Medical Billing Disputes: Finding Peace between Patients and Billers : Don't Be This Billing Service!

Your front-office staff is great. They check patients in, smile, schedule, and do everything right. The doctor or nurse sees the patient, listening intently for any clue that might help them solve whatever the problem. The patient leaves happy.

Then the bill arrives. The patient has a coinsurance they need to pay, and are very willing to do so, but it appears something has gone wrong with the insurance payment amount. They call the number on the statement to pay the bill, and get a not-so-friendly customer service representative. Things go downhill from there. A month later, the patient comes back into the office beside themselves, acting like a lunatic waving a bill around. Once you bring them into a private room away from the rest of your patients, you find out the problem: The patient has been fighting with your billing company for over a month to get a better understanding of what has happened.

This scenario happens far too many times. The office provides excellent service and the billing department — not so much. What is a practice manager to do? First, try to identify the actual problem and go from there.

Here are some tips on conflict resolution between your practice, the patient, and the billing department.

1. Identify the person in the billing department who the patient has been dealing with. Find out the rest of the story, as it could be the patient only had one interaction with the billing department, and the employee could have been trying to explain that the bill was part of the patient deductible and coinsurance. When patients don't want to hear what they don't understand, they start to argue.

2. Once you have a clear understanding of the problem, find out where the customer service portion of the patient experience failed. If it was lack of follow up with the patient or if the representative was indeed rude, that should be addressed with the billing department's manager.

3. Take this opportunity to create a plan with the billing manager to address overall customer service opportunities within the department and how you would like a very specific level of customer service to your patients.

This should include:

• Friendly customer service representatives for your patients.
• If the patient is not satisfied with the level of service, they should be allowed to speak with the manager immediately.
• Follow up with patients. If the representative says, "Let me call you back on that," a phone call best be made within a specific time frame; in most cases 24 hours in a good rule of thumb.
• • If your office is unsure how an insurance is going to pay a claim and the patient needs to be seen multiple times for similar treatments, it is reasonable to ask the billing department to follow a claim from beginning to end. They can then call and let your office know if the insurance is imposing a copay, coinsurance, or deductible for the patient to pay. Your office can then inform the patient. Good billing departments can get most claims through to the major payers in less than two weeks.

Overall, the billing department is part of your team. They need to be on-board with your requests and policies. If you find there is a lack in this area, it's time to set up a meeting and set some standards for them. You are their customer and should be treated as such.

Article By P.j. Cloud-moulds of Physicians Practice http://www.physicianspractice.com/blog/medical-billing-disputes-finding-peace-between-patients-and-billers?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=24092013

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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

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The Affordable Care Act's Effect on Medical Billers

Article By Marsha Sosebee from Physicians Practice

The staunch proponents of Obamacare are joyously dancing in the streets amid a tickertape parade while those who vehemently oppose its inception are hunkered down in a fury of nail-biting anger. I think the vast majority of the population though are in a fog of miscommunication, false hope, and maybe some unnecessary worry.

What does Obamacare really mean to someone like me, an “in the trenches” medical biller? First of all it means that people will be looking to me to answer questions about their insurance now that Obamacare is here. But I have as many questions as they do. The one thing Obamacare has done is put everyone in the same boat, a boat called limbo. We don’t really know how it’s all going to work.

For example, I want to know how reliable eligibility verifications will be. I have claims on my desk right now for which I am fighting retro-termination denials. The day services were rendered, coverage was verified. When the claim was processed, the insurance denied saying the coverage was retro-terminated because the employer didn’t send in notification that the employee had been laid off. In the past, I’ve had denials because the insurance company said the Cobra premiums were not paid. The patient had cancelled checks showing that they did pay the premiums. That fight took me six months to finally receive payment for those outstanding claims. I feel justified in my level of concern for eligibility verification for these government-regulated exchange insurance plans.

Another area of concern for me is precertification. Considering the difficulty regular insurance companies exhibit on occasion, I can’t help but wonder how the governmental connection will affect the precertification process. Just last week, I spent four hours on the phone getting shuffled back and forth between the pre-certification and claims departments of a certain major insurer. The precertification department had told me prior to surgery that no precert was required. I documented the name, date, and time related to this call. Last week the surgery claim was denied because there was no pre-certification. I gave the claims department my documented information and was told that didn’t matter to them because in their system it said precert was required. They said they couldn’t help that the precert department had given me wrong information. I asked if they could get the precert department on the line with us so we could resolve this issue. The response was, “No, we don’t make outgoing calls to other departments.”

So I called the precert department back. They said they were correct, no precert was required and that I should just tell the claims department to pay the claim. I asked if they would please call the claims department for me to verify. That request was met with a prompt, “Once the service is rendered, we are out of the picture.

”Ultimately the issue was resolved, but only because I finally found someone who actually cared about solving the problem and didn’t just pass the buck. I look at instances like this which occur with more regularity that I am comfortable with and I can’t help but think it will there will be worse headaches than this with plans that are overseen by governmental agencies. Maybe we billers should stock up now on aspirin.

My take on the whole Obamacare plan is that making healthcare affordable is a great thing. And if that’s what the Obamacare plan was really doing, I would be more supportive of it. But I think it will do more harm than good. I can very easily see that small businesses will convert employees to part-time status to avoid the penalty. What will that do to families already finding it nearly impossible to stay afloat financially?

I have strong reservations about the government forcing anyone to get health insurance. So many people think that Obamacare is offering free insurance. This is not true. They are forcing you to pay for insurance and the cost of the insurance plans are not readily available. I was just on the healthcare.gov website and I consider myself semi-tech savy. The only way I could find to be able to compare the cost and benefits of the different plans was to actually do your application first. Applying for something before you know the cost is what my dearly departed father would have called "buying a pig in a poke".

"It has been my experience in life that people who are trying to manipulate a situation for their own benefit will create a diversion to get your attention off the truth of what they are doing. I think Obamacare has created a diversion with false concern for the health and well-being of the Amercian people. What is its real agenda? It could be simply to rake in more money for the government or it could be something much more sinister. Whatever the case may be, the next several months are going to be very interesting to say the least.

Article Courtesy of: http://www.physicianspractice.com/blog/The-Affordable-Care-Acts-Effect-on-Medical-Billers?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=01112013

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Medicare Jurisdiction E Part B Updates

Payment Rules Notice

Although we are still assessing the impact of the partial government shutdown on completion of the calendar year 2014 Medicare fee for service payment regulations, we intend to issue the final rules on or before November 27, 2013, generally to be effective on January 1, 2014. The impacted regulations include:

• Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (CMS-1526-F)
• CY 2014 Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System (CMS-1601-FC)
• CY 2014 Home Health Prospective Payment System Final Rule (CMS-1450-F)
• Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule with Comment Period (CMS-1600-FC)

Source: LEARNRESOURCE-L E-mail Update, National Institutes of Health, U.S. Department of Health and Human Services dated October 23, 2013

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Medicare/Noridian New Waived Tests - Revised November 2013

New Waived Tests - Revised

MLN Matters® Number: MM8439 Revised
Related Change Request (CR) #: CR 8439
Related CR Release Date: October 28, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R2804CP
Implementation Date: January 6, 2014

This article was revised on October 29, 2013, to reflect a new Change Request (CR). The CR corrects the spelling of "Premier Integrity Solutions P/Tox Drug Screen Cup." The transmittal number, CR release date and web link to the transmittal was also changed. All other information remains the same.

Provider Types Affected
This MLN Matters® Article is intended for clinical diagnostic laboratories submitting claims to Medicare Claims Administration Contractors (Medicare Contractors) for services to Medicare beneficiaries.

Provider Action Needed
If you do not have a valid, current, Clinical Laboratory Improvement Amendments of 1998 (CLIA) certificate and submit a claim to your Medicare Carrier or A/B MAC for a Current Procedural Terminology (CPT) code that is considered to be a laboratory test requiring a CLIA certificate, your Medicare payment may be impacted.
CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The CPT codes that the Centers for Medicare & Medicaid Services (CMS) consider to be laboratory tests under CLIA (and thus requiring certification) change each year. Change Request (CR) 8439, from which this article is taken, informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits.
Make sure that your billing staffs are aware of these CLIA-related changes for 2014 and that you remain current with certification requirements.

Background
Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test. However, the tests mentioned on the first page of the list attached to CR8439 (i.e., CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.
The CPT code, effective date and description for the latest tests approved by the FDA as waived tests under CLIA are the following: 

• G0434QW, January 23, 2008, Phamatech At Home 12 Drug Test (Model 9308T); 
• G0434QW, January 23, 2008, Phamatech At Home 12 Drug Test (Model 9308Z); 
• 81003QW, January 29, 2013, Henry Schein Urispec Plus Urine Analyzer;  
• G0434QW, February 27, 2013, CLIA waived, Inc. Rapid Drug Test Cup; 
• G0434QW, February 27, 2013, Clinical Reference Laboratory, Inc. Intelligent Transport Cup; 
• G0434QW, February 27, 2013, Noble Medical Inc. Noble 1 Step Cup; 
• G0434QW, February 27, 2013, Premier Integrity Solutions P/Tox Drug Screen Cup; 
• G0434QW, February 27, 2013, US Diagnostics ProScreen Drugs of Abuse Cup; 
• 84443QW, March 5, 2013, BTNX Rapid Response Thyroid Stimulating Hormone (TSH) Test Cassette (Whole Blood); 
• 86308QW, March 11, 2013, Henry Schein OneStep Pro+ Mono {Whole Blood}; 
• G0434QW, May 15, 2013, UCP Biosciences, Inc. UCP Home Drug Screening Test Cups; 
• G0434QW, May 17, 2013, Alere Toxicology Services, Inc. Tox Screen Drugs of Abuse Test Cup; 
• G0434QW, June 24, 2013, Advin Multi-Drug Screen Test; and 
• 87880QW, July 3, 2013, Henry Schein OneStep Pro+ Strep A Cassette.

Additional Information
The official instruction, CR8439, issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2804CP.pdf  on the CMS website.  

Last Updated Nov 04, 2013

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Medi-Cal & Telehealth (California Medicaid)

Medi-Cal & Telehealth

The Department of Health Care Services (DHCS) considers telehealth a cost-effective alternative to health care provided in-person, particularly to underserved areas. Telehealth is not a distinct service, but a way that providers deliver health care to their patients that approximates in-person care. The standard of care is the same whether the patient is seen in-person or through telehealth.

DHCS’s coverage and reimbursement policies for telehealth align with the California Telehealth Advancement Act of 2011 and federal regulations. State law defines telehealth as “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site.” This definition applies to all health care providers in California, not just Medi-Cal providers.

Medi-Cal also complies with federal regulations for telehealth, which are the same for Medicaid as they are for Medicare. Medicaid regulations authorize telehealth using “interactive communications” and asynchronous store and forward technologies. Interactive telecommunications must include, at a minimum, audio and video equipment permitting real-time two-way communication, according to the Centers for Medicare and Medicaid Services.

Medi-Cal pays for current Medi-Cal benefits appropriately provided via telehealth:
 • Selected Evaluation and Management (E&M) services for patient visit and consultation.
 • Selected psychiatric diagnostic interview examination and selected psychiatric therapeutic services.
 • Teledermatology by store and forward.
 • Teleophthalmology by store and forward.
 • Transmission costs (up to 90 minutes per patient, per day, per provider).
 • Originating site facility fee.
 • Interpretation and report of X-rays and electrocardiograms performed via telehealth.

Please see the Medi-Cal Provider Manual: Telehealth for more information.

For additional information about Medi-Cal’s coverage and reimbursement telehealth policies, as well as resources for providers, please see the Telehealth Resources page.

For questions about submitting a claim for services provided by telehealth, please call the Telephone Service Center (TSC) at 1-800-541-5555.

Providers may email questions about Medi-Cal telehealth policy to Medi-Cal_Telehealth@dhcs.ca.gov.

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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

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