On February 17, 2010 from 2:00PM – 3:30PM ET the Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum (ODF) to discuss Medicare provider enrollment issues. During this call, CMS staff will discuss:

• Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for physicians, non-physician practitioners and provider and supplier organizations
• Provider and supplier reporting responsibilities
• Medicare ordering and referring issues
• Revalidation efforts

Afterwards, there will be an opportunity for the public to ask questions.

Open Door Forum Instructions:

**Capacity is limited so dial in early. You may begin dialing into this forum as early as 1:45 PM ET.**

Dial: 1-800-837-1935
Reference Conference ID 52537484
An audio recording of this Special Forum will be posted to the Special ODF website here and will be accessible for
downloading on or around Monday March 1, 2010 and available for 30 days.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to
view Frequently Asked Questions click here.

I like to get complaints from patients. The best situation is when I have the opportunity to meet face-to-face with the patient when they are in the office.  No, I’m not a glutton for punishment. What I like about complaints is that I get to hear directly from the patient what is bothering them, and I have an opportunity to let a patient know what we’re trying to do in the practice.  Here’s my guide to patient apologies.

Step One: I introduce myself and shake the patient’s hand and the hand of anyone else in the exam room.

Step Two: I sit down. There are two reasons for that. One is to send the message that they do not need to hurry -  this conversation can take as long as they need it to. The second is to place myself physically below the patient.  If they are sitting on the exam table, I will sit in the chair. If they are sitting in the chair, I will sit on the step to the exam table. The message I am sending is “I do not consider myself to be above you.”  It sends a very strong message.

Step Three: I say “I understand we have not done a very good job with __________ (returning your calls, giving you an appointment, getting your test results back to you, etc.)  Can you tell me about it?”  I do not take notes as I want to focus on the patient, but I take good mental notes.  The patient and/or anyone with them needs to be able to talk as long as they want. They might need to tell their story twice or many times to get to the point where they’ve gotten relief.  The patient has to get the problem off their chest before the next part can happen.

Step Four: I apologize, saying “I’d like to apologize on behalf of the practice and the staff that this happened.  I want you to know this is not the way we intend for _______ to work in the practice.”  If anything unusual has been happening, a policy has changed, or new staff have been hired, I let them know by saying “So-and-so has just happened, but that’s not your problem. We know our service has slipped, but we’re hoping we are on the way to getting it fixed.”

Step Five: Answer any questions the patient has. How will you fix this for me?  Why did the policy change? What’s the best way to get an appointment? Are you trying to drive patients away? Are you going to hire more doctors?

Step Six: I offer my name again and a way for them to contact me if they have further problems.

Step Seven: I follow-up on the information the patient has given me to find out where the system broke down or where a new system might need to be developed.

I had the opportunity to apologize twice last week.  It helped me to keep a pulse on the practice, know what patients are struggling with, and of course, practice humility.  All good stuff for a practice manager.

For an excellent article on how doctors can apologize to patients for medical mistakes (AmedNews, February 2010) click here.

As of April 5, 2010, if the ordering/referring provider of goods and services on the CMS-1500 claim is not listed in PECOS and eligible to order/refer, the claim will not be paid.  Your patients may not be able to get the items they need, they may have problems with rented items (going three years back) and hospital discharges may be delayed.  Even if your practice doesn’t fall into any of these categories, you will fall into some Medicare category sooner or later, particularly if you need to inform CMS of any practice changes.

If your providers aren’t in the PECOS database, you should bite the bullet and GET STARTED TODAY!

Some terminology I use in this article:

AO = Authorized Official

CMS = Centers for Medicare & Medicaid Services

EUS – External User Services (for CMS PECOS) Help Desk

MAC = Medicare Administrative Contractor

NPPES = National Plan and Provider Enumeration System (the system that assigns the National Provider Identifier (NPI)

Providers = physicians and non-physician practitioners (I know physicians hate being called “providers”, but there it is.)

Type I NPI = National Provider Identifier for a physician or non-physician practitioner

Type II NPI = National Provider Identifier for a practice or organization

WHAT is PECOS?

PECOS stands for the Provider Enrollment and Chain/Ownership System. It was created by CMS as an electronic portal for Medicare enrollment of physicians, non-physician practitioners, and provider and supplier organizations.

Even though some providers are enrolled in Medicare, their enrollment records might not be in PECOS. If they have not sent in a Medicare application to report any changes to their Medicare enrollment information within the past 5 years, they probably do not have an enrollment record in PECOS. These individuals will need to submit a  Medicare enrollment application. To see if a provider is enrolled in PECOS, check here. If the name is not there, the PECOS enrollment is incomplete or missing.

PECOS is designed to electronically:

• Enroll in the Medicare program
• Make changes to Medicare enrollment information
• View existing Medicare enrollment information
• Withdraw from the Medicare program
• Check the status of an Internet-submitted Medicare enrollment application

While PECOS supports most enrollment application actions, there are some limitations. Providers cannot use PECOS to:

• Change his/her name or Social Security Number, or changes in Taxpayer Identification Number (TIN). These must be done using the paper enrollment application (CMS-855)
• Change an existing business structure or changes in Legal Business Name (LBN). These must be done using the paper enrollment application (CMS-855). An example of a change to a business structure is:
  • A sole owner of an enrolled Professional Association, Professional Corporation, or Limited Liability Company cannot change the business structure to a sole proprietorship; or
  • An enrolled sole proprietorship cannot be changed to a solely-owned Professional Association, Professional Corporation, or Limited Liability Company.
• Reassign benefits to another supplier if that supplier does not have a current Medicare enrollment record in PECOS.
• An enrolled Medicare Part A provider or supplier organization wants to enroll with a Medicare carrier or A/B Medicare Administrative Contractor (MAC) to bill for Part B services. This must be done using the paper enrollment application (CMS-855).

WHY should I use PECOS?

Described as being 50% faster than paper, PECOS will alert the applicant when a response is inadequate or unacceptable, thereby decreasing the possibility of a rejected application.

Going forward, Medicare providers are required to notify Medicare of reportable events within a specific timeframe or risk losing their ability to bill for services provided to Medicare patients. A reportable event is any change that affects information in a Medicare enrollment record. A reportable event may affect claims processing, claims payment, or a provider’s eligibility to participate in the Medicare program.

Effective April 4, 2010, providers are required to report the following changes within 30 days of the following reportable events:

• Change in ownership
• Change in practice location, and
• Final adverse action.

A final adverse action includes: (1) a Medicare imposed revocation of any Medicare billing privileges; (2) suspension or revocation of a license to provide health care by any State licensing authority; (3) revocation or suspension by an accreditation organization; (4) a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(i)) within the last ten years preceding enrollment, revalidation, or re-enrollment; or (5) an exclusion or debarment from participation in a Federal or State health care program.

Providers are required to report the following changes immediately, but not later than 90 days, after the reportable event:

• Change in practice status (e.g., retirement, voluntary surrender of medical license or voluntary withdrawal from the Medicare program)
• Change of business structure, Legal Business Name or Taxpayer Identification Number
• Banking arrangements or payment information
• A change in the correspondence or special payments address

Hopefully, PECOS should make this reporting easier by:

• Reducing the time necessary for provider and supplier organizations to enroll or make a change in their Medicare enrollment information;
• Streamlining the Medicare enrollment process for provider and supplier organizations;
• Allowing provider and supplier organizations to view their Medicare enrollment information to ensure that it is accurate; and
• Reducing the administrative burden associated with completing and submitting enrollment information to Medicare.

So far the above has not been the case, but let’s move on.

WHO needs to enroll in PECOS?

• If you are not enrolled in the Medicare program and want to become enrolled,  you do.
• If you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do. If a provider who is currently enrolled in the Medicare program has not submitted a complete Medicare enrollment application (CMS-855) since November 2003, the Medicare contractor will require the individual or organization to submit a complete CMS-855 in order to update or make a change in their enrollment information.

In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application, which you may do in one of two ways:

1. Using Internet-based PECOS (which transmits your enrollment application to the MAC) AND BE SURE to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application.
2. Filling out the appropriate paper Medicare provider enrollment application(s) (CMS-855I and CMS-855R , if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application. Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site here.

If you are already enrolled in Medicare, make sure you have a current enrollment record in PECOS.  You can find out by:

• Calling your designated carrier or A/B MAC (recommended). Find out who your A/B MAC is here.
• Using PECOS to view your enrollment record.
• Going to Medicare.gov and searching for the provider

If you are a dentist or a physician with a specialty such as a pediatricians who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

WHICH paper enrollment form should be used?

CMS uses five different provider and supplier enrollment applications:

• Part A providers are required to use the CMS-855A to enroll or update their enrollment information;
• Part B suppliers (except suppliers of Durable Medical Equipment, and Prosthetics, Orthotics, and Supplies (DMEPOS)) are required to use the CMS-855B to enroll or update their enrollment information;
• Physicians and non-physician practitioners are required to use the CMS-855I to enroll or change their enrollment information;
• DMEPOS suppliers are required to use the CMS-855S to enroll or update their enrollment information.
• Individual practitioners who would like to reassign their benefits to an eligible provider or supplier or terminate an existing reassignment agreement would use the CMS-855R.

You should file a CMS-855A (pdf) with the designated MAC if you would like to enroll your organization in the Medicare program as one of the following types of providers.

• Community Mental Health Center
• Comprehensive Outpatient Rehabilitation Facility
• End-Stage Renal Disease Facility
• Federally Qualified Health Center
• Histocompatibility Laboratory
• Home Health Agency
• Hospital
• Hospice
• Indian Health Services Facility
• Organ Procurement Organization
• Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services
• Religious Non-Medical Health Care Institution
• Rural Health Clinic
• Skilled Nursing Facility

You should file a CMS-855B (pdf) with the designated MAC if you would like to enroll in the Medicare program as one of the following types of suppliers:

• Ambulance Service Supplier
• Ambulatory Surgical Center (site visit or state survey typically required)
• Clinic and Group Practices
• Hospital Departments
• Multi-Specialty Clinic
• Public Health/Welfare Agency
• Physical/Occupational Therapy Group in Private Practice
• Single Specialty
• Independent Clinical Laboratory
• Independent Diagnostic Testing Facility (site visit or state survey typically required)
• Mammography Center
• Mass Immunization – roster biller only
• Portable X-ray Facility (site visit or state survey typically required)
• Radiation Therapy Center
• Slide Preparation Facility
• Voluntary Healthy/Charitable Agency

You should file a CMS-855I (pdf) with the designated MAC  if you would like to enroll in the Medicare program as one of the following types of providers.

• Physicians (all specialties)
• Non-Physicians
  • Anesthesiology Assistant
  • Audiologist
  • Certified Nurse Midwife
  • Certified Nurse Specialist
  • Certified Register Nurse Anesthetist
  • Clinical Social Worker
  • Mass immunization, roster biller (individual only)
  • Nurse Practitioner
  • Occupational Therapist in private practice
  • Physical Therapist in private practice
  • Physician Assistant
  • Psychologist, Clinical
  • Psychologist, billing independently
  • Registered Dietitian or Nutrition Professional

NOTE!! If you are enrolled in Medicare and your NPPES record is correct, you are not re-enrolling, you are revalidating, an important distinction in terminology. The word on the street is that it seems to be easier to revalidate via paper by completing the CMS-855 and writing “REVALIDATION” in the upper margin of the first page.

WHAT information is needed for a PECOS enrollment?

Below is a list of the types of information needed to complete an initial enrollment action using PECOS. This information is similar to the information needed to complete a paper Medicare enrollment application. You may find it useful to print and review the CMS-855 paper enrollment application before initiating an Internet-based PECOS enrollment action.

• An active National Provider Identifier (NPI).
• The NPI of the Practice (PA, PC, or LLC)
• National Plan and Provider Enumeration System (NPPES) User ID and password.
• Personal identifying information. This includes legal name on file with the Social Security Administration, date of birth, Social Security Number
• Professional license and certification information. This includes information regarding the physician’s or non-physician practitioner’s professional license, professional school degrees or certificates.
• Practice location information. This information includes information regarding the practitioner’s medical practice location, the legal business name of a solely-owned Professional Association, Professional Corporation, or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575
• Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
• A photocopy of the CP-575 form;
• If applicable, information regarding any final adverse actions. A final adverse action includes: (1) a Medicare-imposed revocation of any Medicare billing privileges; (2) suspension or revocation of a license to provide health care by any State licensing authority; (3) revocation or suspension by an accreditation organization; (4) a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding enrollment, revalidation, or re-enrollment; or (5) an exclusion or debarment from participation in a Federal or State health care program.

The following forms are routinely submitted with an enrollment application:

• Electronic Funds Transfer (EFT) Authorization Agreement (Form CMS 588)
• Medicare Participating Physician or Supplier Agreement (Form CMS 460)

HOW do you enroll in PECOS?

There are three basic steps to completing an enrollment action using Internet-based PECOS. Providers must:

1. Have an active National Provider Identifier (NPI) and have a web user account (User ID/Password) established.  For security reasons, providers should change passwords periodically, at least once a year. If you/your provider needs help in changing your password, contact the NPI Enumerator at 1-800-465-3203 or send an email to customerservice@npienumerator.com.
2. Go to Internet-based PECOS by clicking on this link and complete, review, and submit the electronic enrollment application via Internet-based PECOS.
3. Print, sign and date the 2-page Certification Statement for each enrollment application submitted and mail the Certification Statement and all supporting paper documentation to the Medicare contractor within 7 days of electronic submission. Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated Certification Statement. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed Certification Statement that is associated with the Internet submission. The Certification Statement must be signed by the provider enrolling or making changes to enrollment information. Signatures must be original and in ink (blue ink recommended). Copied or stamped signatures will not be accepted.  NOTE: CMS encourages providers to print and retain a copy of the enrollment application for their records, however providers should only mail the 2-page Certification Statement and supporting documentation to the designated Medicare contractor.

HOW can managers facilitate the enrollment?

• Look at your original Medicare application to see who is the “authorized official”. The Authorized Official (AO) may be theprovider, or may be the owner of the practice, or the CFO of the hospital, in the case of a hospital-owned practice.  The AO (in an original application) may be registered through PECOS and an approval email will be issued in 3-4 weeks. Print the screen that provides the tracking ID.  You will need to refer to it in the future.
• If you do not have a copy of your organization’s original Medicare enrollment information and do not know who has been designated as your organization’s “authorized official”, an owner of your practice must submit a written letter on the organization’s letterhead to your Medicare contractor authorizing the release of that information.  Medicare contractors are not allowed to release such information over the telephone or in an e-mail, and neither are they allowed to release it to practice staff.
• The organization AO goes into PECOS Identification & Authentication (I & A) and registers. As part of this process, the AO must mail a photocopy of the CP-575 to the CMS EUS Help Desk so that the Help Desk can verify the organization provider/supplier. Print the screen that provides the tracking ID.  You will need to refer to it in the future.
• The Help Desk verifies both the organization provider/supplier and the AO, and approves the AO’s registration. The AO receives a system-generated e-mail indicating that the registration has been approved.
• Once the AO receives this notification, the AO can let the end-user know that he/she can register in PECOS.
• The end-user goes into PECOS I&A and registers. The registration request will be directed to the AO of the provider/supplier organization.
• The AO must approve or reject the end-user in PECOS I&A.
• Once the end-user has been approved in PECOS I&A by the AO for access on behalf of the organization provider/supplier, the end-user will receive a system-generated e-mail indicating that he/she has been approved.
• The end-user then logs into PECOS and downloads the Security Consent Form. He or she fills it out, obtains the signature/date of signature of the AO, and mails the completed Security Consent Form to the CMS EUS Help Desk at P.O. Box 792750, San Antonio, TX 78216.
• The Help Desk verifies the information on the Security Consent Form and also calls the AO to verify that the AO did, in fact, sign the Security Consent Form.
• Once the information on the security Consent Form has been confirmed, the Help Desk approves the Security Consent Form in PECOS and an e-mail is sent to the AO notifying the AO that the end user’s organization has been approved to use Internet-based PECOS on behalf of the organization provider/supplier.
• It is the AO’s responsibility to notify the end-user’s organization that the end-user can now use Internet-based PECOS. An e-mail is sent to the AO (step 9) because the AO is ultimately responsible for the enrollment information and who has access to that enrollment information. It is the AO’s responsibility to inform the end-user that the Security Consent Form has been approved.

TO RECAP:

• Providers, if you search for yourself at Medicare.gov and cannot find your record, you do not have a PECOS record – it is either missing or incomplete.  Call Provider Enrollment at Medicare or your MAC for help.
• If you do not have a PECOS record, send in a paper enrollment or complete the online (PECOS) enrollment.
• The prerequisite for getting a PECOS record is to have a NPPES record.  Make sure you have your NPPES login and password and that your record (Type I NPI) is correct.  Your organization also needs an NPPES record (Type II NPI), and make sure your organization name on the NPPES record matches the name on your IRS letter.

RESOURCES

Read about PECOS in downloadable documents section: Downloads for PECOS

The AMA and MGMA have published an absolutely excellent resource:  “The Medicare Provider Enrollment Toolkit” available here for MGMA members. Enter “Medicare Enrollment” in the search box.

The CMS External User Services (EUS) Help Desk contact information for providers and suppliers using PECOS can be found here (pdf) on the CMS website. The Help Desk hours of operation are Monday – Friday, from 6 a.m. to 6 p.m. Central Standard Time. The Help Desk toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com. Questions about accessing and using PECOS should be directed to the CMS EUS Help Desk, although I have heard lots of complaints about long wait times and conflicting advice.

The Medicare Learning Network has a listserv that will keep you updated on all the CMS news here.

Readers: Please share any clarifying information or tips from your enrollment experiences with everyone.  Leave a comment and share the wealth!

Sometimes in the midst of making changes to improve things,
we inadvertently lose the patient.

Sometimes we literally lose the patient because they say
“Everything is changing and I don’t like it – I’m taking my business elsewhere.”

Sometimes we figuratively lose the patient because they feel a distance in not connecting with the staff, or not understanding why things are changing.

How do we hold on to our patients when all around us the world is changing, healthcare is changing and we are changing to stay alive financially and competitively?

•    Focus on each patient you come in contact with and look into their eyes. We forget to look into people’s eyes. If you find yourself not connecting with a patient, ask yourself what color eyes the patient has. In checking, you will connect.

•    Remind yourself of the preciousness of life and of each life you come in contact with.  The job is do are not just “any” job. We are fortunate to do jobs where we are entrusted with people’s most precious possession – their health and their lives.  We are not telemarketers, we are not selling widgets, and we are making a difference in this world. Don’t forget that – YOU are making a difference. No matter how your job touches a life directly or indirectly, you are in healthcare, one of the most challenging and meaningful jobs out there.

•    Even though we sometimes shake our heads over patient expectations, we can still do our best to let patients know that we are sorry when we cannot do what they are asking. We can’t always see everyone who wants to be seen today.  We can’t always get their forms completed, or their medical records copied, or their test results reported back to them immediately, but we can express the understanding that their needs are important to us.

•    Give everyone the benefit of the doubt.  Believe they are human and doing the best they can.

•    Do not think I expect perfection. I don’t. I expect each of you to do the best you can, but I do not expect perfection of myself and I don’t expect it of you.

Thank you for being in healthcare with me.

Mary Pat

Medicare is a federal health insurance program created in 1965 for:

• people age 65 or older,
• people under age 65 with certain disabilities, and
• people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Medicare Part A - 99% of patients don’t pay a premium for Part A (hospital insurance) because they or a spouse already paid for it through their payroll taxes while working. The $1,100 deductible for 2010, paid by the beneficiary when admitted as a hospital inpatient, is an increase from 2009.   Part A helps cover:

• inpatient care in hospitals (excluding the physician fees), including critical access hospitals
• skilled nursing facilities (not custodial or long-term care)
• some hospice care
• some home health care

Medicare Part B – Part B (outpatient/doctor insurance) base premium for 2010: $96.40/month (no change from 2009.)  Premiums are higher for single people over 65 making more than $85K per year and for couples making over $170K.  Part B premiums cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over.  The remaining Part B costs are financed by Federal general revenues.  In 2010, the Part B deductible is $155.  Part B helps cover:

• physician fees in the hospital
• physician fees in their offices and other outpatient locations
• other outpatient services (x-rays, lab services)
• some services of physical and occupational therapists
• some home health care

Medicare Part C – Medicare now offers beneficiaries the option to have care paid for through private insurance plans.  These private insurance options are part of Medicare Part C, which was previously known as Medicare+Choice, and is now called Medicare Advantage. Medicare Advantage expands options for receiving Medicare coverage through a variety of private insurance plans, including private fee-for-service (PFFS) plans, local health maintenance organizations (HMOs) and regional preferred provider organizations (PPOs), and through new mechanisms such as medical savings accounts (MSAs), as well as adding payment for additional services not covered under Part A or B. Here is a great article by Maria Todd on how Medicare Advantage plans get paid.
Medicare Part D -  Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare.  The so-called “doughnut hole” is the amount the patient pays between the initial coverage limit of $2,830 and the out-of-pocket threshold of $4,550 – a total of $1720 that the patient is responsible for.

• Initial Deductible: $310
• Initial Coverage Limit: $2,830
• Out-of-Pocket Threshold: $4,550

COMPARISON OF MEDICARE PLANS

Original Medicare Plan

WHAT? The traditional pay-per-visit (also called fee-for-service) arrangement available nationwide.

HOW? Providers can choose to participate (“par”) or not participate (“non-par”.)  Participating providers accept the Medicare allowable and collect co-insurance (20% of the allowable.) Reimbursement comes to the providers.  Non-participating providers may charge 15% more (called the “limiting” charge) than the Medicare allowable schedule, but the patient will receive the check, which is why some non-par practices require payment at time of service for Medicare patients. To be able to charge patients for non-covered services, patients must sign an ABN before the service is provided.

Original Medicare Plan With Supplemental Medigap Policy

WHAT? The Original Medicare Plan plus one of up to ten standardized Medicare supplemental insurance policies (also called Medigap insurance) available through private companies.

HOW? Medigap plans may cover Medicare deductibles and co-insurance, but typically will not cover anything Medicare will not.  Medicare primary claims will “cross-over” to many Medigap secondary claims so the practice does not have to file the secondary Medigap claim.  Patients may still have a small balance that is cost-prohibitive to bill for.

Medicare Coordinated Care Plan

WHAT? A Medicare approved network of doctors, hospitals, and other health care providers that agrees to give care in return for a set monthly payment from Medicare. A coordinated care plan may be any of the following: a Health Maintenance Organization (HMO), Provider Sponsored Organization (PSO), local or regional Preferred Provider Organization (PPO), or a Health Maintenance Organization (HMO) with a Point of Service Option (POS).

HOW? You have to have signed a contract or be grandfathered in (called an “all-products” clause) under an existing contract to see patients and get paid. Primary care providers may have to provide referrals and/or authorization for specialty services and providers. A PPO or a POS plan usually provides out of network benefits for patients for an extra out-of pocket cost.

Private Fee-For-Service Plan (PFFS)

WHAT? A Medicare-approved private insurance plan. Medicare pays the plan a premium for Medicare-covered services. A PFFS Plan provides all Medicare benefits. Note: This is not the same as Medigap.

HOW? Most PFFS plans allow patients to be seen by any provider who will see them. PFFS plans do not have to pay providers according to the prevailing Medicare fee schedule or pay in 15 days for clean claims.  Providers may bill patients more than the plan pays, up to a limit. It would be a good thing to notify patients if your practice intends to bill above the plan payment.

Need more?  Click on CMS (provider-oriented) or Medicare (patient-oriented.)

I’ve had lots of questions about financial policies since I did a webinar on patient collections last year.  Here’s a short course on developing a new financial policy for your practice.  The topic is addressed more comprehensively in my book.

I dislike financial policies that are long and wordy.  I prefer a simple format that everyone can understand and use.

The format I recommend is one with three columns titled:

1. Your Plan
2. What You Do
3. What We Do

Here’s an example of how the three columns would read:

Your Plan

Medicare

What You Do

Pay your deductible ($155 for 2010) and co-insurance (20% of the allowable.)

What We Do

We will file Medicare for you.

I use the front of the financial policy to list all the variations of plans that the practice accepts.  For instance, the Medicares might include:

• Medicare
• Medicare/Medicaid
• Medicare/supplemental policy
• Medicare Advantage Plan (HMO/PPO)
• Medicare Advantage Plan (PFFS)
• Medicare secondary (MSP)
• Railroad Medicare

Lump together any like plans that you will treat the same.  Then decide what you will expect from the patient at time of service or after, and what the practice commits to doing. Don’t forget to address patients being seen out-of-network and self-pay patients.

I use the back of the policy to cover everything that you would like the patient to sign off on. This could include:

• Receipt of Notice of Privacy Policies
• Receipt of Advance Directives/Living Will info
• Agreement to Financial Policy
• Assignment of Benefits to Practice
• Guarantee of Payment

When you put a new policy in place, you have a number of options to educate patients. Here are some:

• Put the policy on your website.
• Send a copy of the policy to all new patients.
• Discuss the policy when you call patients to remind them of their appointment.
• Discuss the new policy at check-in and/or check-out and let patients know it will be in effect at their next visit.
• Circle the patient’s plan on the front, have the patient sign the financial policy on the back, and give them a copy to take with them.

How you decide to educate the patients will depend on how much time you have between making the appointment and seeing the patient and the type of practice you have – primary care versus sub-specialty.

Also, don’t forget to educate your staff.  If they have not had to discuss money before, they will need some coaching and some practice.

If you’d like a free copy of my sample financial policy, shoot me an email at marypatwhaley@gmail.com.

You probably can’t.

But that doesn’t mean I haven’t been guilty of trying to in the past. I have typically had a policy in my personnel handbook saying staff can be terminated for discussing wages. But should you really follow through with that threat? Some managers probably have, but I wonder if it is just a convenient excuse to terminate an employee. I would not terminate an employee because s/he did something that is so, well, human.

Employees are going to talk and most will compare wages because they are anxious to know if they are being treated fairly or if someone else in a comparable job is making more per hour. Fair is a word I formerly hoped would be used to describe me as a manager, but the longer I work managing staff, the less I really believe there is a “fair.” There is no absolute fair in my mind because it is very difficult to treat two people exactly the same.  No two people have exactly the same training, experience and talents, or attitude, so trying to place an exact value on their services is difficult. Each of us believes we bring something special to the job, but how does one assess that quality?

The best that can be done, I believe, is to be ready to justify and defend why you are paying any staff member what you are paying them.  Be ready for that question, as it is sure to come.

Photo credit: © Elvinstar | Dreamstime.com

I sat at the checkout desk in my practice last week for the first time and as always, it was a revelation.  If you haven’t worked your check-in and check-out desks recently, I highly recommend it.

An insured patient that I checked out was shocked when I said the charge for her visit was $100.  She said, “But he was only in the room for ten minutes!”  I was briefly at a loss for words.  I recovered, we agreed on a payment plan, I made a note on her encounter form for the billing office and she left.

I’ve been thinking about our conversation, and thinking about what that $100 is supposed to cover…

1. First, we scheduled the appointment, which was a work-in, so it took several people to take the message, pull the medical record (paper charts), call the patient to assess the problem, determine the need for the appointment and schedule it.
2. When the patient arrived, we checked to make sure her address and phone were the same, quickly checked her eligibility to make sure the insurance on file was still in force, and asked for a photo ID for red flags.  An encounter form was generated at the nurse’s station to notify her of the patient’s arrival.
3. The nurse called her from the reception area, weighed her, and took her into an exam room to take her vitals, take a brief chief complaint, review the medications she is taking and check to see if she needed any chronic medication refills while she was there.
4. The physician came in to see her, asked about any changes since she’d last been seen, reviewed her history of present illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems.
5. He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her.
6. He marked the encounter form with the level of service and her diagnoses and gave her the form to take to the check-out desk.
7. He refiled the medication reconciliation in the chart, finished documenting the visit, and placed the chart in the bin to be refiled.  The chart was filed, and the encounter form was sent to the billing office.
8. At the billing office the charges and any payment was posted and the claim was filed.  If there was no problem with the claim, it electronically passed through two scrubs and a final one at the payer.
9. If payment was not denied for any of a dozen reasons, the payment would arrive at the billing office and would be posted.
10. Since the patient did not pay at the check-out desk, the patient-responsible balance is billed to the patient.  If the patient pays on the first statement, it has taken 45 to 60 days to receive complete payment.  Since the patient has BCBS, there is a negotiated rate, so the payment will not even total $100.

I know that patients often say “But he only spent 10 minutes with me.”  Checking back with the provider, I find it was typically longer.  Patients tend to underestimate the time as it goes very fast.

The total visit encompassed the work of the phone operator, the medical records clerk, the triage nurse, the check-in person, the nurse, the doctor, the check-out person and the biller.  It took 8 people, and at least 45 minutes of work to make that appointment happen.  Plus, that visit had to help pay the expenses for the rent, the utilities, malpractice insurance, medical supplies, computers, phones and janitorial services.

The practice, the patients and the overseers of healthcare want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.

Photo credit: © Oleg Pidodnya

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:

1. 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.
2. The allowables for the payers with whom you have contracts and have agreed to accept their rate for their subscribers.
3. 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:

1. 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.
2. 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.
3. 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.