July 24, 2014

Billing for Physician Extenders

A physician extender is a licensed health care provider (not a physician) that provides medical services, typically performed by a physician. The term physician extender is commonly used to identify trained health care professionals such as physician assistants and nurse practitioners. Physician extenders typically work under the direct supervision of physicians.

BILLING HEALTH PLANS

Health plans are free to develop their own policies for credentialing and reimbursing physician extenders. Some health plans will credential the physician extender and some plans will not. Some plans follow Centers of Medicare and Medicaid (CMS) "incident to" guidelines and some plans do not. Therefore, it is important to contact each health plan to determine their policy regarding physician extenders. Below are a list of questions that the practice should ask the payer:

Do you credential physician extenders such as, nurse practitioners (NPs) and physician assistants (PAs)? Do you include them in your provider listing? Do you require any specific level of supervision? If the physician extender is not credentialed with the payer, then can the physician extender bill under the contracted supervising physician's billing numbers with the appropriate modifier? Confirm the appropriate modifier. Do you recognize and follow CMS "incident to"? What is the reimbursement rate for physician extenders if the service rendered is not "incident to"?

BILLING MEDICARE "INCIDENT TO"

Physicians who bill Medicare for "incident to" will be reimbursed at 100% of the Medicare allowable. However, the following criteria must be met:

The physician has to have seen the patient at a previous visit and developed the plan of care that the physician extender will carry out.

The physician has to remained involved in the patient's care.

The physician extender has to be an expense to the physician/practice.

The physician must be physical present in the building.

The services must be provided in the office.

Important: If the patient is being seen by the physician extender for a different problem then this does not qualify as "incident to".

July 23, 2014

“Accountable Care Organizations: What Providers Need to Know” Fact Sheet — Revised

The “Accountable Care Organizations: What Providers Need to Know” Fact Sheet (ICN 907406) has been revised and is now available in a downloadable format from CMA. This fact sheet is designed to provide education on Accountable Care Organizations (ACO) under the Medicare Shared Savings Program. It includes a definition of an ACO, and information on how to participate in an ACO, how shared savings will work, how this program is aligned with other quality initiatives, and how ACOs help doctors coordinate care.

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO_Providers_Factsheet_ICN907406.pdf

July 18, 2014

Fraud Alert-Laboratory Payments to Referring Physicians

The Office of Inspector General of the Department of Health and Human Services today issued a Special Fraud Alert pertaining to relationships between laboratories and referring physicians.  Payments from labs to physicians who refer were targeted in the Alert.  The Alert also reiterates their suspicion of so-called "carve out" compensation relationships where state and federal healthcare program dollars are removed from the payment formula (which was previously addressed last year in Advisory Opinion 13-03).  While the Alert does not add anything new to the government's view of such relationships, it does underscore the very suspect view the OIG has of payment relationships between labs and the physicians who refer to them.

http://oig.hhs.gov/fraud/docs/alertsandbulletins/2014/OIG_SFA_Laboratory_Payments_06252014.pdf

 

July 16, 2014

Reducing physician claim denials

Most practices have the software available that should enable them to produce and analyze reports which will provide valuable information.   By reviewing this information, you are able to see denial trends and provide educational feedback to the individual areas needed.  A new process may need to be implemented in order to prevent these denials from trending again.  Once the new processes are in place, it is important to monitor for improvements needed and if the changes are being implemented appropriately.   There are a few examples listed below that would be a great start to lower denials within your practice.

1. Referring and Ordering Physician incorrect or missing from charges, first thing is to be aware of payer guidelines and any changes that may have occurred.  As you know payer guidelines change often and without warning.  Here are a few things to keep in mind regarding referring and ordering physician requirements that are simple but will slip by.

 o Provider types that are not credentialed to order and/or refer for example an Audiologist or Chiropractor.  

o Be aware of services that require an ordering and/or referring physician missing from charge for example DME, radiology, laboratory and drug charges.

2. Many times Medicare beneficiaries are enrolled in a Medicare Replacement plan, instead of traditional Medicare.  By preventing claims from filing erroneously to Medicare instead of a Medicare Replacement Plan you can prevent extra cost of having to resubmit claims and in turn this will bring in revenue more timely.  Regardless of the carrier submitting claim to the correct payer initially is important.

3. Another denial that should be mentioned is duplicate claim denials, if more than one claim is submitted for the same member, item or service, date of service and provider the second claim will be denied as duplicate.  This can occur even if the original claim is in processing status awaiting payment.  If you resubmit a claim prior to receiving a determination from a carrier you increase risk of payment being held up.

When claims are submitted multiple times for the same service this may cause a claim to be suspended in the carriers system requiring need for human intervention there in causing revenue to slow down.  Some of these issues may appear to be low revenue but once you have a claim out the door you will have cost your business more by resubmitting corrected claim.   For an example, a low drug charge denies because the referring physician is missing with all remaining charges paid on claim it would not be cost effective to resubmit with this low charge amount.  However, if you prevent this denial from ever occurring at the end of the year those lower charge amounts could add up to substantial revenue. 

July 15, 2014

Affordable Care Act Regulations Allow Orientation Period for New Hires

The Affordable Care Act (ACA) prohibits group health plans and group health insurance issuers from applying waiting periods exceeding 90 days. Under newly issued final regulations, employers will be allowed to have an orientation period for new workers of up to one month before the 90-day waiting period begins. During the orientation period, which is the initial period after a worker is hired, the employer and employee "evaluate whether the employment situation is satisfactory for each party." Under these final regulations, one month would be determined by adding one calendar month and subtracting one calendar day to an employee's start date.

July 11, 2014

Contract provision required participation in EHR Meaningful Use Program

I was reviewing a physician's employment agreement and ran across a provision that "requires" the physician to participate in their Electronic Health Record Meaningful Use Program. I think the following provision should be in any physician's employment agreement:

Participation in Electronic Health Record Meaningful Use Program. Physician will take such steps as are reasonably requested in order for Lincoln to realize, to the greatest extent possible, the benefits of the electronic health record meaningful use program, created by the American Recovery and Reinvestment Act of 2009 (the “EHR Meaningful Use Program”), including, but not limited to, participating in the EHR Meaningful Use Program as an Eligible Professional (as defined in 42 CFR §495.100 or §495.302, as applicable), using certified electronic health record technology, and providing such truthful attestations of adoption, implementation, upgrading and meaningful use of such technology as requested or required by Lincoln or any federal or state authority. Physician reassigns to Clinic the right to receive any payments made in connection with Physician’s participation as an Eligible Professional in the EHR Meaningful Use Program. Physician acknowledges that such payments will not be considered Secondary Income to Physician, and Physician’s compensation will not be adjusted in any way on account of Lincoln’s receipt of any such payments, except as may be specifically provided in a separate written agreement between Clinic and Physician.

July 09, 2014

Internal monitoring of physician billing and coding

Physian practices should always be aware of any and all internal risks identified in the past that need to be monitored. Internal monitoring of some of the areas below can also help to identify potential billing and coding compliance risks:

- Medical record requests received by the practice from external entities (e.g., RAC, MAC, CERT, OIG, Medicaid Integrity Contractors, others). These can include routine additional documentation requests, prepayment reviews, postpayment audits, etc.

- Repeated denials for the same type of claim error may be considered submission of false claims.

- Benchmarking of billing patterns by physician, by specialty, and in comparison to other physicians within your system, or using outside data, such as CMS or other commercially available data can allow a practice to identify physicians who are outliers in comparison to their peers.

Internal monitoring can help a practice focus its auditing on the identified potential risk areas. No matter what size a practice you are, you need realize billing and codinig compliance risks can lurk anywhere. Just remember the key to any compliance activity is to:

1. Prevent

2. Detect

3. Correct

July 02, 2014

Improving the physician business office

Most practice management systems are built on relational databases.  This means that almost every field can be pulled into reports and analyzed.  "Data mining" has become a buzz word but is only effective if what we are measuring produces changes in practice behavior.  At the end of the day, cash is still king.  Practices need to analyze those things which most directly affect cash flow.  Most physicians want to do the right thing in the right way, but a business office must communicate how effective a physicians productivity is resulting in positive cash flow.

Lag Days - When a physician understands the direct relationship to when charges get into system and when payment for that charge is posted to system, lights go off.  While we say that charges need to be posted to system as soon as possible, does anyone actually monitor by physician how well that standard is being met?  By physician, how many days "lag" between date of patient encounter and charge posted to system? The practice can then determine why lag days are not consistent or why there is even a significant lag between encounter and posting of charge.

Denial Trending - Categorizing denials by practice and denial type and payer can provide the practice with needed information to change behavior. Payers are constantly  changing the rules, by categorizing by payer, practices can easily adjust to new carrier rules.  Of course, it is also important to have a good relationship with top payers.  Have frequent meetings with them to discuss new rules and how the carrier wants claims to be correctly submitted for proper payment. When a practice can be shown that eligibility denials are most frequent; the front-end staff can make adjustments to check-in procedures to significantly decrease these denials. Coding denials can be addressed with practice coders for review of processes and compliance with carrier rules.  Physicians can be educated on how to comply, via documentation with these rules. Each month, the analysis of each month's denials is invaluable to practice success.  But it must also be communicated, not to point fingers, but to improve cash flow. Perhaps the best use of denial trending is prevention of denials.  This can best be accomplished by targeting claims with frequent denials and making appropriate fixes to claim before sending to carrier.  While some might argue that it holds up the claim; the real argument is do you get paid for a faster claim or an accurate claim?

Credit Balances - Probably the most over-looked report in most business offices is the credit balance report.  Credit balances sit on accounts and claims and are ignored many times preventing claims from being properly adjudicated.  Probably 85% of the time, there are not true credit balances on an account.  There has been a posting error or another problem resulting in a credit balance.  By assigning staff to consistently and methodically work credit balances, problem accounts can be resolved, aging can be addressed and clean-up of accounts can be accomplished.  Many carriers have rules about when credit balances are to be reported to them are refunded. Finding what credit balances are true and what is clean-up will help you meet those guidelines.

Small Balance Write-offs - Does your business office have a small balance write-off policy?  Ever wonder about how much of aging in a balance that could be simply written off and reduce the "appearance" of aging?  Allocating time for staff to work this report can help to clean-up AR and reduce statement costs that will never be turned over to a collection agency.

These reports may seem small and unimportant, but can make a big difference to your bottom line. Take the time to create and analyze these reports to improve your bottom line.

June 27, 2014

Thoughts on physician practice employee retention

Competition and quality. Both of these words define key elements that management personnel within the medical industry must remain focused on in order to be successful. Management teams are responsible for identifying and considering all stakeholders, whether primary or secondary, and incorporating their interests and goals into operational decisions and goal-setting.  Stakeholders of a healthcare facility are primarily viewed to be patients, but staff are stakeholders too. In order to be productive and effective in providing quality healthcare, management teams must develop and nurture their relationship with their staff. Establishing a foundation of trust and reliability will greatly influence a healthcare team’s ability to efficiently operate and effectively communicate. Management must feel confident and secure with their team dynamic and, oppositely, staff must feel confident and secure in their management team’s direction and ability.

According to a survey published by the Society of Human Resource Management, the fourth and fifth top contributing factors to employee satisfaction for 2012 were “communication between employees and senior management” and “relationship with immediate supervisor”, respectively. In some instances, a healthcare team may have several years, or decades, of working together cohesively; therefore, assigning a new manager may be delicate procedure. Responsibility falls to senior administrators to be able to identify key personality traits and potential areas of conflict prior to introducing a new manager to a department. Once that manager has been introduced, responsibility then falls to the manager to integrate themselves into that work environment and establish positive, productive relationships. Both staff and management must have a mutual understanding and respect for their individual roles in their department, as well as, their niche in an organization as a whole. When employees feel their manager has their best interest at heart, staff are more satisfied with their jobs, which directly contributes to increased performance.

Conversely, when a manager interviews for a potential new employee for placement into an established work environment, considerations must be made to ensure an appropriate selection. Staff’s positive reception to a new employee or position will be paramount to successfully onboarding and integrating a newly hired employee. Again, having a basis of trust and reliability between staff and management will allow for more streamlined and seamless transitions when staffing or workflow changes must be implemented. Even in the initial stages of interviewing, potential candidates are projecting potential job satisfaction if they accepted an offer. If managers convey a high interest in a candidates’ success and well being, a new hire may become more driven to perform highly and, thus, improving overall departmental productivity.

Employees and managers alike want to feel comfortable and supported by their co-workers and corporate structure. Developing and nurturing a mutually-respected relationship between managers and their staff should remain highly visible on a management team’s operational radar. New employees must be integrated appropriately and with management’s support to establish a positive foundation; whereas, established working relationships need to be continuously nurtured throughout their development. Improving these critical relationships will, undoubtedly, increase job satisfaction amongst all involved and directly improve productivity by reducing intra-departmental conflict between management and staff. Well-functioning and cohesive teams play an important factor in providing quality healthcare, as well as, creating a successful practice and management personnel should be mindful of prioritizing the concept appropriately.  

June 24, 2014

Common Medicare billing errors per EOBs

Medicare Benefits Message #96 Non-covered charge/s.  Prior to performing or billing a service, ensure that the service is covered under Medicare. Please refer to the Centers for Medicare & Medicaid Services Internet Only Manual, 100-02, Chapter 16.  

Medicare Benefits Message #18 Duplicate claim/service.  Please check claim status through the IVR to see if another claim was paid or is currently being processed. To prevent duplicate denials, allow us sufficient time to process a claim before submitting a second.

Medicare Benefits Message #46 Charges exceeds fee schedule/maximum allowable amount or contracted/registered fee arrangement.  Please check your Medicare Summary Notice for the additional remark codes as to why your claim has been adjusted.

Medicare Benefits Message #109 Claim not covered by this payer/contractor.  This denial indicates that the service is one that is processed or paid by another contractor. Examples of these types of services are: Durable Medical Equipment, hospice related services or Medicare Advantage. You must send the claim to the correct payer/contractor.

Medicare Benefits Message #B7 This provider was not covered by Medicare when you received this service.  This provider was not certified/eligible to be paid for this procedure/service on the date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110) Service Payment Information REF), if present.

Medicare Benefits Message #183 The referring provider is not eligible to refer the service billed. Note: Refer to the 834 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  This item or service is not covered when performed, referred or ordered by this provider.

Medicare Benefits Message #246 This non-payable code is for required reporting only.  This code is for information/reporting purposes only.