Medical Billing

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Billing and Collections is a Team Effort!

Rub employees the right wayIf you want your billing and collections to be as smooth and effective as possible, it must be a team effort.  It can’t be up to just a couple of people and it definitely can’t be a blame game.

Practices are overwhelmed with phone calls, paperwork, pre-authorizations, and patient care.  Sometimes the ‘paper’ things can fall through the cracks.  It is these things that end up snowballing and result in more work, frantic calls and denied claims.

Here are some tips that will help smooth out the process.  They may seem insignificant or deemed to be more trouble than they are worth.  But, in the long run, if everyone on the team does their part, it means less clean-up work, less stress, and faster payments.

The collection process starts BEFORE the patient shows up for their appointment.

  1. If the patient is new to the practice send a welcome packet with all of the paperwork that they need to complete.  Sending it before the appointment helps to ensure they will have all of the correct information.
  2. If they are established patients then remind them to bring their current insurance card.
  3. On the day of the visit, ask to see a copy of the patient’s insurance card.  Too many times this step is either omitted or the staff will just ask if anything has changed.  Most patients will automatically say no simply because they don’t remember.  Insurance plans change more frequently these days, so it is best to verify and update all information at every visit.
  4. Make sure that the name on the insurance card matches exactly to what is entered in your practice management system.  Mis-spellings, missing middle initials, and typographical errors will all result in denied claims.
  5. Collect all outstanding patient balances before the patient goes into the exam room.
  6. Make it as easy as possible for patients to pay their deductibles, copay or self-pay payments.  Allow payments via credit cards, patient portals, mobile devices, and paper checks.
  7. Train select employees to set up payment plans for those patients that can’t pay their portion of the bill in full.  Make sure your back office or billing company knows of these payment plans so they can track compliance.
  8. The billing staff or company can’t bill and collect if charges aren’t submitted.  Make sure that charges are submitted daily.  There should be a check and balance to ensure that a charge was submitted for every patient that had an appointment that day.
  9. Make sure that coding is accurate.  Do you have the correct modifier?  Are the number of units correct?
  10. Make sure the pre-authorization/referral matches the service and the date of service exactly.  Make sure the information is noted on the claim.

When everyone on the team takes their part of the billing and collection process seriously things will go much smoother.  The practice will see an increase in revenue and the staff won’t struggle with clean-up work.  That is a win for everyone.

8 Ways to Play the Prior Authorization Game

prior authorization
The prior authorization game is an art, not a science.

There is nothing more frustrating to physicians than knowing a patient needs a certain diagnostic test or medication and having them not be able to get it because their health insurance company won’t cover it. All too often, many services require prior authorization.It wouldn’t be so bad if the insurance companies made the guidelines they use to make these determinations readily apparent to those practicing medicine. However, these guidelines are created by the insurance company.  The guidelines are unavailable to treating clinicians, and often they use decades-old recommendations. We are often left to predict the insurance company’s decision.  The carrier’s main goal is cost containment rather than evidence-based medicine.

Many of us feel that it is like playing an epic game where we try to give our best care to our patients, while the insurance companies deny as many tests as possible to increase their profits. The loser of this game is not the one who was able to get the least amount of services covered or earned the least money. Rather, it is the patient: delayed diagnoses/treatment; denied tests; or forced to use less effective medications based on formularies developed by insurance companies using their own guidelines, and footing increased costs.

How can this prior-authorization game be played for better odds of winning?

– Whoever does the prior authorization needs to have the progress notes in front of them. They will be asked clinical data and it should be at their fingertips.

– Know what needs to be documented in the chart. For example, I had a patient with knee pain who I suspected a torn ligament in the knee. When talking to the rep to get prior-authorization for an MRI, I told her the patient had a positive drawer sign. She never heard of this before and because I didn’t record the results of the Lachman test in the note, she could not approve the MRI. She didn’t know what this test was (I asked) either, but it was a checkmark on her decision tree. I record them all.

– Learn what is needed to get an approval. One example is that with certain insurance companies, every time I order an MRI of the lower back, they want the patient to have had a plain X-ray first. Why? There is no evidence that X-rays are a good test to diagnose back problems. In fact, if I am looking for a herniated disc, a plain X-ray will not show it but rather an MRI is needed. I know this but sometimes the only way to get the patient to get the test is to do it anyway.

– Don’t give up. If a test is denied, appeal it. I find that this is not often successful but sometimes is. Plus, the insurance company should not be given an easy pass for refusing to cover something a patient needs.

– Get the patient involved. Patients should be contacting their insurance company as well. They will be talking to member services and sometimes they find a sympathetic ear who helps them get coverage or reveals the holy grail of coverage determination to them. They are often successful when we are not.

– Remember human resources. If a patient works at a company that has an HR department, have the patient get them involved. Insurance companies do not want to lose any covered lives so if they find a company is unhappy with the services provided, this can be a very effective weapon.

– Ask for the medical director of the insurance company. Most of them were practicing medicine at some point and understand our struggles on the frontlines. If we present our medical reasoning with them, they often are able to authorize a test. Not always.

– Talk to your provider rep at the insurance company. They often know the right person to talk to that may help you get the service covered.

While these tips may help get some prior authorizations approved, they often still do not work. The insurance companies hold a lot of power over these medical decisions. The most important thing is to keep fighting the ones we don’t medically agree with. The day we all quit the battle is the day we lose the game.  Don’t let the big insurance companies win and determine medical care. We must remain diligent in our fight for optimal clinical outcomes in all and each of our patients.

By: Linda Girgis, MD

April 4, 2018

Improper Billing and Testing Results in Fines and Jail Time for Providers

Improper billing and testing can result in fines and jail time.  The government is taking a very aggressive stance.  Providers beware!

Most providers aren’t even aware that they may be guilty of improper billing.  Many times providers appear before the courts and say they didn’t know.  Unfortunately, they soon learn that ignorance is not a defense.

Two recent cases underscore the importance of making sure the provider listed on the claim submission form is the same provider that performed the services, and the same one who documents and signs the medical note.

April was a busy month for the U.S. Department of Justice (DOJ). Two settlements highlight the notion that the U.S. government has a low tolerance for providers who defraud its programs such as Medicare, Medicaid, TRICARE, and the Federal Employee Health Benefits Program (FEHB).

Garrett Okubo (Honolulu) 

According to the DOJ, Garrett Okubo, the owner and operator of a physical therapy business in Honolulu, submitted claims for physical therapy services between January 2011 and October 2017 for payment from Medicare, Medicaid, TRICARE, and the Hawaii Medical Service Association. Okubo, in violation of 18 USC § 1347, executed a scheme by “falsely stating that Okubo himself had personally provided the physical therapy services to his patients, when in reality the services were provided by Okubo’s unlicensed staff members, including at times when Okubo was traveling on the U.S. mainland or in a foreign country.”

Although Okubo is not a physician, the issues raised in his case, which resulted in both monetary penalties and jail time, parallel those of improper billing of non-physician providers (NPPs) such as physician assistants, nurse practitioners, and clinical nurse specialists.

In general, Title 42 must be consulted regarding the scope of the reimbursement. If a nurse practitioner, for example, is billing under their own Medicare provider number, then the reimbursement by Medicare is 85 percent of the Medicare Physician Fee Schedule. It is also imperative to read the respective state law in order to ascertain the scope of practice, licensure requirements and level of supervision.

Biotheranostics, Inc. (San Diego)

According to the Acting Assistant Attorney General of the DOJ’s Civil Division, “laboratories that knowingly submit claims for non-reimbursable services will be held accountable.”

On April 19, Biotheranostics, Inc. agreed to pay $2 million to resolve allegations that it both submitted and caused to be submitted Breast Cancer Index (BCI) tests for Medicare reimbursement. These tests were not “reasonable and necessary” and, therefore, failed to meet the medical necessity standard.

The Medicare statute expressly states that laboratory tests may be reimbursed by Medicare only if they are “reasonable and necessary for the diagnosis or treatment of a patient’ illness or injury.” Relying on evidence-based medicine standards, the DOJ determined that the BCI test was being performed on breast cancer patients who neither had been in remission for five years nor had been taking tamoxifen. Therefore, substantiating that a number of claims that were submitted for Medicare payment were unauthorized and unnecessary.

The take-a-ways for physicians are as follows:

  • Make sure that NPPs are billing in the appropriate manner in conjunction with state and federal law and that the definition of “supervision” in a respective state is understood;
  • The person’s name on the claim’s submission form needs to be the one performing the service and indicated in the medical records;
  • Ensure that the diagnostic tests or treatment being order is substantiated by medical necessity; and
  • Failing to be compliant can and often does result in False Claims Act cases, which can carry both civil and criminal penalties.

 

By: Rachel V. Rose, JD, MBA. 
Rose is an attorney who represents and advises both corporate clients and individuals on healthcare, cybersecurity, securities, False Claims Act and Dodd-Frank causes of action.  She is also a Principal at Rachel V. Rose – Attorney at Law, PLLC, who also teaches bioethics at Baylor College of Medicine.

5 Common Reasons Your Claims are Bouncing Back

Billing is a complex and often tedious procedure, especially with ICD-10 codes. However, the reasons for returned and delayed claims often boil down to a few basics. Here are some of the most common billing mistakes practices make, and how to make sure your practice avoids them.

  1. Little Typos, Big Headaches

    Often reimbursements are delayed or denied because of very small, easy-to-make mistakes. “When I was assistant director of billing for a large multi-specialty practice,” says Brennan Cantrell, “the front office would often transpose the numbers or letters in policy number or omit a group number or plan ID. The front desk is extremely busy, and these are easy mistakes to make.” Cantrell, who is now commercial health insurance strategist for the American Academy of Family Physicians, says that the ideal solution is having an employee dedicated to watching for and correcting these errors. For small practices, this may not be a full-time employee, and the time saved by not having to resubmit claims might offset the time spent rooting out mistakes.

  2. Something’s Missing Here

    Sometimes payers delay payment because you didn’t send enough information. Often you can see this coming. “For example, when you file workers’ compensation claims, you will always need to submit documentation with the claim,” says Tammie Olson of Management Resource Group, an Ocean Springs, Miss., a firm offering financial management and support services for the healthcare community. “If you know you need to send the documentation to get a claim paid, do so when you file.”

  3. Please Ask First

    Another incredibly easy—but costly—mistake is not getting prior authorization. “Before you perform procedures, make sure you verify whether or not a prior authorization is required,” says Olson. “If it is, send in the request before scheduling the procedure.” And when you get ready to bill the procedure, “make sure the authorization number is on the claim,” she adds. Prior authorizations can be a pain, but having a routine for them when they are necessary can save time and prevent payment delays.

  4. Let Me See that One More Time

    Claims are increasingly denied because the patient’s coverage has been terminated or the plan or payer has changed.  Most of the time everything is just as it was the last time the patient came in but you should still ask to see the patient’s insurance card at every encounter. “People change insurance plans more often than they used to,” says Cantrell. “It’s a simple thing, but important.” Olson agrees, and adds, “If you do this, you should never have a claim denied for “policy terminated.”

  5. Keep up with the Changes

    Even when policies haven’t changed, what is and is not covered on a given plan sometimes does. You can be left holding the bag if a payer changes its policies about what procedures they cover or what labs they use, and you don’t hear about it. “Most payers send out a policy bulletin announcing these changes,” says Cantrell, “but it’s difficult to find time to keep up with this.” Large practices often have administrators who watch for these changes and pass the word on to each billing office. However, in smaller practices that job may fall to the front desk or billing staff. Make sure whoever does this understands the importance of carefully reviewing these bulletins when they are issued.

 

By: Avery Hurt

Ms. Hurt is a freelance writer based in Birmingham, Ala. Her work has appeared in publications including Newsweek, The New Physician, Muse, Parents, USA Today, and the Washington Post

Three Coding Updates – Provider Beware

Coding

CodingCODING IT RIGHT

We know everyone is busy and there is no way you can read every single article that comes in your inbox or crosses your desk.  So we thought we’d share three bullet items regarding coding that may impact your practice.

  • New Vaccine Codes for 2018

Medicare has announced a coding change.  After January 1, 2018 they will cover the new influenza virus vaccine code 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use).

During the interim period of Aug. 1, 2017, through Dec. 31, 2017, Medicare Administrative Contractors (MACs) will use code Q2039 (Influenza virus vaccine, not otherwise specified) to handle bills for this new influenza virus vaccine product (Influenza virus vaccine, quadrivalent (ccIIV4). Q2039 is already an active code.

The new influenza virus vaccine code 90756 will then be implemented for DOS on or after Jan. 1, 2018.

  • Consult Codes not being paid

United Healthcare, has announced that they will stop paying for consult codes effective October 1, 2017.  This may be the wave of the future so make sure your billing service or office manager notifies you if other payers follow suit.

  • Documentation requirements for coding by time

Before you code by time make sure you know the documentation requirements.  The documentation must include the total time of the visit, a summary of the discussion or counseling AND support that over 50% of the visit was spent in counseling or coordination of care.