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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How to Start Your Own Medical Billing Service, a Great Stocking Stuffer For the Entrepreneur in Your Family! On Sale! $19.99!

This would be an excellent stocking stuffer for that family member looking to start their own business. Or even for a stay at home Mom or Dad!

http://www.amazon.com/Start-Your-Medical-Billing-Service/dp/1484928180/ref=sr_1_1?ie=UTF8&qid=1386715770&sr=8-1&keywords=how+to+start+your+own+medical+billing+service

Comment on this post with your email address and I will invoice you directly for the low, low price of $19.99 (Ca sales tax will be applied for all California state purchases)!  Regular price $34.99.

This offer is available for the rest of the month of December 2013! Order yours today!

READ MORE - How to Start Your Own Medical Billing Service, a Great Stocking Stuffer For the Entrepreneur in Your Family! On Sale! $19.99!

Keeping Up with the Copay: Health Plan Changes Always Happen

By Melissa Young, MD from Physicians Practice

I’ll be the first to admit: I don’t know all the details of my own medical insurance plan. And I’m the one who chose it! I reviewed the benefits at the time. I looked at what the copays would be for office visits and meds, and I looked at what the out-of-network benefits would be. Thankfully, I have not really needed to use it much, so I have forgotten much of the details.

Many of my patients are no better. I doesn’t help that their employers change their plans from year to year. And even if they keep the same plan, the insurance companies change their formularies and their benefits all the time. It often comes as a complete surprise to patients.

For example, I have one patient for whom I prescribed a medication earlier this year. The cost to her at the time was minimal; her prescription plan paid for most of it. She is due for it again now, but now she has this big deductible and it is going to cost her hundreds of dollars. I also have a patient whose ultrasounds I used to do in the office …until her plan decided they didn’t cover it if it was done here, so now she has to get it done in radiology. Of course, neither of us knew that before the last ultrasound I did here. Drugs that didn’t need prior authorization six months ago need it now.

I am certain patients are informed one way or the other about changes in their copay (although many of them seem surprised when my staff asks them for $40 instead of $25 like they paid last time), and maybe they get notice about other changes, but I would not be surprised if they give any mail they get from their insurance company a quick glance and then toss it. I can’t say I blame them. We all get so much mail that looks like junk; it can be hard to figure out which ones are really important. And since things change from month to month, who can keep track of it all?

Courtesy of Physicians Practice: http://www.physicianspractice.com/blog/keeping-copay-health-plan-changes-always-happen?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=22112013

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Is Your Billing Company Registered for HBMA's Free Professional Billing Service Locator Service?

Physician owners and medical practice administrators are already signing up and may be looking for you! Today, the HBMA unveiled the free, fully automated Professional Billing Service Locator (PBSL) service, a platform that provides an efficient way for physician owners and medical practice administrators to easily find a trusted, professional medical billing partner. HBMA developed the offering to help providers with the arduous task of navigating through the thousands of medical billing companies on the market to find a the HBMA member organization that will best meet their specific needs. After registration, the PBSL will immediately identify the specialties, service details, and contact information of the most relevant and qualified medical billing companies in the region that fit a medical practice's specific profile. Finding that perfect match with the right professional billing service will help providers secure appropriate reimbursement for services delivered, achieve timely claims adjudication, and reduce claims denials to lessen days in accounts receivable. To learn more about how to register your billing company into the PBSL directory, visit Professional Billing Service Locator or call 877.640.4262.

http://www.hbma.org/blog/is-your-billing-company-registered-for-hbmas-free-professional-billing-service-locator-service

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2014 Medicare Physicians Fee Schedule (MPFS) Available Soon

2014 MPFS Available Soon Watch for the 2014 Medicare Physician Fee Schedule (MPFS). It will be published on the “Fee Schedules” webpage at med.noridianmedicare.com/web/jeb/fees-news/fee-schedules after its regulation is put on display.
Last Updated Nov 27, 2013

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Health Insurance Exchanges: Two Key Issues to Discuss with Patients

The American Academy of Family Physicians (AAFP) is encouraging its members to provide their patients with information regarding health insurance exchanges.

The AAFP website advises: "During patient visits, be prepared to discuss the insurance options available through the marketplaces and encourage patients to make coverage decisions that are appropriate for their health care needs. "But not all doctors are ready to get involved.

The majority of physician respondents to a recent Medscape survey said that they should either have a limited role or no role in providing health insurance and health insurance exchange information to patients.

Yet, spending a few minutes sharing some key information about health insurance exchanges with interested patients may benefit you and your practice in the long run.

Here's why: If your patients that are shopping on the health insurance exchanges don't make well-informed purchasing decisions, you may see them less frequently. In fact, you may not see them at all.

Many of the health plans offered in the exchanges appear to have narrower networks — meaning patients will likely have fewer physicians and health systems to choose from within the plans.

In addition, many of the health plans offered in the exchanges have higher deductibles — meaning patients may end up shouldering more of their healthcare costs.

"They are trying to funnel people into narrow networks overall, and simultaneously shift people into higher cost sharing that is higher deductible, higher copay kind of plans," Kip Piper, a healthcare consultant in Washington, D.C., recently told Physicians Practice.

If patients purchase those higher cost sharing plans, it's likely that they will put off or avoid visiting your practice due to cost concerns, said Piper. In addition, higher patient cost sharing will place more burdens on your collections staff, as they will need to step up patient payment collection efforts. 
For that reason, you might want to consider talking to your patients about the importance of finding a plan that does not require a lot of out of pocket costs. "Make sure that ... they're not enticed by a low premium to pick a plan that has a high cost sharing that then keeps them out of the doctor's office," said Piper.

The narrower networks offered by many of the plans may also pose problems for your practice.

If you are excluded from a plan or if you have decided to opt-out of a plan, you run the risk of losing your patients to providers who are participating in that plan. For that reason, you might want to share which plans you are participating in with patients.

"I'm afraid of a lot of people in January are going to start making an appointment and then they're going to find out they can't go to their doctor," said Piper.

Article By Aubrey Westgate from Physicians Practice http://www.physicianspractice.com/blog/health-insurance-exchanges-two-key-issues-discuss-patients?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03122013

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Presentations to Physicians: Don't just Share Data, Provide Direction

Knowledge is power when it directs action. When someone is presenting a case or clinical research to a physician, both the presenter and the physician understand how the information can help the physician successfully address similar clinical circumstances in the future.

The purpose is the same in presentations of non-clinical information, but the implicit call for physician action is neither universally recognized nor understood. As a consequence, physicians are often left feeling helpless in the face of what is clearly bad news.

Consider some information recently shared during a Grand Rounds presentation to a group of orthopedic surgeons:

• In 2011, healthcare spending in the U.S. amounted to almost 19 percent of GDP. The inescapable conclusion is that we have reached the limit of funds available for healthcare, if we have not surpassed it.  Physicians cannot rely upon new money coming into the healthcare system

• The payment system is opaque, particularly to patients. Most hospitals in a recent survey were either unable or unwilling to hazard even an estimate of the costs for a total hip replacement for a patient with no co morbidities. Other studies have shown that there is no relationship between hospital charges and what they actually get paid for services.  Patients surveyed thought physicians' Medicare reimbursement for the surgery was five times what it is, and the patients thought it ought to be about four times the current rate.

• There is a mismatch between supply and demand. The population is aging, and the obesity epidemic puts unsustainable demands on lower extremity joints. Physicians are opting to limit their Medicare participation or retire early, rather than accept prospectively lower levels of reimbursement. Concurrent with a potential shortage of surgeons, hospitals have a lot of unused beds and are continuing to expand their physical plants.

• Physicians have not been effective in preserving their reimbursement rates. Reimbursement levels for hip surgery have declined by as much as 50 percent, in non-inflation adjusted dollars, in the last 30 years. At the same time, hospitals and implant manufacturers have seen their reimbursements more than double.

• The very high volume of total hip replacements performed in the US makes the procedure an obvious target for cost containment and cost reduction.

A lot of knowledge was shared, but it did not indicate a clear path forward. What can and should a physician do with the information?

As in a clinical presentation, the answers were implicit. The difference is that they were not obvious to the audience:

• There will be winners. The current system is unsustainable; and disruptive, systemic change is inevitable. The imperative is either to be one of the people who figures out how to thrive in the new environment, or to align with them.

• Patients are on their doctors' sides. Physicians can leverage that by being more transparent about the reimbursement levels and the problems they present. To be effective, this requires talking actual dollars. "The reimbursements don't cover my costs," sounds like sour grapes. Patients can be moved to contact their representatives in support of physicians, especially if their access to care is a potential casualty of the status quo.

• Given that the pie is not growing, physicians need to get a bigger piece of it. This may be the best news about bundled reimbursements. Hospitals and device manufacturers have done a good job of maintaining healthy margins. Physicians should be able to argue for and achieve a more appropriate piece of the total cost of a procedure for two reasons:

1. The physicians are the ones who are doing the actual work that drives all hospital and implant revenue.
2. Patients tend to choose physicians, as opposed to hospitals or specific devices.
The redistribution will not happen automatically. If physicians are not aggressive and effective in advocating for themselves in the allocation of bundled payments, they will encounter a reprise of the Medicare fee-for-service situation.

The critical question for any presenter is "What do you want me to do with that information?"  Each presenter has a duty to provide the answer, either in the course of the presentation or in response to audience questions,

Article By Carol Stryker from Physicians Practice http://www.physicianspractice.com/blog/presentations-physicians-dont-just-share-data-provide-direction?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=06122013

READ MORE - Presentations to Physicians: Don't just Share Data, Provide Direction

Maximizing Physician Compensation at Your Medical Practice

The financial pressure is on for physicians to get compensated not just fairly, but well, at their practices, and Shawn Harkey's medical group is no different.

"We definitely keep a close eye on both fixed and variable components," says Harkey, the financial services director of Texas Retina, an ophthalmology practice with 13 locations in the Dallas-Fort Worth area. "Medicare payments aren't necessarily increasing and we're fighting that battle because the high majority of our patients are over [the age of] 60. That's forcing us to become leaner, more efficient in providing patient care.

" Harkey's practice, which has been using its NextGen EHR for six years and its accompanying practice management system for three years, has already seen improved efficiency (physicians can see patients in a more timely manner) and a reduction in overhead costs, such as paper, storage, and staff time spent manually pulling charts.

Today, the practice is also using its Navicure claims clearinghouse technology to verify patient insurance in advance of appointments to avoid a cash-flow slowdown.

"We see a high volume of patients every day so we make sure we have everything checked, such as benefits and referrals, and we use a number of high-cost drugs so we can make sure there's no issues in place with payers," says Harkey.  The state of physician pay is not only changing, but it is also challenging, as Harkey and our annual Physician Compensation Survey respondents would attest. But by taking a proactive approach — taking stock of the trends and seeking new ways to maximize compensation — physicians can not only stay alive, but they can also thrive, financially.

 * (To see the data, check out the details of our 2013 Physicians Compensation Survey here.)

The state of physician compensation

Today's physicians are under increasing pressure to make money and see more patients.

While more than two-thirds of the 1,474 physicians who answered our survey told us their income is, to some degree or entirely, tied to productivity, just one-third of physicians said their income is tied, at least in part, to value-based metrics. Twenty-four percent of physicians told us their income relies in part on patient satisfaction.

"[Value-based reimbursement] is growing at a small level, and the reason is that there is not funding available for it," says Kenneth Hertz, a Medical Group Management Association healthcare consultant. "If you're earning $250,000 per year and your practice wants to put in place this value-based reimbursement, quality metrics, and other performance metrics, the practice will need to secure additional funds to pay you. Right now, the payers are not providing additional significant dollars to do this. In most cases, practices are having to carve out a pool of money from the current funds available to pay physicians, and then pay those that meet the quality metrics out of that pool."
Regardless of the basis of their payment, more than half of docs in this year's survey — 53 percent — said they were either "slightly" or "highly" disappointed with their income.

"I think there are financial pressures [such as] the changing payment models, the increase in expenses, the reduction in reimbursement in practices," says Hertz. "If you're in private practice you're seeing your expenses go up, and you're seeing reimbursements go down."
Today, many specialists are making more while primary-care physicians are staying flat, income-wise, adds Tommy Bohannon, divisional vice president of recruiting at Merritt Hawkins, a physician staffing agency.

Article By Marisa Torrieri Courtesy of:
 http://www.physicianspractice.com/physician-compensation-survey/maximizing-physician-compensation-your-medical-practice?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=06122013

READ MORE - Maximizing Physician Compensation at Your Medical Practice

You Need to Adapt in Order to Survive: How Your Medical Billing Service Can Prosper During the Healthcare Industry Chaos

How Your Company Can Prosper During the
Healthcare Industry Chaos

By Patrick Phillips

The healthcare industry is facing a state of complete disorder and confusion: Uncertainty surrounding the implementation of the Affordable Care Act, the looming switch to ICD-10, EHR and "meaningful use" deadlines, hospital acquisitions of physician practices, new HIPAA rules, and Health Insurance Exchanges... the list goes on. It seems like a challenging time for medical billing companies – and it is.

 

The good news is that not only can you prosper, you can bring hope and financial stability to struggling practices and salvage some that would otherwise collapse and shut down (or get swallowed up by a hospital or other acquisition entity). How can you assure your and your clients' continued prosperity and growth?

 

Focus on becoming a full-service revenue cycle management company.
In today's dynamic marketplace, billing companies that do not keep up with the constant changes will be left in the dust by companies that do. You must not only stay current with what is happening in the industry, you need to make alliances with other companies that can provide services to your clients that will help them solve cash-flow challenges beyond just their medical billing. The more services you can offer to your clients, the more you will be perceived as "the expert" who can solve their cash flow problems.

A brief review of the latest issue of Billing will introduce you to vendors that can be valuable to you in assisting your clients with medical coding questions, HIPAA compliance, EHR Meaningful Use attestation, online document management, patient portals, integrated payment channels, patient collections, and other revenue cycle issues. Do not forget that HBMA conferences will introduce you to technology partners that can help you keep up with changes in this dynamic industry.

Make sure you are using a billing system that is fully integrated with an EHR system.
Many outdated, server-based billing systems are trying to patch together a practice management system with one of the new electronic health record systems designed by a different company or on a different platform. The company that developed the practice management (PM) system creates an interface with an EHR system developed by another company. Chaos generally ensues.

If this is the case with your PM system, you are only asking for headaches and a possible loss of clientele. EHR companies are dropping by the wayside every day. Some of them are also server-based. Trying to get them to work together with billing software is like using "bubble gum and bailing wire" and will only lead to ongoing issues in your company. Two different companies, with two groups of programmers, trying to keep all the different parts of both systems running smoothly is almost impossible and can lead to turmoil in your company.

As painful as it may seem now, it may be a good idea to begin looking for a billing system that is totally integrated with an EHR system. That means that it was designed from the ground up by the same programmers in the same company. There are such systems available, and most of them are cloud-based (accessed securely 24/7 through a browser via the Internet).

Anything less than total integration of the two systems could be a disaster waiting to happen. Start your research now and find a system that will take you into the future, especially with any new clients you bring on. And, as part of your due diligence, make sure there is a way to import the data from your current system into the new system (at least the patient demographics). Then, begin to educate your current clients on why they need to start using an EHR, if they are not already, and why they might need to use a system that is fully integrated with your billing system.

Look for a system that has a way to electronically communicate with insurance company databases. You need one that checks for eligibility and automatically imports the patient data directly from the insurance company's database to create new patient charts. This will save you hours of data input and will help you keep employee costs under control. It will also prevent you from submitting claims that are sure to be rejected because the patient was not eligible for the service and it will keep the practice from spending time seeing patients that insurances will not cover. This will increase your revenue for that practice and will eliminate a large number of claim rejections as well.

 

Keep up with changes in the industry.
I can predict the success you are going to have in your business – and in life in general – if you will tell me just two things: the people you associate with and the books (and periodicals) that you read. Do not get bogged down in the details of your billing business. You need to set aside time to attend industry conferences at least once a year and to read industry newsletters and books.

The person who does not read is no better off than the person who cannot read, so set aside time each week to read about our industry and keep up with the constant changes. Change is what life itself is based on, and if you are willing to change along with the industry, you and your clients will prosper.

Do not assume you will have your current clients forever.
You won't. Things change in medical practices: staff turnover, new policies and procedures, new government rules and regulations, competition, updated technology, and the marketplace itself. All these things can cause you to lose a client from time to time. You must always be marketing.

Whether you realize it or not, your competition in this industry is not just other medical billing companies. The practice itself is your biggest competition. All it would take is for a new office manager to come into one of your practices and decide that they would rather not outsource their billing: they think they can do it themselves more efficiently and more economically. You must keep reselling your clients on your efficiencies and on your cost savings versus doing the billing themselves internally. Provide them with revenue reports that delineate what percentage of billed dollars (expected) are actually being collected. Show them you are the expert in this industry by producing and providing to them a professional newsletter with articles that show that you keep up with the changes in the industry. HBMA has a newsletter you can purchase and tailor with your company logo (www.hbma.org). 

Take the practice administrator (or the doctor) to lunch from time to time and show them printed reports that illustrate the revenue collections from both insurance providers and patients. Hold "Lunch 'n Learns" on a regular basis with your clients to bring them up to date on what is happening in the medical industry. Position yourself as the expert. People want to do business with "the expert" in every field.

When you buy a home, you do not want the new real estate agent: you want the guy or gal who has sold 100+ homes. When you look for a CPA, you do not want one who just hung out his or her shingle: you search for one who pays less than double digits of their own taxes and has a number of clients who they service. The same is true of a doctor's office. They want to feel that they are dealing with the company that can bring in every last dime that is due to the practice.

Continue to network with other business people in the community and join your local BNI group or chamber of commerce. Get out once a week and let people know you can solve the cash crunch for doctors and help them build their practices through your contacts.

Set up an automated way of keeping in touch with everyone you come in contact with who is a prospective client. Let them know that you are the only company that they should do business with. When it comes time for them to decide to outsource their billing, you are the only choice that makes sense. People do not buy when you are ready to sell – they buy when they are feeling the pain. Be at the top of their list when they decide it is time for change.

Remind your current doctors and office administrators that you are looking to build your business. Assuming you have done a good job for them, ask them for a referral. You would be surprised as to how many billing company owners never ask their clients for referrals. Do not just ask for the name of someone. Ask your client to pick up the phone and call the other doctor or office administrator and tell them how pleased they are with your billing service and that they think it would be in their interest to meet with you.

You can shrivel up and die in this ever-changing industry, or you can make the choice to grow and prosper, starting right now!

 

READ MORE - You Need to Adapt in Order to Survive: How Your Medical Billing Service Can Prosper During the Healthcare Industry Chaos

Everest College Announces Partnership with HBMA

Everest College, a provider of career-oriented diploma and degree programs at more than 100 campuses across the nation, recently announced an alliance with the most influential healthcare revenue cycle and management services association, HBMA (www.hbma.org). Under the agreement, HBMA will provide externship and placement opportunities within its large membership base for Everest's Medical Insurance, Billing, and Coding (MIBC) students and assist in the development of the school's MIBC curriculum.
"HBMA will help us enhance our MIBC program for our students. In turn, we'll be able to provide more well-trained, highly qualified students and graduates to work with HBMA member companies," said Anthony Mann, director of national employer development for Everest College. "For instance, Everest's externship, or '200 hour interview' as it is commonly referred to as, provides an in-depth opportunity for an employer to see a potential employee in their work environment. This opportunity opens doors to new externship and – and ultimately job opportunities – for our students and graduates."

"Currently, we are working on a website presence that will enable Everest students to view externship and placement opportunities, and to enable our membership base to view the credentials of Everest students. We are confident that our alliance with Everest will be fruitful in helping more graduates find employment, as well as provide our members with quality recruits," stated HBMA Director of Operations Sherri Dumford.

Barbara Lewis, director of talent management with HBMA member organization AdvantEdge Healthcare Solutions, shared that her organization has participated in Everest's externship program for a number of years and states, "Everest provides us with a qualified candidate pool that we can turn to when there is an immediate need for talent. These trained students and graduates are vested in our industry and are motivated to learn and do well."

If you are interested in finding out more about how your organization can participate in this program, contact Anthony Mann at anmann@cci.edu or (714) 913-7251 or Sherri Dumford at sherri@hbma.org or (877) 640-4262, ext. 201.

Courtesy of: http://www.hbma.org/news/public-news/n_everest-college-announces-partnership-with-hbma#.UpIbleU9JkQ.blogger

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Improve Clinical Documentation for ICD-10

By Rhonda Buckholtz, CPC, CPMA from Physicians Practice

With less than a year left before the "go-live" date for ICD-10, industry focus is turning more and more to clinical documentation improvement (CDI), as it will be even more vital to every facility. -

Under ICD-10’s more rigorous specificity requirements, physician documentation will need to meet the higher standard as well. If your practice is fully prepared for ICD-10 in every other aspect, but clinical documentation has not improved, accurate coding and proper payment will not be possible.

A recent study of more than 20,000 audits of physicians’ clinical documentation revealed that only 63 percent of current documentation is sufficient for ICD-10’s specificity levels. Keep in mind, the insufficient documentation found in these audits often represented a larger percentage of at-risk revenue. For example, in one larger assessment, findings indicated seven of the most commonly used diagnosis codes accounted for 93 percent of the facility’s revenue.

Here are a few examples of where documentation changes will likely be needed:

Diabetes documentation must include:
• Type of diabetes
• Body system affected
• Complication or manifestation
• If a patient with type 2 diabetes is using insulin, a secondary code for long term insulin use is required

Neoplasms documentation must include:
•Type:Malignant (Primary, Secondary, Ca in situ)
Benign
Uncertain
Unspecified behavior
• Location(s) (site specific)
• If malignant, any secondary sites should also be determined
• Laterality, in some cases

Asthma documentation must include:
• Severity of disease:
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
• Acute exacerbation
• Status asthmaticus
• Other types (exercise induced, cough variant, other)

These are only a few examples of the more specific documentation requirements.

To avoid an increase in denied claims under ICD-10, perform an ICD-10 readiness assessment. Here's how:

Start by running a report in your computer system and sorting it by diagnosis code. Next, take your top 10 most commonly used diagnoses and run another report of patients that had those diagnoses appended to them. Pull 10 to 20 charts for your most commonly used diagnosis code. Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis only. Look at the history and the assessment, and see how much can be coded under ICD-10-CM.

Based on the documentation, determine how many of these notes:
• Could be coded under ICD-10-CM
• Need more specific information to code
• Had to be coded to an unspecified code

Each provider in your facility should review these findings so they understand what documentation is needed to support this specific diagnosis in ICD-10. Then, move on to the next diagnosis on your top 10 list, and keep evaluating until your list is complete.

The facility should have a target percentage for the assessments and schedule future readiness evaluations, even if the goal is reached along the way.

How often these evaluations take place will depend on the number of providers at your facility, the number of different specialties, the type of specialties (some are seeing more changes in ICD-10 than others), and how providers perform. To ensure a smooth transition and a minimal impact on revenue, these assessments should become part of the regular audit process even after implementation of ICD-10. 

Courtesy of: Physicians Practice http://www.physicianspractice.com/blog/improve-clinical-documentation-icd-10?cid=fbP2Buckholtz120413

READ MORE - Improve Clinical Documentation for ICD-10