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.
There’s a new ABN form required to be in use in January 2012 – read about it here in my article “Everybodys Favorite Form: New Advance Beneficiary Notice of Noncoverage (ABN) Form Begins in 2012″
Note from Mary Pat: The Advance Beneficiary Notice of Noncoverage (ABN) is a collection tool that many medical practices do not know how to implement. It is particularly difficult to determine who has ownership of this process, because the form must be completed and signed by the patient before the service is provided. The patient is in the exam room or the lab, ready for the service or test, and a knowledgeable staff person must step in, explain the rules and pricing and obtain the patient’s signature.
Blogger Charlene Burgett does a great job of explaining the ins and outs of using the ABN, and has agreed to share an article originally published on her blog “Conundrum” with MMP readers.
The use of the ABN is required by Medicare to alert patients when a service will not be paid by Medicare and to allow the patient to choose to pay for the service or to refuse the service.
If the practice does not have a signed ABN from the patient and Medicare denies the service, the charge must be written off and the patient cannot be billed for it. The only exception is for statutorily excluded services (those that Medicare never covers like cosmetic surgery and complete physicals for example). In this case, a practice can bill the patient for the non-covered service despite not having an ABN. It is, however, a good idea to have the ABN signed for non-covered services so the patient is made aware that they are responsible.
If the patient signs the ABN and is made aware of their financial responsibility you may require the patient to pay for this service on the date the service is provided. You may also charge the patient 100 percent of your fee. You do not have to reduce your charge to the Medicare allowable.
With a signed ABN, the practice has proof of the patient’s informed consent to provide the service and their agreement to be financially responsible for the service. In the past, Medicare had a Notice of Exclusion of Medicare Benefits (NEMB) that we could provide to the patient (no signature required) to alert them of Medicares non-covered services. The ABN has replaced the NEMB.
The typical reasons that Medicare will not cover certain services and that would be applicable are:
- Statutorily Excluded service/procedure (non-covered service)
- Frequency Limitations
- Not Medically Necessary
Statutorily Excluded items are services that Medicare will never cover, such as (not a complete list):
- Complete physicals (excluding Welcome to Medicare Screenings, with caveats)
- Most immunizations (Hepatitis A, Td)
- Personal comfort items
- Cosmetic surgery
For these items, it is a good idea (not a requirement) to complete the ABN and have the patient check the appropriate box under options and sign the ABN. For the sake of the billing department, I strongly encourage the use of ABNs for statutorily excluded items.
Frequency Limitations are for services that have a specific time frame between services. For example, Medicare allows one pap smear every 24 months if the pap is normal. If the patient wants one every 12 months for their peace of mind, Medicare will pay for year one and the patient will pay for year two and that pattern continues. The ABN needs to be on file for the year that the patient is responsible for paying. If the patient fits Medicares guidelines for high risk they are allowed to have the pap every 12 months and no ABN is required.
Services that are not considered Medically Necessary are those that do not have a covered diagnosis code based on Local Coverage Determinations (LCD). One example is for excision of a lesion. If the lesion is being removed because the patient just doesnt like how it looks, that is considered cosmetic surgery. If the lesion is showing some changes (i.e. bleeding, growing, changing color, etc), then it is considered medically necessary because it potentially can be malignant. The removal needs to have diagnosis coding to substantiate the medical necessity and Medicare has Local Coverage Determinations that list all the codes/coding combinations that Medicare will approve for payment.
A rule of thumb in trying to discern the necessity of ABNs is to ask yourself if there may be some times that the service isnt covered by Medicare. The times the service isnt covered, an ABN is required. To illustrate this point, here are two examples:
- EKGs are covered for certain cardiac and respiratory conditions. The only time an EKG is covered for preventive screening is during the patients first year enrolled in the Medicare program and when being done during the Welcome to Medicare screening. After that time, Medicare will never cover an EKG for preventive screening. To notify the patient of this and to show that the patient agrees to be financially responsible for the EKG, an ABN should be completed.
- Another example is for the Tetanus immunization. Medicare will cover tetanus when medically necessary; if the patient has cut themselves and the tetanus is provided due to that injury. If the tetanus is provided to the patient because it has been ten years since the last tetanus and the tetanus is not in response to a recent injury, then it will be non-covered because it is not medically necessary and the ABN will need to be on file.
ABNs need to be completed in their entirety. The Options box can only be completed by the patient and it states that We cannot choose a box for you. That would appear to be coercion.
A blanket ABN, one that is signed by the patient for all services provided within a certain time period, is not acceptable and is illegal.
In addition, there is a small area to provide additional information that can be used by either the patient or the providers office. This could be anything pertinent to the information that the ABN covers. The bottom of the form is where the patient signs and dates. We keep the original ABN in the chart behind the progress note for that day. Providers MUST provide a copy of the signed ABN to the patient.
The current ABN form with instructions can be found here.
If a service is denied by Medicare and the physician does not have a signed ABN prior to the service being rendered, the service can not be billed to the patient and will need to be written off. Sometimes a patient may refuse to sign the ABN – if this happens it is appropriate for the physician to document the refusal and sign, along with having a witness sign. Medicare will accept this and the patient can be billed for the service if denied by Medicare.
How does Medicare know whether or not you have a signed ABN? You tell them, by adding a modifier to the CPT code when completing the claim form. The appropriate modifiers are:
GA: The ABN is signed, but the service may not be covered.
GY: A statutorily excluded service.
GZ: The service is expected to be denied as not reasonable or necessary. This is typically used when there is a secondary payer that requires the Medicare denial before they pay benefits.
The use of the ABN is often misunderstood; however, it is the only way a patient can be informed about their financial responsibility prior to agreeing to a service being rendered. This is an issue that the OIG has reportedly been interested in investigating for fraud and abuse.
Charlene Burgett, MA-HCM
Note: Readers, how do you make the ABN work in your practice? Do you train the clinical staff, the physicians, or other staff to recognize the “ABN Moment”? How do you make it work? Please share your ideas by responding with a comment.
At last, here is what all the shouting’s about! A new website and a new book all in one day. Just for kicks, I interviewed myself about these changes.
Q: Mary Pat, why all the changes all at once?
A: I didn’t start out to publish a book and redo my website all at once, it just happened that way. My site has been online for almost a year and a half now and after spending lots of time on the web, I knew I wanted to make some changes to my site – clean it up a little, and hopefully make it easier to read and navigate.
Q: What about the book?
A: I’ve been working on the book for about 9 months, and every day I have been reading about practices struggling with less reimbursement and more expense. Medfusion asked me to do a webinar on patient collections and I thought it was a perfect time to get the book completed.
Q: Why an eBook?
A: I decided on an eBook because that’s what I prefer. I like information on a specific topic and I like to be able to get to it immediately. More of a cookie-sized topic, than a cake. I love big business books full of information, but it takes me forever to read them. I wanted something that a manager could see, buy and start using all in the same day.
Q: You mentioned a webinar for Medfusion – when is that happening?
A: The webinar was November 17th and is archived on the Medfusion website so you can listen to it whenever you want.
Q: I see you’ve added a new tab called “Vendor.” What’s that all about?
A: I’ve been wanting to give my readers access to vendor names in categories and now seemed like a good time to do that. Right now there are 6 categories: Employee Background Check, Eligibility Products, External Financing, Creditworthiness Products, Payment Portals, and Special Resources. As time goes on I will add more categories so readers can access vendors in a certain category in one place.
Q: Are these vendors that you are recommending?
A: No, these are vendors that I’ve checked to make sure they have the service or goods that fit in the category, but I’ve not screened the vendors for my readers at all. Maybe down the line I’ll have some sort of feedback on vendors, but for now, I’m just listing them.
Q: Why didn’t you put the vendors in your book?
A: Because the field is always changing and vendors are coming and going all the time. I don’t think that the print medium is the right place for listing vendors for such a fluid and changing market as healthcare.
Click here to view “The Smart Manager’s Guide to Collecting at Check-Out.”
From the Introduction:
It has never been more urgent or more difficult to collect patient-responsible balances. The combination of high-deductible health insurance plans increasing in popularity and the massive loss of medical benefits creates a pressing need for medical practices to re-evaluate patient collections. A strong collections program and the timely collection of patient balances are critical to the viability of the modern healthcare practice – important to the communities served as a source of patient care and a contributor to the local economy.
Healthcare has traditionally been a care-first and collect the money later type of business. Traditionally, payments from insurance companies were enough to keep medical practices viable, and many practices did not worry about patient collections. Today, the financial responsibility for payment for health services is swinging further and further toward the patient, and often without many patients understanding what is happening.
The Practice Should Assume Responsibility for Being the Insurance Expert for the Patient
Learn the payers, learn the plans, and help the patient understand what coverage and financial responsibilities they have. This book does not focus on filing claims, but insurance cannot be separated from the total payment process. To know the patient-responsible portion, the practice must know what the insurer/payer will pay. The ideal relationship is one where the patient relies on the practice for straightforward, non-biased information about paying for healthcare.
Disclose All Fees and Terms of Service Before the Patient Incurs a Financial Responsibility
Patients have the right to know your prices, compare your prices with other healthcare providers and make an informed decision about spending their money. It is part of the practice of healthcare that the patient acknowledges (whether they have the means to pay or not) that they have received something of value.
Remember Your Practice Is In the Business of Compassion
Patients are not buying televisions or cars from you, they are buying the most important thing in the world good, quality healthcare services and advice. Whether you believe that healthcare is a privilege or a right, always temper patient collections with the knowledge that paying for healthcare for themselves or their loved ones is a personal and often emotional transaction.
The Book: “The Smart Manager’s Guide to Collecting at Check-Out” $39.95
Released this Monday, November 16th, the book is only available for download here on this website.
This is not your traditional textbook! It is an eBook – downloadable in minutes and ready to start using immediately. It contains bookmarks that make it easy to jump to specific sections, and you can print only the pages you want.
This book will help any type of medical practice develop a front-end collections program. The 30 day program can be intense, but for most medical practices, the need to start a patient collections program is so pressing that the sooner the program can be launched the better.
The book addresses the components of setting up a front-end collection program that is ready to launch in 30 days. Depending on the resources (people, time, energy) that you have in your practice, your program could launch in more or less than 30 days. Your timetable could change if you have significant barriers or insufficient resources, or if you elect to take the planning more slowly.
An integral part of the book is the calendar that you will use to complete the program within the time frame. I supply the steps, the worksheets, the templates and the 30 day calendar, and you add or subtract days as needed. The steps are in order for a reason, but you should rearrange them based on your practices needs and resources.
Packed with templates, worksheets and examples, this book leads you every step of the way through designing a program appropriate for your practice or healthcare entity.
In conjunction with the book launch, I will also be unveiling my brand-new website! My tech guy has outdone himself in designing a more user-friendly and intuitive site. See you on Monday!
Click here to view “The Smart Manager’s Guide to Collecting at Check-Out.”
I took last week off to complete a project I’ve been working on since early this year – my first book!
It’s really a workbook and it guides the reader through a program to move their practice from a back-end collection process to a front-end collection process. What is the difference? A back-end program collects the majority of patient-owed balances after the payer has adjudicated the claim and has submitted payment to the practice. A front-end program takes all the available information about the payer/plan and collects payment or arranges future electronic payments with the patient at the time of service.
The book has step-by-step instructions for implementing the program in any practice, and more than a dozen worksheets and templates are included. Some examples are:
- Patient Collections Benchmarks
- 30-Day Project Calendar
- Responsibility Assignment Worksheet
- Budget Template
- Sample Job Description and Hiring Worksheet
- Product Evaluation Forms
- Sample Financial Policy and Financial Policy Template
- Patient Frequently Asked Questions (FAQ)
You really can implement a program like this in your practice. It’s hard work, but well worth the effort.
Click here to view “The Smart Manager’s Guide to Collecting at Check-Out.”
I invited readers of MMP, colleagues on LinkedIn, and Tweeps (friends on Twitter) to comment on my post “101 ideas for Increasing Revenue and Decreasing Expenses.” I’ve listed their ideas below and hope you’ll chime in on the comments with even more ideas! Thanks to everyone for contributing.
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Partner at B2B CFO – Experienced CFO for Rent. Fast, Effective, Affordable.
Consider adding a part-time CFO to the mix. Many medical offices have very weak financial capability or understanding. Assistance can range from better financial reports, capital expenditure analysis, budgeting and exit plans.
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Eastern Region Sales Manager – Billing Tree
1) Build a relationship with the patient before he/she leaves the practice.
2) Make sure they know you are expecting payment on the portion they owe, and when you are expecting that payment.
3) Let them know what your process is for collecting, and when they will go to an outside agency.
4) Enable a web site to take payments 24 hours a day.
5) Set up an IVR system to take phone payments after hours.
6) Communicate your available payment acceptance methods in writing, on the phone and every time you speak with your patients.
7) Send the invoice or statement when you intend to send it.
Re-inforce the payment acceptance methods on the first and any subsequent invoices.
9) Adopt a plan for following up with any patients that don’t pay after 10 days.
10) Get email addresses from all of your patients and their permission to contact them in that manner.
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Sr. Product/Process Trainer and EDI Implementation Consultant
One suggestion would be to integrate the revenue cycle mangement function with your clearinghouse {for electronic billing} with integrated solutions like Coding database and Updates, Industry Broadcast, Performance and Audit reports for Claim Edits, Transmission and Rejects. Also, better training resources for billing staff actively into the practice management system.
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Consultant at Pacific Women’s Medical Group
I would add effective cash management (even if interest rates are so low).
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Medical and Business Consultant at Transworld Systems
Utilize a Flat Fee Collections Agency for Non-responsive Patient Pay concerns.
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Principal Consultant – Culbert Healthcare Solutions
- Do you collect co-payments on the way in rather than on the way out?
- Does your PM/Scheduling system show the patient co-payment and outstanding patient balance in the appointment screen? If not, then can you download a listing for your front desk staff?
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DPT Healthcare Consulting & Training
I’d like to add “acknowledge the patient with eye contact” and offer “polished customer service” and they will WANT to return = return on your $ $
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Managing Partner, Dynamic Grape Companies
One other thought… don’t be afraid to try new technology. For example, one of my clients has developed a kiosk that allows patients to take their own weight and bp and electronically feeds the data into their EMR. The whole set up costs about $3500 and can save a ton of staff time. Tele-health in general should also be considered.
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VP at Operations
If you select a reasonably priced EMR and you implement enhancements then you more than save on staff cost. Keep in mind that my practice rolled out the EMR five years ago, so we have had time to get it right. Here are some of the savings/revenue opportunities:1. We utilize our electronic technology to send text messages and emails to our patients to remind them of their appointments. This function alone saves my practice one FTE. Not only do we save with staff time we improve patient satisfaction, as our Blackberry users loves the email or text that they can directly add to their calendars. The revenue enhancement to this function, we decrease no shows and lag time in our physician’s schedules.
2. The robust reporting within the EMR allows the organization to assemble important quality measures that we use in contract negotiations. Without the EMR this would be a labor intensive task.
3. We are able to push a secure message to our patients regarding their pathology results saving staff time on the telephone and increasing patient satisfaction by eliminating a visit just to obtain a normal result.
4. No more chasing charts for a phone message. My call center takes ALL clinical messages. This is attached to the patient’s electronic chart and routed to either a nurse to respond or a physician. This process greatly reduces staff time, decreases the time it takes to respond to the patient’s issue and provides a legal record of the telephone call which is often missed in a paper environment.
5. We receive a discount on our mal-practice insurance because in an electronic environment it is guarantee that your notes are legible.
6. The formulary function built into most EMR’s provides the physician will a real time snapshot if a prescription that he/she is about to write is covered by the patient’s health plan and provides alternatives if available.
I have just highlighted only a couple examples of the administrative benefits. There are many more. It is tough to imagine going back to a paper chart.
I have done the math and we could cover our current EMR with the incentives offered through the government initiative.
I will comment that physicians need to be trained on how to use the EMR. You can lose site of the patient and focus the entire visit on the computer versus the patient, however, we teach our physicians that the patient first and then chart completion. We conduct patient satisfaction surveys and I rarely receive a complaint regarding the physician’s time at the computer. I do however, receive praises from patients regarding the ePrescribe as it decreases their wait times when the arrive at the pharmacy, the prescription is ready.
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Okay Readers, it’s your turn – what’s your secret weapon for increasing revenue or decreasing expenses?
Mary Pat
For those of you who have not tapped into the amazing wealth of information generously shared by Frank Cohen, go to his site now and see what he has that could help you.
Most recently Frank analyzed the October 2009 NCCI Edits Release 15.3 and organized the information into meaningful categories as well as providing an executive summary.
As a reminder, the CMS website tells us:
The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits.
Per Frank’s assessment of the 2009 changes effective on October 1:
There are 706 terminated edit pairs but once again, around half have been terminated retrospectively. Two are terminated back to last quarter (7.1.09), 357 back to April, 2009 and 27 all the way back to January, 2009. This means that, if you were denied payment on edit pairs that are part of this last over the past few quarters, you should be able to resubmit and get paid. The big hitters for terminated codes in both column 1 and column 2 fell within the surgical code category (520 and 513, respectively).
For more information, go to Frank’s site here, go to the Download tab and you will see the link at the top of the page.
BUILD ON WHAT YOU’RE CURRENTLY DOING:
1. Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.
2. Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.
3. Set a minimum number of providers to be in the office seeing patients at all times the office is open.
4. Have each provider add one new patient visit to his/her schedule weekly.
5. Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)
6. Report PQRI measures to recoup additional Medicare revenue.
7. Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.
8. Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)
9. If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.
10. If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.
ADD TO YOUR CURRENT SERVICES:
11. Allergy testing & treatment
12. Dispensing pharmaceuticals
13. Dispensing nutriceuticals
14. Dispensing Durable Medical Equipment
15. Group patient visits
16. Coumadin Clinic
17. Heart Failure Clinic
18. Diabetes Education Classes
19. Add primary care to specialty care practices
20. Add specialty care to primary care practices
21. Research
22. Joint Ventures with other practices or hospital
23. Lease space to other entities
24. eVisits (virtual visits or email visits)
25. Elective procedures or services
26. Mid-level providers
27. Walk-in clinic
28. Occupational medicine: drug screens, employment physicals, etc.
29. Hospitalists
30. Medical Director of local nursing homes
31. Complementary & alternative medicine (CAM)
32. Aging in Place services
33. Social worker
34. Concierge practice
35. School team physician
EVALUATE YOUR REVENUE CYCLE MANAGEMENT:
36. Are you renegotiating payer contracts regularly?
37. Do your scheduling staff know how to educate patients about what payers you have contracts with and are in network with and what the patient’s financial responsibility will be?
38. Do staff know what typical new patient charges are to tell the patient?
39. Do you check every patient’s eligibility for insurance benefits immediately prior to every service?
40. Do you have patients sign a financial policy to acknowledge what they are responsible for based on their payer type?
41. Do you copy the patient’s insurance cards at every visit, or at least compare their current card to the card you have on file? Are you able to scan patient insurance cards and driver’s licenses into your practice management (PM) system?
42. Is your PM system able to download the information from the scan into the patient registration screen? If not, do you have a way to confirm that demographic and insurance information has been entered correctly from the cards?
43. Are your charges being posted daily?
44. Does the person who provides the service, or a documentation coding specialist, choose the CPT and ICD9 code?
45. Is the documentation for the charges being completed within 24 hours of the service?
46. Is your encounter form up-to-date with current CPT and ICD9 codes; do you order smaller batches of them so you can change the codes as new services are added in the practice?
47. Do you check the CPT and ICDD9 matching to make sure the codes are valid for the year, the codes adhere to NCCI and LCD edits before you finalize the charges?
48. Do you regularly audit medical records for coding and documentation and give providers feedback on where coding could be improved?
49. Are you using ABNs for Medicare patients who want services that Medicare might not pay for?
50. Do you file claims daily?
51. Do you correct claims daily when they are rejected at the practice management, claims clearinghouse or payer level?
52. Do you correct claims daily when they are rejected at the claim level and are not paid for for reasons that can be corrected?
53. Do you have your contract allowables in your PM system so you know when you are not being paid correctly by contract?
54. Do you appeal unpaid or underpaid claims?
55. Do you check recoupments or requests for refunds from payers and make sure they truly should be refunded?
56. Do you send insurance and patient payments to a lockbox to be scanned and stored digitally for your staff to post from?
57. Do you make payment arrangements in the office for balances after insurance has paid, or payment plans by drafting credit or debit cards?
58. Do you have a policy of not sending statements?
59. Do you collect the patient’s portion of the service at the time of service?
60. Do you collect fees for elective services prior to providing these services?
61. Can your patients make payments online through your website?
62. Do you file a claim with a patient’s estate if they have died?
63. Do you accept cash only from patients who have passed bad checks?
64. Do you accept cash only from patients who have filed bankruptcy with your practice?
65. Do you inadvertently see patients who have been dismissed from your practice?
66. When adding a physician to the practice, do you timeline the credentialing appropriately so the physician can see patients with insurance as well as those without?
67. If your new physician is only partially credentialed with payers, do you have him/her see the patients with payers they are credentialed with and add payers to their schedule load as the credentialing comes through?
68. Do you meet with representatives from your largest payers monthly to establish relationships and bring problems to their attention? (the squeeky wheel theory of payer relations)
69. Are you pre-certing everything that needs pre-certification or pre-authorization or pre-notification to be sure the service will be paid?
70. Are you receiving payments via electronic funds transfer (EFT)?
71. Are you receiving explanation of benefits (EOBs) or remittance advice (RA) electronically?
72. Are you posting your RA electronically?
73. Are you protecting your practice from embezzlement? (see my post on this here.)
74. Is someone in the practice responsible for staying current on changing coding requirements for Medicare, Medicaid, Tricare and commercial payers?
DECREASE EXPENSES:
75. Eliminate overtime. Evaluate the need for additional staff (part-time?) vs. overtime.
76. Send some staff home (sometimes called “low census”) when there are no patients to be seen.
77. Use volunteers. Tap into the local hospital volunteers, or recruit and train your own.
78. Hire an after-school student employee to do routine jobs.
79. Discontinue paying staff for inclement weather closings when the practice is not open.
80. Shop everything. Negotiate existing service contracts. Do not assume anything is non-negotiable. Negotiate the rent.
81. Get rid of yellow pages advertising. It rarely brings you new patients and is primarily a place to look up phone numbers. You will still get your white pages listing free with your phone service.
82. Utilize pre-employment testing to make sure job applicants have the skills you need.
83. Shop postage machines or look into stamps.com.
84. Join a group purchasing entity (hospital, professional association, etc.)
85. Improve your accounting cycle. Invoices and statements are matched up with packing slips and negotiated prices. Use purchase order numbers.
86. Get the payment discount by paying on time or early – ask vendors for an on-time or early payment discount.
87. Make sure office supplies are not going home with the employees. Make sure office supplies that are ordered are “really need” and not “sure would be nice.”
88. Remind patients of their appointments to decrease no-shows. Call patients who no-show and attempt to reschedule (unless they feel better!) Track no-shows and evaluate the reasons for them.
89. Consider charging for no-shows or dismissing patients for no-shows.
90. Have a good recall system in place. If patients leave without scheduling a needed follow-up, make sure that they are called if they have not scheduled within a certain amount of time. Keep track of annual wellness visits and remind patients to schedule them.
91. Take advantage of any discounts offered by your malpractice carrier by completing risk management surveys and having speakers give annual updates on decreasing malpractice claims. Some carriers give discounts for managers who are members of MGMA or Fellows in the ACMPE.
92. Evaluate any discounts on services or products offered by your physicians’ professional associations and societies.
93. Evaluate your leases - are those big old copiers and faxes worth paying for a service contract?
94. Consider speech recognition/voice recognition and eliminate transcription.
95. Review your computer maintenance contracts. Are you paying for maintenance on equipment or software that is no longer being used?
96. Take advantage of online CME for physicians, midlevel providers, clinical staff and managers.
97. Make plans to attend face-to-face seminars well in advance to take advantage of early enrollment discounts and good flight deals.
98. Evaluate outsourcing. Think about outsourcing transcription, coding, billing, pre-authorizations, credentialing, switchboard, payroll, accounting and medical records copying.
99. Replace your answering service with an answering machine educating patients on the limited reasons for calling after hours and giving the number of the physician on call.
100. Destroy archived financial and medical records that you are paying to store, once you have ascertained that they exceed the required time limit.
101. Hold a brainstorming session with the staff and ask for their ideas for increasing revenue and reducing expenses. The people on the front lines will have excellent ideas. In return, do not nickle and dime the staff to death by charging for coffee, reducing parking stipends or eliminating uniform allowances. Keep in mind that for your rank and file staff, having to pay for their own uniforms or paying more for parking might be a deal-breaker that causes them to search for work elsewhere. Try to focus on the bigger items for savings and make sure the staff know you are trying to keep their small benefits in place in appreciation for their work.
Today I was fortunate enough to attend an outreach session designed to educate hospitals, physicians and other providers about Recovery Audit Contractors (RAC), specifically Connolly Consulting, the RAC for North Carolina. Although I cannot vouch that the information I am sharing for Region C will be consistent for the other three RACs, the fact that there is a standard handout being used for all RAC outreach sessions makes me think there’s a very good chance that CMS is encouraging a high level of consistency.
If you read the recent Manage My Practice article here by Carla Hannibal, you already know that the RACs were established after CMS demonstration projects proved “to be successful in returning dollars to the Medicare Trust Funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments.” (CMS website)
Each RAC bid for and won the jurisdiction as follows:
- Region A: CT, DE, DC, MD, ME, MA, NH, NJ, NY, PA, RI, VT Diversified Collection Services (DCS) -1-866-201-0580, website here
- Region B: MN, WI, IL, IN, OH, MI, KY CGI Technologies and Solutions -1-877-316-7222, website here
- Region C: AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV and the territories of Puerto Rico and U.S. Virgin Islands. Connolly Consulting, Inc. -1-866-360-2507, website here
- Region D: WA, OR, ID, CA, NV, MT, WY, UT, AZ, ND, SD, NE, KS, IA, MO, AK, HI HealthDataInsights, Inc.-Part A: 866-590-5598, Part B: 866-376-2319, e-mail: website here
Each RAC is required to provide outreach education sessions in their region prior to sending out any letters. Any hospital or physician who bills fee-for-service programs (Part A and/or Part B) for Medicare beneficiaries is eligible for a RAC audit.
These are the important points that I took away from attending this outreach program:
- RACs may review claims as far back as October 1, 2007.
- RACs review claims after they have been paid using the same Medicare policies used to pay the claim initially.
- There are two types of reviews: Automated Reviews which do not request the medical record and Complex Reviews which will request the medical record.
- Automated Reviews are “done deals” and the claim will be adjudicated and a letter sent detailing the dollars requested.
- Providers may return the payment by writing a check, allowing a recoupment from future payments or may apply for an extended payment plan.
- Complex Reviews entail a request for medical records. Records can be mailed, faxed, or sent on a CD/DVD. Mailed records must be sent in a tamper-proof package, and should be sent via trackable carriers (FedEx, UPS, Registered USPS.) Multiple records may be sent in one package if each record set is in a separate envelope inside the package.
- Note: if faxing, fax the records to yourself to check for readability before you fax to the RAC.
- Email records are currently not acceptable due to HIPAA.
- Providers have 45 days plus 10 mailing days for a total of 55 days to send the records, but extensions are available if this is not abused. If you do not communicate with your RAC about any problems you are having sending the records (e.g. you can’t find the record!), you risk having the claim(s) automatically recouped. The Connolly representative even mentioned something to the effect that she wasn’t above calling the practice/entity CEO to let them know that their contact person wasn’t playing by the rules.
- Once a claim has been reviewed and a Complex Review is in play, the provider will receive a Demand Letter from the RAC and the provider will have a “discussion period” to contact the RAC and ask questions and/or provide additional information. The RAC representative emphasized to communicate, communicate, communicate and to call the RAC and speak to the reviewer of the claim. Once you have spoken to the reviewer, if you still disagree with the decision, you should ask to speak to the supervisor, and if there still is no agreement, you need to file an appeal.
- Appeals must be filed within 120 days of the receipt of the demand letter from the RAC.
Here is a suggested action plan for physician practices to prepare for the RAC process:
- Visit the CMS website here and click on Demonstration Projects to see what improper payments were found by the RAC demonstration projects.
- Visit the CMS and OIG websites to see what improper payments were found by reading the OIG (Office of Inspector General) reports here and CERT (Comprehensive Error Rate Testing) reports here.
- Conduct an internal assessment to see if you are in compliance with Medicare rules, and if not, identify corrective actions needed to bring your group into compliance. Corrective actions may include provider education and a periodic internal audit to rate the improvement.
- Provide your RAC (they will tell you how to do this) with a contact person who will receive RAC letters and who will be the point person for providing the RAC with additional documentation. The RAC will also ask for information about providers and their NPIs, including any providers who were with the group between October 1, 2007 and now, even if the provider is no longer with you. Connolly suggests copying the list of providers you supply to the RAC and placing it in the personnel file of the contact person to be reminded of this important responsibility if this person leaves the organization.
- Develop a basic tracking system for receipt of letters, and activity for each request.
- VISIT YOUR RAC WEBSITE AT LEAST WEEKLY.
I have received lots of questions about what a RAC letter will look like, and the speaker today provided a sliver of information saying that the Region C letters will have the CMS logo at the top of the letter and Connolly’s logo at the bottom of the letter. Because your practice/entity will be providing the RAC with a contact person’s name, unless things are in total chaos at your place of business, the letters will go to the person you’ve entrusted with this important responsibility.
Here are some other questions and answers from the program today:
Q: Does the RAC pay for the copying/mailing for records?
A: They will pay hospitals, but will not pay physicians for record expense.
Q: If a claim is refunded to Medicare, must the patient be refunded their portion?
A: Yes.
Q:What determines which region the practice/entity belongs to for RAC?
A: The state that the practice/entity is located in.
Q: Are patients contacted if their claim is audited?
A: They receive a notice if the claim is adjusted in any way.
Q: I heard that there are consultants selling RAC insurance – is that a good idea?
A: There is no such thing as audit insurance, but there is such a thing as appeal insurance.
Q: Will a claim be audited if a practice/entity self-audits, finds an error and corrects it?
A: As long as an amended claim is filed by the provider, RAC will not audit the claim.
Q:Who sets the guidelines for medical necessity?
A: The medical director of the RAC.
Q: Are the number of claims that can be audited in each period counted by transaction lines (5 per CMS form) or by claim/single CMS form?
A: By transaction lines.
Q: Will the RACs extrapolate their findings?
A: The RACs are entitled to extrapolate their findings if they so choose.
Q: Are the RACs paid on a percentage of their findings?
A: Yes, RACs are paid a percentage of both overpayments and underpayments. The percentage ranges from 9% to 12.50% based on each RAC’s bid.
If this information is new to you, I suggest you click on some of the links provided in this article, start developing your RAC plan, and start educating your providers and staff. This topic is also a good one for sharing of best practices between local and regional groups. To get email updates on RAC from CMS, sign-up here. Remember to bookmark your RAC’s website and visit often!
Photo credit: Milosluz | Dreamstime.com
Bill Moyers spoke with ex-insurance executive Wendell Potter recently, exploring why Potter left CIGNA and is now revealing insider information on how insurance companies maximize profits and influence lawmakers. Potter testified before Congress in June and writes and speaks on his now/new understanding of why insurance companies are lobbying ferociously against a single-payer system. He is now the Senior Fellow on Health Care with the Center for Media and Democracy, of which he says,
“One of the reasons I chose to become affiliated with the Center for Media and Democracy is because of the important work the organization does to expose often devious, dishonest and unethical PR practices that further the self interests of big corporations and special interest groups at the expense of the American people and the democratic principles this country was founded on.”
What I found most interesting is Potter’s discussion on how insurance companies dump businesses by raising premiums absurdly high for those companies whom they determine to have overly-expensive claims. Through the years I have had many meetings with physicians and staff discussing what increased premiums would mean for the practice.
In my earliest days, medical practices typically paid 100% of the employee (and sometimes the dependent) premium for very rich plans. As time went on, practices stopped paying for dependent coverage, started offering tiered plans (paying in full for the lowest tier), then increased co-pays and deductibles, then introduced cost-sharing, and now are offering high-deductible plans and health savings accounts. If I believe Wendell Potter, and I think I do, practice premiums have been raised year after year after year, not because the claims experience of the group was particularly high or off-ratio, but because there were other small businesses whose claim experience was lower, thereby affording the retention of more of the premium dollar by the insurance company.
It’s almost humorous to think of the time I’ve spent evaluating the administrative and customer service received from each insurance company, balancing the out-of-pocket dollars for the employees with the out-of-practice dollars paid by the physicians, trying to make each new yearly plan as palatable to everyone as possible, when offerings were priced in double digits to DISCOURAGE our business!
Possibly the most humorous (or depressing) of all situations is when I am simultaneously negotiating with an insurance company for health insurance for my staff, and negotiating with them for professional fees to provide care to their subscribers. Let us pray that insurance companies don’t decide to get into the food or sunshine business…
Bill Moyers’ Interview with Wendell Potter here.
Wendell Potter’s testimony to Congress here.
