My book on front-end collections has been doing really well and I’m pleased that a number of people have called me or emailed me with questions. Here’s one question that a number of people have asked – “Can you tell me more about knowing what to collect from the patient at check-out”?
Hopefully, you have followed my advice and collected co-pays and previous balances before the visit. The portion that you collect after the visit is the co-insurance and the deductible.
The guideline on collecting after the visit is directly related to the allowables on the services the patient received. Allowables are the amount that payers consider payment in full. Of the total allowable, a portion will come from the payer and the balance will come from the patient. Knowing that percentage is the secret to collecting at the check-out desk. The percentage of the allowable that the patient will pay is the critical piece of information you need to successfully and accurately collect after the visit.
Allowables fall into three categories:
- The Medicare allowable for your area of the country, or state, for the current year. If you participate with Medicare, you have an allowable, if you do not participate with Medicare, you have a limiting charge that you must use for Medicare patients.
- The allowables for the payers with whom you have contracts and have agreed to accept their rate for their subscribers.
- The rates paid by payers with whom you do not have a contract. Their payment for out-of-network services (non-contracted physicians) will determine the amount owed by the patient.
How Do You Collect This Information – Medicare
Medicare allowables are published every year, both in the federal register and online at the CMS (Centers for Medicare and Medicaid) website. If you are fortunate enough to have a practice management system that loads this information automatically for you, you are golden. If not, you will need to enter these manually. The good news is that very few practices need to add more than 50 – 100 allowables to get started.
You can also use a paper cheat sheet to fill in your top 50 – 100 codes. Make a chart with your fee, the Medicare allowable, and the 20% of the allowable that Medicare patients must pay at every visit. A note of caution – many Medicare patients have secondary coverage and it can be difficult to know what the secondary coverage will pay. Most practices will not collect anything for patients with secondary coverage because it can mean a lot of refunds have to be written when the secondary payments come in.
How Do You Collect This Information – Payers You Have Contracted With
If you have a contract with a payer, they must furnish you with a full allowable fee schedule, or with an payment model. For example, their payment model may be 150% of the 2007 Medicare schedule. You will need to go to the CMS lookup page here and get these allowables for your services for 2007 and multiply it out.
Example: the 2007 allowable for 99213 established patient office visit is $56.98 for North Carolina (use your locality)
If the payer is paying 150% of that allowable, it will be $85.47, and if the patient has to pay 20% of that allowable, they will owe $17.09. Don’t forget to include the deductible in this equation, as the patient will need to satisfy the deductible before the payer will pay you 80% of their allowable.
Some practice management systems will have the ability to take that information and calculate it for you, so be sure to ask your vendor about this before you do the work.
If you are constructing a manual cheat sheet, you’ll have your fee (even though it doesn’t come into play, I suggest practices always keep their fee on cheat sheets, so staff can bring anything unusual to the administrator’s attention. Also as you increase fees, you have a handy visual.) Add the payer’s allowable, and calculate the percentage the patient will owe.
Use this same sheet for your payment posters to make sure you are getting paid the correct amount if your practice management system doesn’t do this for you.
By the way, if an insurance company that you have contracted with refuses to give you a schedule of allowables or a payment model, contact your state medical society, your state insurance commisioner, or your state legislators for help.
How Do You Collect This Information – Payers You Have Not Contracted With
If you do not have a contract with a payer, getting information on their allowables can be tough. Some practices will have the patient pay in full and either file the claim for the patient, or give/mail the patient a claim form for them to submit. In this case, you do not need the allowables. If your specialty has higher in-office fees due to tests, etc., it may be difficult for a patient to pay $250 – $500 in full at time of service. You may want to consider one of these strategies for collecting at time of service:
- Collect a deposit based on the total charge. Let the patient know it is an estimate and that more or less may be owed. I do not believe in sending statements. In my book I recommend using a payment portal to securely store patient credit cards, and adjust the remaining balance up or down according to the actual payment. As payments come in you can develop a knowledge base for what different payers and plans will pay. This will assist you in estimating the patient’s portion more accurately over time.
- You can give patients information about the services they most likely will receive at their visit and ask them to call their payer and get information on payment. This is a great strategy. If patients are shocked about their portion, they may want to reconsider becoming your patient. The last thing you want is a patient who is surprised by the payment due after they have received the services. Some payers supply subscribers with allowable information on their website.
- You can usually get the allowable information by phone if you have the subscriber’s information, or if you have the subscriber on a three-way conference call, or in the room with you. This is more typically done when the subscriber is contemplating surgery or an expensive procedure and you are working on a payment plan, or outside financing with them.
Knowing what the patient owes and making arrangements for payment in full at time of service is one of the most significant things you can do to increase your receipts and decrease your accounts receivable. No practice can afford to “wait and see what insurance pays” and bill the patient months after the service has been rendered.
If you don’t have the following ten items on a manual checklist or in your EMR, you might want to add them. Any time I hear someone list things that improve quality of life and downstream health, I think to myself “This is future reimbursement criteria.” Actually, several of these are already included as measures in the 2010 PQRI (Physician Quality Reporting Initiative) list.
I came across this list on the physician blog “The Examining Room by Dr. Charles”. Dr. Charles writes:
“These items were chosen by the National Commission on Prevention Priorities, and highlight those preventive services including immunizations, screenings, preventive medications, and counseling that give the most bang for the buck.
- Discuss Daily Aspirin Use
- Childhood Immunization
- Smoking Cessation Advice and Help to Quit
- Screening for Alcohol Misuse and Brief Counseling
- Colorectal Cancer Screening
- Hypertension Screening
- Influenza Immunization
- Vision Screening
- Cervical Cancer Screening
- Cholesterol Screening
Get ahead of the curve, and discuss with your providers how you can give your patients more bang for their preventive care buck by making these ten items standard questions in your practice.
Read more on Dr. Charles blog here.
I received an email today from SubroShare founder and CIO Stephen Ambrose, letting me know that SubroShare has changed its marketing model from what he described in his recent interview here.
He describes the new model:
It was thought at one time that the health providers, by knowing about when a payer PURCHASED CRRs, could thereby use such information to effect reimbursement. However, this has proven to not be applicable on an individual provider to payer basis – and actually a hindrance to interested payer clients.
Steve goes on to say that it is now clear that the two clients of SubroShare will be payers and outsourced provider networks such as third-party administrators (TPAs), repricing agencies and preferred provider organizations (PPOs). Physicians and care providers will not be marketed to as:
In fact, there are NO benefits to the Provider they are simply mandated to participate. The information that is submitted by the Provider is known as ROI Data, and is simply an extension of the obligation they already have to provide the patients payer with TPL/COB information.
Coming soon to a contract near you: a clause requiring you to submit attorney requests for medical records to the payer.
Okay, okay, so I shamelessly lured you into reading this post by telling you Rosemarie Nelson would reveal the “best” EMR product on the market, and she really does, only not in the way you wish she would. Read on to the end of this post for her EMR advice.
It was my pleasure to talk with Rosemarie Nelson after she had given her third presentation (!) at the North Carolina MGM Fall Meeting at Pinehurst this past October. As we visited, I realized I’ve been listening to Rosemarie talk about electronic medical records for at least 10 years. If you don’t know Rosemarie, she’s a running fanatic, an EMR guru, Principal Consultant with Medical Group Management Association (MGMA) and she has 15 years of consulting in operations and technology under her belt.
When I asked her why it’s so hard to implement electronic medical records in a physician’s office she said: “Medical practices are a home-grown industry, really a cottage industry, so every single one is different. There are specialty differences and workflow differences and many EMR vendors don’t know how to address this.”
Rosemarie particularly enjoys helping groups to fix poorly implemented systems and often finds that vendors have not carefully looked at the way the client physicians work before selling them a system. She has experienced the many unique ways that practices operate, and why they operate that way, and has been able to bring EMR success to over 300 practices during her tenure.
Rosemarie recommends that practices take electronic records a bite at a time. She suggests that groups start with one component, maybe ePrescribing, or messaging or electronic test results, and get it working really well. Although vendors might prefer that a group follow its timeline, there is no reason that a practice cannot set its own timeline. Finding out if a vendor will be flexible to a group’s unique needs and timeline is a must-have question when developing a RFP (Request for Proposal.)
The dichotomy of the physician (“make it so”) and the administrator (“take it slow”) is another challenge medical practices face. Many physicians want EMR to happen quickly and painlessly with no interruption of workflow. Rosemarie suggests to these physicians that they should “refer their business to a specialist (her), just as they would refer their patient to a specialist.” Working through the process takes time.
Here are some other observations from Rosemarie:
- “Apply the EMR as a tool to the operations, it is not an end to itself.”
- “Accept the incremental benefits” of the electronic medical record. “All or nothing is a losing propostition.”
- On the Stimulus Money for implementing EMR: “Do it because of the benefits and if you qualify for the stimulus, all the better.”
- On preparing an RFP (Request for Proposal): “Define the deliverables, the timeline and the money and focus on your practice’s absolute needs.”
- On scanning old paper records into the EMR, she says “Only 25% of documents stored are ever used again.”
- On savings using ePrescribing (besides the Medicare bump): “ePrescribing can save each FTE provider $15,000 per year on average.”
- On using electronics to make the medical practice more efficient, “A typical primary care practice might get 85-100 patient calls per day. Try to offload 30% of those calls per day to electronics – ePrescribing, patient secure messasging, electronic lab results, appointment requests, etc.”
- On her favorite client story: “A cardiologist who did not want to do ANYTHING differently, saw me two years later and told me that EMR was the best thing that had ever happened in his practice!”
- Her favorite tip: “Add your website address to your appointment reminder calls!”
- And…her most asked question ever – Tell Me Which EMR to Buy, to which she replies, “There really is more than one good product out there. Buy the one that matches your needs and your workflow the best, and it will be the right one for you!”
You can reach Rosemarie Nelson here: RosemarieNelson@alum.syracuse.edu
I recently interviewed Stephen Ambrose, the Founder and CIO of SubroShare, a database of medical record requests. Steve has a lot of passion for his innovative product and envisions SubroShare playing a starring role in payer contract negotiations.
Mary Pat: Steve, what is subrogation?
Steve: Subrogation is a legal right and necessary tool used throughout the insurance industry with many types of policies. It allows insurers to recover part or full amounts of claim monies, which they have previously paid out to, or on behalf of a claimant.
In certain circles, subrogation is considered the great equalizer because it allows insurers to reduce or eliminate the passing of unnecessary cost related to third-party liability (TPL) claims, to policyholder premiums and provider reimbursement rates.
Overpayment of health care claims is a form of waste in cases where previously paid health care claims are re-billed to a third party and subsequently paid for again as part of a successful injury claim settlement.
Mary Pat: How does your product SubroShare relate to subrogation?
Steve: First, apart from Medicares MSP (Medicare Secondary Payer) program, I know of no law or obligation where injury claimants or their attorneys must proactively volunteer information to a health payer, alerting them of a case, where the payer has a right to recover. For this reason payers have always been responsible for data mining claim form information, and to this end, use software products and vendor services to do so.
SubroShare recognizes that the claim form/data itself is limited in holding the correct, identifying data for third party cases. In many cases, the use of the claims data results in payers having false positives or dead end investigations. Even claims vendors who claim to use the latest and greatest tools, freely admit that they do not find all of the cases available to the payer.
Our company has developed a new patent-pending technology in Collaborative Subrogation, where we work to connect just one small part of a health providers record department with an applicable payer. This is only for certain ROIs (Release of Information) made by the patient or their attorney involved in a patients injury claim.
Mary Pat: What is the physician’s office or healthcare provider’s role?
Steve: In most payer agreements, the health provider has a contractual obligation to provide coordination of benefits (COB) and third party liability (TPL) information to the payer, when known. This is reflected in certain sections of the CMS 1500/UB-04 forms and their 837 data record electronic counterparts.
The SubroShare exchange handles non-billing TPL data, specific ONLY to those times where a record request is made on a patient of the provider. This ROI Data, is submitted to SubroShare at the time of record request fulfillment, by the provider submitting either a one or two page fax / secure email attachment. The first page is typically only a -page section and the second page is a copy of the request letter, sent by an attorney (if applicable).
Providers can learn more by watching the provider tutorial here.
Mary Pat: How does this sharing of information work within HIPAA rules?
Steve: Under 45-164.501 of the Health Insurance Portability and Accountability Act (HIPAA), the ROI data that is collected and shared between health providers and payers, through the SubroShare network, is specific to insurance subrogation operations and falls under the HIPAA provision of “Payment”, in the automatic exclusion of “Treatment”, “Payment” and “Operations”.
This means that patient authorization is not necessary, nor can the patient request to withhold the limited disclosure of their PHI to SubroShare and eventually, to their health insurance company.
Finally, every health provider who participates with SubroShare must sign a HIPAA Business Associate agreement, which is signed digitally on the joining section of our website.
Mary Pat: What is the health plan or payer’s part of this?
Steve: Payer members or Subscriber Entities of SubroShare login and freely search for established Certified Recovery Reports within our system. Once found, the payer downloads the information, which both guarantees policyholder involvement and uniqueness from any existing payers claims management software and vendors.
Mary Pat: I can see how this benefits the payer, but how does it benefit the physician practice?
Steve: Under the new HITECH guidelines to go into effect in later 2010, health providers cannot receive compensation from the transfer of PHI. Therefore, we felt it prudent to be able to create financial transparency on both the payer and provider sides of SubroShare.
Essentially, providers will know the specific payers who downloaded their submitted ROI data, as well as the date of download and patient referenced. This data, coupled with a providers analysis on the amount of paid claims for such patients, provides a clearer picture on the fact that a provider is now becoming a new type of asset to the payer and to an extent, which can be measured by the provider, as well as the payer. We believe such a change in value could denote an improvement in reimbursement levels within various payer relationships.
Mary Pat: Could payers use this information to deny payment or request a refund for payments already made?
Steve: There are numerous laws and rules, inherent to different states, communities and health plans, allowing for cost avoidance. This term denotes when a government, commercial or self-insured payer determines that a policyholders care should be or will be covered by a payment party other than themselves.
Unfortunately, we cannot keep a health payer from pursuing cost avoidance policies, which they have in place. However, Id like to mention that not all plans have this provision; and for those which do, this simply makes the point that it could be a future point of provider-payer negotiation, perhaps with relation to all such claims, not just the ones from SubroShare.
Mary Pat: If the practice uses an outsourced company to copy medical records, can the medical records company send the information to SubroShare?
Steve: Yes, provided two conditions are met.
First, the health provider is the one, which joins SubroShare – not the outsourced company. Health providers can give their login details and appropriate permissions to their ROI or outsourced information vendor.
Second, the outsourced vendor MUST have an existing HIPAA Business Associate Agreement with any applicable health providers. I assume this is the case anyway, but if I didnt mention it the answer would be less than complete.
Mary Pat: It’s a leap of faith you’re asking a medical practice to take, isn’t it? Is there any way you give the practice a guarantee of negotiating better fee schedules with payers, or any way you could compensate them for their time?
Steve: I dont think the leap is that large…heres why. Its becoming increasingly obvious that past provider strategies on reimbursement rates will be largely overshadowed and trumped by a tightening healthcare system and monies, which are drying up for many of its participants. If the monies are not there for payers, they wont be there for providers.
SubroShare creates revenue, without charging higher premiums to policyholders, but rather, in redistributing monies, which are generated through the legal industry and might never make their way back into the healthcare arena. Providers need to look at the information, which they are already holding. Can it help their valuation and reimbursement with payers? I suppose thats up to each payer. Medicare already has demo programs, which trade off payment for valuable data submission and we expect that to find its way into the private payer sector as well.
Our President and both sides of Congress have made it very clear that finding and reducing waste is one of the top priorities. Therefore, we want our collaborative model to demonstrate to todays leaders that payers and providers CAN work together for the good of the system.
Mary Pat: What would you say to a practice manager to convince them to work with SubroShare?
Steve: As a practice manager, if you are bitter about what insurers have done TO you?, then you are not the right practice for SubroShare. Youll probably be coming on through payer mandate, as your payers adopt these measures. I will state that voluntary participation will offer you the ability to proactively come to the negotiating table with results in hand.
If you understand that its about future positioning and NOT the payer taking advantage of you, then youll begin to understand the importance of positioning and collaborative strategy. Were in a whole new arena of healthcare and old models and adversarial relations will not do well.
There is no cost to join, no cost to participate, no software to buy or integrate and no patient authorization necessary. All that is required is a fax and a simple internet connection. Please visit us here or call (804) 750-1389 for more information.