports of medical ethics cases, many dating to the 1950s, I began to see a clear picture of something I wasn’t expecting to find.  Virtually every federal regulatory concern currently plaguing the modern practice of medicine also existed in some form in the 1950s.

Comparable to Medicare RAC and external audits; physicians were losing their practices for improper charting and documentation. However, these losses usually pertained to life-and death matters, such as the prescription of narcotics. “Off-label promotion,” similar to the fen-phen scandal, usually concerned mundane, unapproved uses of common household remedies.

For example, a physician in the 1950s lost his license for charging patients $49 each for a treatment to remove gallstones using olive oil. (The board found that the oil, mixed with stomach acid, actually produced “soap balls,” not gallstones, as the physician improperly claimed.)

“Bundling and unbundling” issues were also present sixty years ago when a physician was disciplined by the board for routinely including fee-for-services charges that were already billed to the patient as part of the hospital’s charges.

Time and again, modern coding, charting and regulatory issues “pop” from the pages of history. Some cases represent quaint precursors to FTC “advertising” regulations. These appear as ethics disputes over the size of the lettering appearing on a physician’s office window, to questions about the exact line between acceptable public service promotion and impermissible advertising.

Half a century ago, one party was notably absent from the dusty pages of medical ethics cases: the federal government. There is a reason for this. Until the post-Civil War period of reconstruction, no federal laws governed a person’s conduct in any way. Slowly, beginning with the regulation of racially motivated murder, and laws pertaining to civil rights violations, Title 42 of the United States Code (containing laws related to civil rights and health and human services), began to grow in size and scope.

Today, in addition to racial offenses (42 U.S.C. §1983); Stark Law (42 U.S.C. 1395nn); the Anti-kickback Statute, (42 USC § 1320a–7b); HIPAA (42 U.S.C. § 300gg); and the Medicare law (42 U.S.C. 1395) are located in the growing Title 42 of the United States Code.

Many fear, and rightly so, that as healthcare insurance exchanges offered at healthcare.gov become fully operational, the federal takeover of the practice of medicine will soon be complete.

In the not-too-distant future, the common law principle, “A physician and patient are free to contract for services in any way they see fit,” will seem just as quaintly anachronistic as limits on the size of lettering on a physician’s office window.

Courtesy of Physicians Practice http://www.physicianspractice.com/blog/evolution-government-intrusion-medical-profession?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=22102013

“Expanded Coverage Under the Affordable Care Act: Information for Health Care Professionals” Fact Sheet — Released

The “Expanded Coverage Under the Affordable Care Act: Information for Health Care Professionals” Fact Sheet (ICN 908826) was released and is now available in downloadable format. This fact sheet is designed to provide education on the Health Insurance Marketplace under the Affordable Care Act. It includes information health care professionals need to know about the Marketplace, an explanation of how the Affordable Care Act expands access to health coverage, and an explanation of the Marketplace, how it affects health care professionals and their patients, and resources.
From Medicare Learning Network eNews update.

How to Code, Negotiate After-Hours Reimbursement at Your Practice

There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.

Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.

To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Know the Codes

Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.

If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).

Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

G. John Verhovshek, MA, CPC, is the managing editor for AAPC's publications. He has written, co-written, and edited dozens of coding and compliance resource manuals, including the Part B Survival Guide (1st edition) and The Official CPC Certification Study Guide (1st edition). E-mail him here.

Article By G. John Verhovshek, MA, CPC http://www.physicianspractice.com/coding/how-code-negotiate-after-hours-reimbursement-your-practice?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03102013

Reduce Medical Practice Embezzlement Risk by Implementing Cash Controls

By Karen Zupko and Cheryl Toth Of Physicians Practice

Several years ago, we visited a practice in which the receptionist drove a Jaguar. We were particularly intrigued about this after we learned that her husband had been in and out of work for several years. As part of our engagement, we observed the receptionist checking in and checking out patients, and noticed fairly quickly that the encounter forms for several patients who paid in cash had "disappeared."

The next day, the receptionist called in sick and within a few days had resigned. In the end it became clear she had been tossing encounter tickets and pocketing cash for years. But because the practice didn't require anyone to account for all the day's encounter forms, nor balance money collected against what was posted to the computer system, no one was the wiser.

Front-desk embezzlement schemes are not uncommon and they are typically the result of loose protocols and lack of oversight. Reduce your financial risk by tightening cash controls using these proven practices.

1. Confirm that all encounter tickets for the day have been posted and "closed." At the end of each day, generate a "missing ticket" report from the practice management system and verify that all encounters have had charges and payments posted to them. This indicates the ticket has been closed. If your practice uses paper, ensure each ticket has a number. If your practice is paperless, the practice management system will generate and store an electronic tracking number. Tickets for patients who cancelled or did not show up for their appointment should be closed with a reason code for "cancelled" or "no-show."

Closing and accounting for all encounter tickets is the foundation of front-desk cash control, yet many practices skip this step. When we asked a neurosurgery group to generate a missing ticket report for the first time, it included more than 600 open tickets from the previous two years. Was someone in the practice on the take? Hard to say. But these days no one goes home from this practice until all tickets are located and closed.

2. Balance the ticket totals, posted payments, and actual money collected. This is standard operating procedure in any retail store or restaurant and should be your standard operating procedure too. Balance all three totals to the penny, and designate a manager or supervisor to review and sign off on the work. Thievery is thwarted when employees know someone is paying attention. For each day's balance, bundle the closed tickets (or equivalent electronic report) with credit card receipts, check copies, and the reconciled total payments collected and file them by day (electronically or on paper).

3. Lock it up. We were stunned to spot an unlocked strong box on the front desk of a small internal medicine group, from which staff and doctors regularly withdrew money for everything from the physicians' lunches to a box of copy paper. No lock, no protocol for who could withdraw money, and no paper trail of what was taken out. The timid manager simply put more money in when the balance was low. Be smart: Keep all money in a locked drawer (or overnight safe), and establish guidelines for who has access and what the money should be used for.

4. Separate the "change fund" from "petty cash." There is a difference. The change fund is an amount in small bills that's always the same — say, $200. This is the money staff use to make change for patients who pay in cash. Every day when they balance to the penny, the amount is counted out and kept in the drawer for change-making the next day.

The petty cash fund is a small account from which you borrow for small purchases. Each transaction is logged on a "chit," and ultimately posted as an expense in your bookkeeping system. When the petty cash fund is low, the manager replenishes it, and records this in the bookkeeping system too. If you don't track petty cash separately from change, you risk an easy-to-play financial shell game that never matches money spent with specific transactions. And it's difficult to spot missing money if there are no controls for reconciling transactions in the first place.

5. Randomly audit no-shows and cancelled appointments to make sure they are valid. In one surgical practice, we uncovered a front-desk staffer deleting appointments using the reason code "no-show" for patients who were seen and paid in cash. How did we catch it? An inordinate number of no-shows prompted us to pull charts. In several we found visit notes for patients who supposedly did not show up for their appointment — when they actually did. Not only had the practice lost the patient's payment, but because the staff person had made these encounters disappear, none of these services had been billed to insurance either.

6. Conduct background checks for EVERY employee who handles money. An attorney colleague is currently working on five cases that involve practice or billing service employees accused of stealing. Background checks should be an essential part of the hiring process. You'll be amazed at how many candidates are up to their ears in credit card debt, or who have been convicted of a crime. Both are clues that the candidate should not be hired to handle money.

Don't wait until after the hire to learn the facts. Companies such as Trusted Employees offer inexpensive background checks for employees of hospitals and physician offices, as well as other industries. (www.trustedemployees.com)

7. Pay attention to the personal situations of staff. A person who cannot pay their mortgage or has racked up thousands of dollars in credit card debt can feel desperate and act in ways they normally may not. Or, in the case of the Jaguar-driving receptionist, the luxury car should have been a signal to the manager and physicians that something was amiss.

Yes, we recognize that physicians and managers are busy. But when it comes to managing people who handle your money, there is no amount of busy that should get in the way of good old acuity and common sense.

Karen Zupko is President of KarenZupko & Associates, Inc., a firm that has helped physicians save time, save money, and reduce risk for more than 25 years.

Cheryl Toth is a KZA consultant and writer focused on technologies and process change that improve practice profitability and the patient experience.

Article courtesy of Physician's Practice: http://www.physicianspractice.com/embezzlement/reduce-medical-practice-embezzlement-risk-implementing-cash-controls?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03102013

Patient Out-of-Pocket Expenses Rise, Squeezing Physician Cash Flow

Maintaining cash flow is a growing challenge for physician practices now that their "bread and butter" privately insured patients are paying more and more of their healthcare expenses out of pocket, and it will get worse.

Out-of-pocket expenses not including premiums have increased to an average $768 for each privately insured consumer in 2012 according to the nonprofit, non-partisan Health Care Cost Institute, and are projected to skyrocket as much as 50 percent in 2015 under Obamacare’s numerous mandates.

Maintaining your practice’s cash flow requires much more than initiating more aggressive patient obligation collections policies. Payer contracting, practice marketing, and patient-service strategies must change to keep pace.

Payer Contracting

The market will soon be flooded with newly insured and reinsured through exchanges, mostly women because newly mandated coverage favors women and relies on men to share the cost. Employers will be re-evaluating policies and, if they keep insurance at all, will be gravitating to higher-deductible policies to keep pace with subsidized premiums.

Identifying major area employers with whom they insure, and whether or not they have high-deductible policies, is a new must. It isn’t just how much the insurer pays you anymore, it is how much the employee must pay you as well. Upscale employers typically have upscale insurance with higher reimbursements, lower co-pays and deductibles, and employees who can afford to pay them. As obvious as focusing on them as this may seem, going in-network with these payers and competing for their members has not dawned on most, if any, practices as a strategy.

Practice Marketing

Identifying and stratifying the best-insured employees and their families is a key competitive and marketing strategy. Getting those patients established with your practice is goal number one. Strategically, getting in network and understanding their needs is a must. Tactically, your marketing should be keyed to them. Your message should resonate with them. Your practice services should cater to their needs. And, you should be using experienced professionals for research, branding, messaging, and marketing.

Patient Services

Doing things right to gain a competitive advantage requires an investment in time and money. Keeping patients does not. It requires something else except in rare cases: a change in practice culture.

With all of the focus on patient-centered care, there is almost none on patient-centered services despite reams of literature showing that satisfied patients feel better, do better, and bring their friends and family along with them.

Change begins at the front desk with two very simple things: welcoming people and having an experienced staffer answer phones. How patients are treated sets the tone for the rest of the visit and determines the “patient experience,” and it all rests on office culture: Does your practice accept patients, or welcome them?

It all circles back to the beginning with two straightforward quirks of human nature: Happy patients are most likely to pay their bills while unhappy patients are most likely to sue.

For good advice on how to provide excellent customer service, click here.

Health Insurance Exchange Information for Physicians and Patients

A primary mission of the Affordable Care Act is to provide universal health coverage through the creation of health insurance exchanges or marketplaces. The triad of employer-sponsored coverage, marketplace insurance exchanges, and expanded Medicaid coverage should cover most Americans under 65 years old, with some exceptions.

Unfortunately, there will be coverage gaps for low-income people who fall between certain income levels and live in states where the Medicaid expansion was rejected, according to Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation.

Tolbert is charged with monitoring state implementation of the Affordable Care Act and the establishment of state insurance exchanges for Kaiser. She recently discussed in a webinar some consumer-based elements of the law that are also helpful for medical practices to understand and communicate with current or potential new patients.

Consumers will be able to shop and enroll in new insurance plans through the federal government's website (www.healthcare.gov), or their own state's website if available, beginning Oct. 1, 2013. Open enrollment will continue through Mar. 31, 2014, with the option of enrolling after that date if a qualifying event occurs.

Coverage through the marketplaces and the expanded Medicaid program (where approved by individual states) will begin Jan. 1, 2014, when insurance market rules also go into effect. That is also when the individual mandate to have insurance coverage begins.

The exchanges will offer a choice between four plans (figures are for single coverage; family coverage would be double):

• Bronze – typical deductible $5,000 / typical coinsurance 30 percent
• Silver – typical deductible $2,000 / typical coinsurance 20 percent
• Gold – typical deductible $0 / typical coinsurance 20 percent
• Platinum – typical deductible $0 / typical coinsurance 10 percent

They will also offer a catastrophic plan for people up to age 30, with a typical deductible of $6,350 and no coinsurance. While these levels of cost sharing may seem prohibitive, most consumers will be eligible for federal subsidies and tax credits.

The cost of premiums will vary by state and locality; and also by age. Consumers who wish to get a ballpark estimate of the costs of different plans can use the Health Insurance Subsidy Calculator provided by Kaiser.

For example: A 40-year-old pre-school teacher making $30,750 — or 250 percent to 300 percent of the federal poverty level —  would be required to pay 8 percent to 9.5 percent of her income for healthcare premiums on the exchange. Her subsidized cost for the Silver Plan would be $2,633 annually. (The unsubsidized annual cost would be $3,857.)

All of the plans offered on the health insurance exchanges are mandated to offer "essential health benefits," said Karen Pollitz, a senior fellow on health reform and private insurance for Kaiser:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and wellness services, and chronic disease management
8. Pediatric services, including oral and vision care

There are multiple health-reform resources available online through Kaiser and Healthcare.gov that would be helpful additions to your own medical practice website; even if your own patients don't need this information, most everyone has a family member who may benefit from knowing the facts, e.g. a young adult child who does not receive health insurance from her workplace, or perhaps a single professional who does freelance work or is self-employed.

As leaders in the health community, it is important for physicians to be knowledgeable about the coming changes in health insurance coverage. It also allows physicians to make informed choices about the types of new insurance they will participate in, and the numbers of new patients they take into their practices.

Article By Erica Sprey, Courtesy of Physicians Practice http://www.physicianspractice.com/blog/health-insurance-exchange-information-physicians-patients?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=17092013

Collecting Patient Payment during Scheduling

Scheduling is the first contact with the patient and by far one of the most important. It is a time you can obtain all the information needed to check eligibility, notify the physician in advance for the reason of the visit, set the expectation that payment is owed at the time of service, and start building a rapport with the patient.

Obtaining all information needed to check eligibility and perform pre-visit preparation can be time consuming, but is by far worth its weight in collected dollars when reviewing financials at the end of the month.During scheduling, the following minimum information should be obtained:• Patient demographics (name, cell number, address, work number, social security number, date of birth)• Insurance information (ID number, group number, payer ID, guarantor information)• Reason for visit• An answer to the question: Are there records or test results needed before being seen? After the information is obtained, the scheduler should request payment of any balance on the patient’s account. This can sometimes be an uncomfortable process for staff, but by providing staff with scripts and role playing, they can perfect the process in no time.  It can even make patient collections feel natural. For example, instead of saying, “Ms. Smith you have a balance on your account. Would you like to pay that today?” Train your staff to say, “Ms. Smith I see you have a past due amount of $50.How would you like to take care of that today? We accept Visa, MasterCard, or do you have a FSA card?” It is amazing how many more payments practices can collect, just by being prepared and having the proper scripts in place.
Once the practice has obtained all the needed information, checking eligibility and benefits in advance is a piece of cake. The process should no longer be considered an option for practices today. It is estimated that only 41 percent of providers collect at the time of service, while 36 percent collect at the time of service some of the time. This is surprising considering it costs approximately $7 a statement (if not sent electronically) and eligibility costs between $0 to $0.74. So at worst-case scenario the practice saves $6.26 per patient if the money is collected at the time of service. If the patient is sent more than one invoice the number continues to increase.

 Let’s compare the two different approaches:

Collection at the time of service (patient responsibility minus cost of eligibility check):
• $50- $0.74 = $49.26

Patient is billed for amount owed (patient responsibility minus cost of statements):
• $50 – 7= $43 (1st statement)
• $43 - $7= $36 (2nd statement)
• $36 - $7= $29 (3rd statement)

(If utilizing an electronic statement process the cost for three statements can vary between $2.25 to $5 depending on the process and vendor).

Comparing the two scenarios, it seems there would be no question as to which process is more efficient, but 49 percent of providers are still using the second scenario. In previous years, it was a cumbersome process to investigate patient responsibility in advance. Many times insurance feedback would not be current or correct. This in turn made the process frustrating and in many cases a waste of time and money. This made it understandable why many practices avoided the process. However, today the process could not be easier. There are various options for practices depending on their practice-management software and clearinghouse vendor.

These options include:

• Automating the process by utilizing your practice management software if offered. This will allow the practice to set up the system to check eligibility and benefits in advance before the patient is seen without staff utilizing time to retrieve the data. The information is commonly imported directly into the patient’s chart and can be viewed immediately.
• If automation is not an option for checking eligibility and benefits then centralize. Centralization can be done by utilizing a clearinghouse or other vendors that specializes in these types of services. (Tip: Make sure the vendor works closely and is compatible with your practice management software).
• Lastly, if the above options do not work, practices should go directly to their payers’ websites or call their payers. This option is more time consuming and costly considering hourly employees are performing the process manually, instead of automating after hours.

Once the process has been determined, the criteria must be decided. The information should be obtained at minimum of three days in advance of the appointment. This will allow the practice to compare the patient coverage to their fee schedule. By comparing the two, the patient responsibility can be estimated in advance, allowing the practice to contact the patient in advance. The more the process is utilized the more savings the practice will endure over time. This allows the practice to not only know patient financial responsibility, but also issues with insurance or coverage such as invalid insurance ID or that the service will not be covered.

Regardless of the method, the key is being prepared. Once the practice is prepared the practice can reach out to the patient to discuss their financial responsibility and payment expectations before treatment is performed. Before reaching out to the patient regarding their responsibility, the practice should have insight as to what will be owed. In order to calculate responsibility, fee schedules and contracts will have to be examined and compared by the practice to the patient’s coverage. Many practice management software programs have the ability to calculate this information, if it is set up and maintained properly. If the practice management software does not have the functionality, the information can even be calculated by utilizing an Excel spreadsheet if needed.

Once the amount owed is calculated, the patient counselor should contact the patient regarding the balance. The patient counselor should have strong customer service skills with a high level of billing knowledge, and the ability to be compassionate and considerate when speaking to the patients. Many times if handled properly, the patient will pay in advance or set up payment arrangements before being seen in the practice. More importantly, the patient is entering the practice with an understanding of their financial responsibility and can take ownership of the bill.

Healthcare is one of the few expenses that can unexpectedly occur but be as high as the cost of an automobile or mortgage. Isn’t it only fair we prepare our patients and set the expectation that money is to be paid at the time of service?

Article By Chastity Werner, RHIT
Courtesy of: http://www.physicianspractice.com/blog/collecting-patient-payment-during-scheduling?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=10092013

Getting Patients to Pay Early at Your Medical Practice

In many parts of the country, the economy is still in recovery while healthcare costs are continuing to rise. The end result for physician practices? More stress when it comes to getting patients to pay in a timely manner, and less-than-ideal collection rates.

Technology now allows practices to offer prepayment services to patients. But can such technology really help a practice collect payments at (or even before) the time of service? And will patients actually take to the idea of paying earlier rather than later? For Holly Springs Pediatrics in Holly Springs, N.C., the answer to both these questions is yes. But there has to be a good incentive in place. “It’s very hard getting money from people up front,” practice billing manager Judy Downing told Physicians Practice. “With the economy the way it is, we have so many people out of work. And they don’t look at a doctor’s office as an actual business. They look at it as ‘oh, let me bring you my chicken, and we’ll trade this chicken for your healthcare.’” Tapping into its eligibility verification technology from its billing vendor, InstaMed, which is integrated with its Office Practicum practice management software, Holly Springs Pediatrics recently started offering “prompt-pay” benefits for patients who pay their bills early. Charges are based on the estimated cost of the medical services. “We give them three different options,” said Downing, noting that these options are presented in a self-pay agreement form. “They can pay the estimated charges and receive a 30 percent discount if they pay the balance in full. Or they can pay 50 percent of their estimated charges and if they pay within 30 days, they get a 20 percent discount. They can pay a minimum payment and make an arrangement with the billing department.” By offering these three options, practice has improved collections, and is seen as more flexible by patients. It has also reduced patient no-shows. “We have had a lot of success with people paying it because they get that discount,” said Downing.Aspen Valley Hospital, which uses the same InstaMed program, has also seen a 124 percent increase in collections over the last four years since it started offering a 20 percent adjusted discount off the patient’s portion of the bill for paying in full at the time of service. Along with their two satellite practices, the hospital initially offered a 5 percent discount but found the 20 percent discount to be more successful.  Additionally, the practice reduced overall patient collection costs by 65 percent. “We start by telling a patient when we schedule, then the financial counselor will call and go over the expectation and say, ‘by the way, we offer 20 percent [adjustment] if you take care of your payment in full,” Debby Essex, the hospital’s director of admissions, told Physicians Practice. “Also, there’s a call before the patient comes to the front desk, and when they come to the front desk. They’re fully informed.”

Article by Marisa Torrieri
- See more at: http://www.physicianspractice.com/blog/getting-patients-pay-early-your-medical-practice?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03092013#sthash.wgmU6iRC.dpuf

Revenue Cycle Management Is More Than Billing Patients

Revenue cycle management (RCM) is the lifeblood of any practice — private or nonprofit. Effective patient registration, insurance and benefit verification, charge capture, and claims processing are essential to maintaining practice viability. Before you can improve any process, you need to assess where you are now. Here are some questions you should think about:

• Do you know if you are achieving best practice standards in accounts-receivable management? • Does it take your practice too long to collect, and/or are your write-offs and adjustments too high? • Do you know your claim-denial rate on first submission (4 percent of claims or fewer is best practice)? • Have you determined that you are not leaving any money on the table with a reimbursement analysis? • What are your days in A/R? What percentage of your accounts receivable is more than 120 days old (10 percent or less is best practice)?

Patient registration The revenue cycle starts with patient registration. Patient registration begins with a phone call for an appointment request. Your front-desk staff should interview the patient on the phone to collect billing and insurance information;  invite the patient to go online to your website to complete their registration information; and follow up if registration isn't completed two days prior to the appointment — so that the patient's insurance coverage can be verified. You can use an in-office kiosk for patient check in and to collect demographic information. Some kiosks will automatically verify insurance eligibility too.  Charge capture Transferring patient charges from the EHR to your practice management (PM) system should be seamless — electronically transmitting data is an example of efficient workflow. But, if you are forcing your providers to first complete a paper visit-encounter form, and then transfer that information to the EHR, it can lead to inconsistencies, lost data, and redundant work processes. Furthermore, asking your check-out station to compare electronic patient information against the paper encounter form is burdensome and creates even more work when discrepancies arise.  Automatic payment posting Automatic payment posting can significantly reduce staff work, so why don't more billing staff embrace and drive implementation of auto-post opportunities? Holding tight to the status quo — manual payment posting and reconciliation — is an inefficient use of our most costly resource: staff. Routinely ask your payers, clearinghouses, and software vendors about new services coming online, and roll out every new payer as electronic remittance and auto-posting become available. Investigate a bank lockbox service that converts the paper explanation of benefits (EOBs) to electronic transactions (837s) for automatic posting to patient accounts.  Insurance eligibility verification Investigate and incorporate automatic insurance eligibility verification into your work flows. You can use your clearinghouse service to upload the appointment schedule a couple of days in advance, in a batch process. For walk-in patients, use real-time verification through your PM system. An integrated verification solution creates a history within the patient's record that supports follow-up collection efforts, if there are later discrepancies with the payer.

Article by Rosemarie Nelson - See more at: http://www.physicianspractice.com/billing-and-collections/revenue-cycle-management-more-billing-patients?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=29082013#sthash.Bbvb2ywQ.dpuf

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.

 

Courtesy of: http://www.hbma.org/news/public-news/n_choosing-the-right-clearinghouse-five-essential-qualities

 

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.

 

From the Jan/Feb issue of HBMA Billing by Penny Noyes http://www.hbma.org/news/public-news/n_what-to-do-when-services-are-not-paid-by-a-commercial-payer

 

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

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

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

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 claims" 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