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General Billing Tips

Top 5 Don’ts of Medical Billing

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Flaws in the medical billing process can cripple your RCM and burn a hole in your pocket. Know the top five don’ts of billing to avoid bottlenecks in the revenue collection.

Medical billing has direct connection with your RCM. Minor mistakes can delay the process of getting the desired reimbursements from insurance companies. So, to have a smooth revenue cycle and track-able flow of money, avoid the following ten billing mistakes.

1. No Document No Billing

When you have nothing to prove your claims, refrain from billing the same and I am not indicating malpractice here! Consider this, you have a genuine suffering patient but he doesn’t have his symptoms documented by the physician and thus, in the records too. Now, you have incurred losses alright but how do you convince the payer?

2. Club the Particulars of the Bill

A visit to the doctor involves all these things together: diagnosis, tests for ruling out conditions or pinpoint diseases, the treatment, prescription of medicines, other services to assist the treatment. So, it is important to club all of these together when billing.

3. Do Code When There’s a Code

There is a reason why a certain code exists in the CPT to describe the patient’s condition. Having proper knowledge of which code to assign plays an important role in not getting a denial. Hence, the billing staff should assign the precise code instead of a non-specified one.

4. Be Lenient with Modifiers

A modifier is an alpha numeric code which should be assigned when multiple services are performed on the patient under special or unusual circumstances. Do not forget to add E&M (Evaluation and Management) coding when clubbed with any kind of surgery.

5. Submit Non-Standardized Forms

Bills should be submitted in the proper format and that very much includes the prescribed forms, e.g. the CMS-1500. This is as far as the hardcopy submissions are concerned. As for the electronic records are concerned HIPAA rules should be diligently followed to avoid audits.

 

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sing Personal Stories to Heighten Interest in Medicaid and CHIP Enrollment

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Personal stories resonate. They grab our attention and reel us in. For parents who may not know about Medicaid or the Children’s Health Insurance Program (CHIP), hearing about other families – like Shellie’s recently highlighted on the U.S. Department of Health and Human Services blog – who obtained health coverage for their children and teens through these programs can spark interest. It can even drive parents to take the first step toward enrollment by visiting websites such as InsureKidsNow.gov or HealthCare.gov, calling national or local assistance lines for more information or attending an enrollment event.
Parents who have enrolled their children – and themselves – in Medicaid or CHIP can be great ambassadors for your organization’s outreach efforts. A personal story can be especially powerful in bringing program facts to life. See how the Valles family obtained health coverage for their kids when they went grocery shopping and stopped by an enrollment table hosted by the Children’s Defense Fun-TX  (CDF-TX). CDF-TX’s storybanking expertise was featured on a Campaign webinar on April 3, 2014, “Enrolling Eligible Children & Teens in Medicaid and CHIP Year Round.”

Identifying Parents with Personal Stories to Share
Here are a few tips for identifying and vetting families with personal stories:

·         To identify families with compelling personal stories, connect with organizations and trained assisters who help eligible individuals enroll in Medicaid and CHIP. People who help families enroll are likely to have established trust and have a good rapport with them. Ask enrollment assisters for basic information about the family to help you determine if the story is a good fit for your organization’s outreach efforts.
·         Once you identify a family with a story to share, set up a one-on-one conversation to get more information. Ask how the family learned about Medicaid and CHIP and whether they got help enrolling in the program or enrolled on their own. Ask for details that can help others identify with the story – for example, does the enrolled child have any particular health problems? Seek specific examples of how enrollment in Medicaid or CHIP has improved the family’s quality of life. You may have to ask some sensitive questions about their worries before health insurance and how they managed to get through illnesses, along with questions about household income to confirm that they are eligible for Medicaid and CHIP in your state.

Working with Media Outlets
Having at least one or two families that are willing to talk to the media can increase the likelihood that your organization and your issue will be featured by local news outlets. Personal stories, such as this one shared by a parent with a child receiving CHIP coverage during a recent radio interview featuring Positively Kids in Las Vegas, NV, may be a “news hook” and can demonstrate the relevance of the story to the local community. Always obtain the family’s permission before sharing their information with the media, each and every time. Don’t assume that family members will be comfortable meeting the news team at their home, workplace or school. Always confirm with the family before suggesting a location to a reporter. Listen carefully during these conversations, if someone seems uncomfortable, don’t push the person to give the interview.

Before introducing a family spokesperson to a media contact, make sure he or she feels comfortable sharing his or her story and responding to questions. For all media interactions, encourage your spokespeople to speak clearly and with confidence, stay on the topics you practiced and smile when appropriate. When possible, join the family for the interview to help respond to difficult questions about the program and jump in if the spokesperson is struggling for an answer or has veered off topic. Campaign Resources: Check out this Connecting Kids to Coverage Back-to-School Booster, or watch the recorded webinar “Using Media to Amplify Outreach and Enrollment Efforts” for tips on media outreach.

Campaign in Action – Health Care for All (MA)
Health Care for All in Massachusetts uses personal stories to generate media coverage and reach the diverse families in their community. After identifying and confirming the stories of Spanish- and Portuguese-speaking families, Health Care for All features them in language-specific newspapers or on radio shows. Health Care for All helps the families prepare to speak to the media and have their stories featured in written materials and on the news. Families may also attend public events to share their experiences with other eligible families. Campaign Resources: Check out our Outreach Video Library to learn more about how Health Care for All effectively reached out to ethnic media outlets and faith-based communities to execute a successful phone-a-thon.

Other Helpful Resources
Several organizations that have additional tools and helpful ideas on effective storybanking:

·         Community Catalyst has an online guide on storybanking, with resources, such as a sample discussion guide.
·         Families USA has a PDF guide that provides a step-by-step process for gathering stories. If your organization does in-person enrollments, you may also want to listen to Families USA’s May 14, 2014webinar specifically geared to help enrollment assisters start story banks.

Stay Connected With the National Campaign – In 3 Easy Steps
· Follow the Campaign on Facebook and Twitter. Don’t forget to re-tweet or share our messages with your network or use our #Enroll365 hashtag in your posts.
· Share our materials widely. We have more than 50 National Campaign resources available, including translated print materials, to use in outreach and enrollment efforts.
· Contact us to get more involved with the National Campaign at InsureKidsNow@fleishman.com or 1-855-313-KIDS (5437).

 

 

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New Affordable Care Act tools and payment models deliver $372 million in savings, improve care

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Pioneer ACO Model and Medicare Shared Savings Program ACOs part of plan to improve care and lower health costs across the health system
The Centers for Medicare & Medicaid Services (CMS) today issued quality and financial performance results showing that Medicare Accountable Care Organizations (ACOs) have improved patient care and produced hundreds of millions of dollars in savings for the program.
In addition to providing more Americans with access to quality, affordable health care, the Affordable Care Act encourages doctors, hospitals and other health care providers to work together to better coordinate care and keep people healthy rather than treat them when they are sick, which also helps to reduce health care costs. ACOs are one example of the innovative ways to improve care and reduce costs. In an ACO, providers who join these groups become eligible to share savings with Medicare when they deliver that care more efficiently.
ACOs in the Pioneer ACO Model and Medicare Shared Savings Program (Shared Savings Program) generated over $372 million in total program savings for Medicare ACOs. The encouraging news comes from preliminary quality and financial results from the second year of performance for 23 Pioneer ACOs, and final results from the first year of performance for 220 Shared Savings Program ACOs.
Meanwhile, the ACOs outperformed published benchmarks for quality and patient experience last year and improved significantly on almost all measures of quality and patient experience this year. (Please see the accompanying fact sheet for additional details.)
“We all have a stake in improving the quality of care we receive, while spending our dollars more wisely,” Health and Human Services Secretary Sylvia M. Burwell said. “It’s good for businesses, for our middle class, and for our country’s global competitiveness. That’s why at HHS we are committed to partnering across sectors to make progress.”
This news comes as historically slow growth in health care costs is continuing. Health care prices are rising at their lowest rates in nearly 50 years, Medicare spending per beneficiary is currently falling outright, and, according to a major annual survey released last week, employer premiums for family coverage grew just 3.0 percent in 2014, tied with 2010 for the lowest on record back to 1999.
Since passage of the Affordable Care Act, more than 360 Medicare ACOs have been established in 47 states, serving over 5.6 million Americans with Medicare. Medicare ACOs are groups of providers and suppliers of services that work together to coordinate care for the Medicare fee-for-service (FFS) beneficiaries they serve and achieve program goals.
ACOs represent one part of a comprehensive series of initiatives and programs in the Affordable Care Act that are designed to lower costs and improve care by advancing three key strategies for improving care while investing dollars more wisely: incentives, tools, and information.
Incentives
We are interested in advancing efforts to strengthen incentives to reward higher value care rather than higher volume of care. The Center for Medicare and Medicaid Innovation, created by the Affordable Care Act, is testing new models of care in two of the biggest health insurance plans in the world – Medicare and Medicaid. One example is ACOs, where groups of health care providers receive a financial incentive for coordinating care delivery. As we announced today, they are already seeing success. By working with state and private partners, we can drive more improvement through supporting payment models that reward higher quality care.
Tools
We recognize that giving providers and states the tools and capacity for change in the health care delivery system is crucial to the success of these efforts. The HHS Office of the National Coordinator for Health Information Technology and CMS are managing $27 billion in funding from the American Recovery and Reinvestment Act of 2009 and other sources to promote the adoption of electronic health records (EHR) in hospitals and doctor’s offices. More than 75 percent of eligible health care professionals, and over 90 percent of eligible hospitals, have already qualified for EHR incentive payments for using certified EHR technology to meet the objectives and measures of the program.
And HHS is providing technical assistance and grants in areas such as practice design and transformation, supporting states in leveraging state-wide alignment towards value in health spending, and recruiting and training a world-class health care workforce.
Information
The more we empower doctors and patients with information, the better choices they are able to make about their care. HHS has set out to improve the flow of information for consumers, providers, and payers by, for example, releasing more Medicare data, and supporting the ability of health information technology systems to talk to each other for patients’ benefit.
For fact sheets on Pioneer ACO Model and Medicare Shared Savings Program ACOs results, and delivering better care at lower cost, please visit: http://www.cms.gov/Newsroom/Search-Results/index.html?filter=Fact%20Sheets.

Source: http://www.hhs.gov/news/press/2014pres/09/20140916a.html

CMS News

National Partnership to Improve Dementia Care exceeds goal to reduce use of antipsychotic medications in nursing homes: CMS announces new goal

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Date: 2014-09-19

Coalition provides tools and support to achieve continued decreases
The National Partnership to Improve Dementia Care, a public-private coalition, today established a new national goal of reducing the use of antipsychotic medications in long-stay nursing home residents by 25 percent by the end of 2015, and 30 percent by the end of 2016. The coalition includes the Centers for Medicare & Medicaid Services (CMS), consumers, advocacy organizations, providers and professional associations.
Between the end of 2011 and the end of 2013, the national prevalence of antipsychotic use in long-stay nursing home residents was reduced by 15.1 percent, decreasing from 23.8 percent to 20.2 percent nationwide. The National Partnership is now working with nursing homes to reduce that rate even further.
“We know that many of the diagnoses in nursing home residents do not merit antipsychotics but they were being used anyway,” said Patrick Conway, M.D., deputy administrator for innovation and quality and the CMS chief medical officer. “In partnership with key stakeholders, we have set ambitious goals to reduce use of antipsychotics because there are – for many people with dementia – behavioral and other approaches to provide this care more effectively and safely.”
Coalition members, including AMDA – The Society for Post-Acute and Long-Term Care Medicine, American Health Care Association (AHCA), LeadingAge and Advancing Excellence in America’s Nursing Homes, are committed to achieving these new goals. The groups set these goals because they are challenging, yet achievable with the continued hard work of many stakeholders. These goals build on the progress made to date and express the coalition’s commitment to continue this important effort. The National Partnership seeks to optimize the quality of life for residents in America’s nursing homes by improving care for all residents, especially those with dementia.
“We have created many tools for nursing homes to use to help achieve these goals,” said Dr. Conway. “Ultimately, nursing homes should re-think their approach to dementia care, re-connect with the person and their families, and use a comprehensive team-based approach to provide care.”
While the initial focus is on reducing the use of antipsychotic medications, the Partnership’s larger mission is to enhance the use of non-pharmacologic approaches and person-centered dementia care practices. CMS will monitor the reduction of antipsychotics as well as the possible consequences. For example, CMS will review prescriptions of anxiolytics and sedative/hypnotics to make sure nursing homes do not just replace antipsychotics with other drugs. In addition, CMS will review the cases of residents whose antipsychotics are withdrawn to make sure they don’t suffer an unnecessary decline in functional or cognitive status as a nursing home tries to reduce its usage.
Some states have achieved significant reduction in their rate of antipsychotic usage. For example, Georgia reduced its rate by 26.4 percent and North Carolina saw a 27.1 percent reduction. CMS released a fact sheet today with full state-by-state data as well as other data from the program.
CMS and its partners are committed to finding new ways to implement practices that enhance the quality of life for people with dementia, protect them from substandard care and promote goal-directed, person-centered care for every nursing home resident. The Partnership has engaged the nursing home industry across the country around reducing use of antipsychotic medications with momentum and success in this area that is expected to continue. In 2011, Medicare Part D spending on antipsychotic drugs totaled $7.6 billion, which was the second highest class of drugs, accounting for 8.4 percent of Part D spending.
In addition to posting a measure of each nursing home’s use of antipsychotic medications on the CMS Nursing Home Compare website, in the coming months CMS plans to add the antipsychotic measure to the calculations that CMS makes for each nursing home’s rating on the agency’s Five Star Quality Rating System.

Source: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-09-19.html

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Top Healthcare Technology Tools and Trends of 2013

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One year ago, physician practices were singing the praises of tablets, patient portals, and cloud-based EHRs. Not to be outdone, 2013 also brought in some great technology and tools to medical practices. Here’s a look back on what, technology-wise made doctors’ “hot” lists this year.
1. Security: Blame it on the passage of the more-stringent HIPAA Omnibus Rule, the growth in healthcare data breaches, or the influx of tablet-wielding physicians who use theirs to log into their EHR — privacy and security took center stage in 2013. And so did the number of products available to physicians that wanted to make sure protected health information (PHI) stayed protected. “The three biggest security technologies this year that created sighs of relief all over the country were privacy monitoring, data-loss prevention, and encryption [tools],” said Mac McMillan, CEO, CynergisTek. “Those healthcare entities that deployed these technologies in their enterprises learned firsthand the power and confidence of proactive security.”
2. Meaningful use: It’s been a few years since CMS released its EHR Incentive Program, and many physicians are still striving to meet Stage 1 rules for “meaningful use.” Some are even preparing for Stage 2, which will require more proof of patient engagement, care coordination, and information exchange. And technology decisions were largely centered around meeting meaningful use incentives, said Rosemarie Nelson, a Medical Group Management Association consultant. “More practices that had not yet adopted an EHR started down the path because of meaningful use,” said Nelson. “Practices that have used an EHR for several years started to examine their own implementation to determine if indeed it would be the tool to get them through meaningful us. The portal gained traction because of meaningful use, not because it is a great tool for patients and increases efficiencies in the practice.”
3. Patient payment estimation tools: Patients were faced with a greater financial burden in 2013, with larger deductibles and copays, which meant that practices had a tough time collecting payments. The bad news is that paid at your medical practices is only going to get harder, our recent PayerView 2013 data, compiled by athenahealth, revealed. The survey revealed that higher deductibles continue to impact provider collection burden, a measure of how much of the patient’s bill must be collected by the practice. That’s why tools that help patients determine how much they owe saw increasing interest, especially in the second half of 2013. “Tools like patient responsibility estimators help providers begin the financial discussion with patients early, ultimately increasing patient satisfaction and giving the patient a higher propensity to pay their balance,” said Kim Labow, vice president of marketing for ZirMed.
4. Tools to better manage patient health: The past 12 months saw an increased interest tools technology to support higher-quality care. “Our industry continues to emphasize the collection, integration, and analysis of patient data as a means to drive more personalized, impactful care,” said ophthalmologist Jonathan Javitt, who is also the CEO and vice chairman of Telcare. Michael Lee, director of clinical informatics for Massachusetts-based Atrius Health said this year practices truly started implementing tools that support population health, managing panels of patients and quality reporting. “There is a lot of technology needed to care for patients on a large scale,” said Lee.
5. Mobile health monitoring. Telehealth enjoyed big strides this year, and is now being seen as a cost-effective alternative to in-person care for those who live in rural areas. In tandem, mobile-health monitoring systems and mobile applications, which allow patients to engage in their own care and send data to their physicians, are starting to take off. “Mobile-health monitoring in particular has seen explosive growth thanks to the advancement of cellular-enabled platforms that can offer real-time data sharing,” said Javitt.

By: Marisa Torrieri

– Source: http://www.physicianspractice.com/medical-billing-collections/top-healthcare-technology-tools-and-trends-2013#sthash.sJ2I6IyL.dpuf

General Billing Tips

Improving Patient Relations at Your Medical Practice in 2014

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I started an incredible journey last year. One that I never thought I would have to take. In May of 2012 I found a lump at the base of my neck which was eventually found to be thyroid cancer. Thank God I am now cancer free, but having gone through the medical system as a patient I came away with some insight into the lives of patients that billers usually don’t see or deal with.
Having been in the medical field for more than 20 years, you know I had scores of colleagues, coworkers, friends, and acquaintances who wanted to give me expert advice. I had people tell me their take on the situation or detail their story to me in detail by agonizing detail. Why is it that when something happens to you, everybody in the world seems to know all there is to know about what you should do or shouldn’t do and feel compelled to tell you every “worst-case scenario” they have ever heard about?

So this is what I learned about how to deal with patients from being one myself:
1. Be careful what you say and how you say it.
I wanted people to be honest with me, but I also wanted more positivity that I was getting.

I didn’t want to hear things like, “Oh well if you’re going to have cancer, thyroid cancer is the kind you want.” So, “Um, no, I don’t want any cancer, thank you very much,” is what I wanted to say back to these hopefully well-meaning folks.
2. Don’t make light of what they are going through.

Another common thing I heard was, “Oh, it’s just thyroid cancer.” Anytime you say “it’s JUST” this or that, you are belittling the seriousness of the issue being discussed. Yes I understand that thyroid cancer is not as life threatening or treatment intensive as some other cancers, but it is still cancer and still an ordeal with which you much come to terms.

You might be able to handle a certain diagnosis better than someone else. That fact does not lessen the impact of what they are experiencing.
3. Don’t assume you know what they are feeling.

If I had a nickel for every time someone told me they knew exactly how I felt, I would be a millionaire. Everyone comes into a situation from a different vantage point and with different baggage. Each of us possesses a unique set of emotional triggers and a particular breaking point. Many things go into what feel during a medical crisis… … the external aspects of our lives at that given time, our personality, our previous experiences with similar episodes, our outlook on life, and our faith or lack thereof. Even if you have had the exact same diagnosis as the patient you are dealing with, you did not come from the exact same background nor have you lived the exact same life as that patient, so you do not know exactly how they feel. And feelings are fickle, how you feel today can be completely different than how you feel tomorrow. One thing I experienced during my sickness was that my emotions were wide ranging. Some days I felt strong and blessed while on other days I felt weak and overlooked.
4. Realize that you are not the only biller calling them.
When you have an extended illness or a condition requiring numerous tests, procedures, surgeries, and visits, the bills quickly add up. All billers know that deductibles and out-of-pocket limits have skyrocketed. A few years ago, the average out-of-pocket limit for most insurance plans was $3,000. This year, the average out-of-pocket limit is $9,000. The majority of patients must make monthly payments and that amounts to $750 per month out of their salary. Combine that with lost time from work and there is a very real danger of the patient’s savings being depleted or worse.
As billers, we are in a position to offer tremendous help to patients as they try to navigate through the pitfalls of dealing with their insurance company and their medical condition at the same time. Our insensitivity to them can make or break our office’s relationship with that patient and eventually other patients as well.

By: Marsha Sosebee

– Source: http://www.physicianspractice.com/medical-billing-collections/improving-patient-relations-your-medical-practice-2014#sthash.rPSj8PWU.dpuf

CMS News

Don’t Let Patients Take Advantage of Your Medical Practice

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I met with a colleague yesterday for a nice lunch and great conversation. She and her husband are small business owners and have two clinics in the area; truly dynamic people who are always willing to help someone out who needs it. The dilemma: They are too trusting to a fault. By her own admission, mind you. She described several situations where they have been taken advantage of by people they thought were friends or even other close colleagues. This woman does not have a “victim” attitude, rather she would never behave in a poor and selfish fashion so that is never her first thought when lending a hand or “giving someone a break.”
Let me tell you, there are plenty of people who will take advantage of your good nature, and are most likely doing so right now. I have recently encountered a few over the past several months. This scenario may ring a bell to you, as I’m sure you have experienced this, as well.
There was a patient, Mr. Smith, who insisted that a physician bill his wife’s insurance (a really stinky Aetna plan) knowing full well the insurance was going to deny the treatment because she had exceeded her plan limit on that treatment for the year. Once the insurance denies the claim, the patient wanted the physician to fight the insurance plan on his behalf to get the claim paid.
Let me tell you what is wrong with this situation:
1. As a medical professional, you are billing a patient insurance plan as a courtesy, not as a requirement.
2. With the stinky Aetna plan they possessed, the payment for the claim was under the break-even point for the appointment.
3. When the billing department employed by the physician had to try to appeal (and lost) the claim, they had to spend significant time gathering the required information, writing the appeal letter, reprinting the claims, etc. This is more administrative cost taking away from the profit of the already costly (for the physician) appointment.
4. Did I mention that the couple who had the stinky Aetna plan lived in a very prestigious area and were multi-millionaires?
5. Patients should never get to dictate your policy. If you know that a treatment is going to get denied, call the insurance company and explain that the patient needs the treatment and ask to charge them the plan cash rate for the treatment. By letting the insurance company know this is your plan, you have not breached your contract with them, and you are paid immediately.
6. By knowing the denial was going to deny, and then an appeal made, you have stretched that claim out into your 60-day to 90-day category.
All of these reasons are just an unacceptable way to manage your billing of claims, and this is just one scenario. Remember that you run your business, you make the rules, you follow your contract obligations, and you should never have to lose money on any claim because a patient tells you to. Where will they be when you close your doors? At one of your colleagues doing the same thing to them, that’s where.
Educate your front- and back-office staff along with your billing staff on your policies and never as the “norm” perform below your own standards. There is a fine line between customer service and people taking advantage of you. Write-down situations like these are start finding that line. Your accounts receivable and bank account will thank you.

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/dont-let-patients-take-advantage-your-medical-practice#sthash.a89q6G9Z.dpuf

BCBS News

‘Incident To’ Billing: Is It Worth It for Medical Practices?

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I think most employees think the term is “incident 2.” It might be better if it were known as “incidental to,” since in theory the midlevel provider is working in a capacity that is incidental to the work of the physician. But no matter what you call it “incident to” can be one of the more confusing concepts for medical practice employees and physicians alike to grasp.
When Medicare is billed “incident to” for nonphysician practitioner (NPP) services, the bill goes out under the physician’s NPI number, even though the midlevel has performed the work. Reimbursement is 100 percent of the Medicare fee schedule, as opposed to 85 percent when the service is billed under the midlevel’s own number.
There are certain criteria that must be met in order to bill “incident to.” According to CMS, NPP services may be billed under the physician’s NPI when the service is part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. The physician does not have to be physically present in the patient’s treatment room while these services are provided, but must provide direct supervision. This means that the physician must be present in the office suite to render assistance if necessary. The patient visit documentation should show that the essential requirements for incident to services were met.
The previous paragraph raises all sorts of problems and pitfalls with getting that extra 15 percent reimbursement. One of these pitfalls is that in order to bill “incident to,” the physician must see the patient first and initiate a plan of care, which the midlevel provider can then carry out. Employees must know not to put a new patient, or an established patient with a new problem, on the midlevel’s schedule if billing is being done “incident to.” If the patient brings up a new problem during the course of the visit, it cannot be billed “incident to.” But how does this get communicated to the billing staff? Remember, NPPs can see new patients or new problems to the extent allowed under their state licensure. They just have to bill the new patient or new problem under their own NPI. This can be very confusing to staff members who you are depending on to get the right provider number on the bill.
In my opinion, the biggest problem when billing “incident to” is the direct supervision requirement. This is a considerable problem in a practice such as a surgery group, where physicians are regularly in the operating room rather than the office. The rules on “incident to” are very clear that having the physician in the same building is not adequate to fulfill the “direct supervision” condition. Having the doctor at the operating room in an adjacent building on the same medical campus is not good enough. When some doctors are in on one day, and some are in on another it creates a very confusing situation for the biller in knowing whose provider number to bill under. And if the bill is going out under the name of whichever doctor is in the clinic that day, does it really meet the requirement for the physician initiating treatment to be actively involved in the care?
Or what happens if the physician runs over to the hospital to do rounds while the NPP continues to see patients? The mid-level’s services cannot be billed “incident to” while the doctor is not in the office suite, requiring the staff to switch provider numbers for billing during certain periods of time. This creates a situation where the staff may not know the doctor is not in, especially if the assignment of provider numbers has to be done by the biller after the fact.
Another issue I have had with “incident to” billing is confusion on the part of the patient, who gets an explanation of benefits from Medicare or another payer showing that they saw Dr. X, when they actually saw the NPP. This is especially confusing if the NPP’s service was billed under whichever doctor happened to be at the clinic at that time, and whom the patient may never have seen at all.
In my practices, I have chosen not to bill NPPs under “incident to” because there are so many inflexible requirements and administrative burdens. Each individual practice will have to make the decision as to whether the extra 15 percent reimbursement is worth the risk of error and penalties if those errors are discovered in an audit

By: Beth A. Balen

– Source: http://www.physicianspractice.com/medical-billing-collections/incident-to-billing-it-worth-it-medical-practices#sthash.P9lWRhIi.dpuf

AMA News

Healthcare Reform, ERISA Claims, and Government Health Plans

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The medical provider community is becoming more aware of the health plan claims procedures contained in the Employee Retirement Income Security Act (ERISA). The federal ERISA claims regulations provide many advantages to physicians when they pursue payment on their patient’s claims covered under private; i.e., non-government, group-sponsored plans. These advantages include the right to prompt claim decisions, the right to full and complete explanations on all EOBs, and the right to obtain e-mails, data, and documents from group health insurers or administrators when claim determinations are “adverse” (a complete or partial claim denial).
According to a little-known provision in the Affordable Care Act, these ERISA processes — designed to promote speed, fairness, and transparency — are now also required to be incorporated into every government employee group health plan. Beginning in about 2011, the healthcare reform law required that these ERISA procedures be added to government-sponsored plans, such as those covering the employees of cities, school districts, states, and even the federal government.
This article outlines the main benefits of these regulations and explains how physicians can use them to address the vague and frustrating claim denials often seen in EOBs. With some education and perseverance, using these tools can improve a physician’s bottom line.
First, we should be clear that these regulations apply to all group health plans. Many physicians have been under the impression that the rules only apply to self-insured plans and not to plans that are funded by a group insurance policy. Let’s debunk that myth here: ERISA applies to all group plans, whether insured or not; and now, through the Affordable Care Act, ERISA’s regulations apply to all government employer-sponsored plans as well.
Second, as a threshold matter, physicians must recognize that not only do the patients have legal rights here, but so does the physician. As ERISA beneficiaries, the physicians can pursue the same pathways as their patients can, under the patient’s health plan. Simple language — often already contained in a physician’s intake paperwork — and certain wording in the patient’s health plan can create beneficiary rights in the physician.
While the insurance industry and most claim administrators have vigorously fought this concept, there is solid legal authority supporting a physician’s rights here. Thus, once the physician is legally deemed a beneficiary, he or she can hold the insurer or claim administrator’s feet to the fire when it comes to pursuing payment on claims.
The ERISA health plan claims regulations have, for example, the following advantages:
• Insurers and claims administrators must respond to all health plan claims within 30 days;
• The burden is on insurers and claim administrators to justify a claim denial based upon an alleged lack of medical necessity or if it is allegedly experimental of investigational, with scientific or clinical evidence; and
• If a claim is denied, the insurer or administrator must provide internal documents to a requesting physician, such as their internal emails and memos.
The first important concept is the timing rule: An insurer or administrator must respond to a filed claim within 30 days. And if the response is a request for medical records, there is only a one-time request allowed per claim, and only a 15-day extension of the requirement to render a timely claim decision. If these deadlines are blown, the physician should demand payment in full, regardless of the type of services rendered. Legal counsel can pursue payment in full, using other methods, if a written demand by the physician is unsuccessful.
The next significant rule is that an insurer or claim administrator must explain the scientific or clinical basis for any decision that alleges a lack of medical necessity or that a service rendered was experimental or investigational. Insurance companies try to shift the burden to the physician, but the law places the burden in reverse: If a claim is denied on these grounds, the insurer or administrator needs to step up to the plate — with proof. And the insurer or administrator cannot transmit numerous and untimely requests for records as to medical necessity, after the 30-day deadline.
And finally, when a claim decision is adverse, the physician should demand all of the insurer’s internal medical documentation, e-mails, or other documents that allegedly support the insurance company or claim administrator’s decision. The regulations have contained these rights for 12 years, but physicians have not become aware of them, nor pressed for these materials on denied claims. Using this tool can often result in the receipt of a check, on a disputed claim, representing payment in full.
Be assured that these rules are a tool kit that will serve physicians well in their quest for payment and fair treatment on all claims filed under both public and private group health plans.

By: Richard Quadrino

– Source: http://www.physicianspractice.com/medical-billing-collections/healthcare-reform-erisa-claims-and-government-health-plans#sthash.Z94Pt11P.dpuf

General Billing Tips

Getting Paid for Value: Defining New Reimbursement Models: Page 2 of 4

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Medical home incentives
In addition to incentives for meeting performance targets, many payers are offering value-based incentives that relate to improved care coordination and case management.
Practices that have gained recognition as Patient-Centered Medical Homes (PCMHs), or that have met medical home recognition criteria set forth by payers, are most likely to be offered this type of incentive. Typically, medical homes must demonstrate improved care access, care coordination, and care quality to gain recognition.
The incentives offered to medical homes vary by payer, says Mary Witt, senior vice president of The Camden Group, a healthcare management and consulting services company based in El Segundo, Calif. They include funding for infrastructure development or care coordination, such as funding to hire a care coordinator in a practice; a percentage increase to a practice’s fee schedule; a per member, per month stipend for care coordination activities; or even shared savings opportunities, for instance, when a medical home manages to decrease emergency department utilization or hospital readmissions.
Still, while medical-home-related incentives are gaining traction, not all practices that become medical homes experience them, cautions Lutz. “At the end of the day, the physician may actually see [fewer] patients and do better economically as a result of participating and sponsoring these kinds of initiatives, but they have to do it in collaboration with a payer that’s going to be an active participant,” he says. “Depending on where you go in the country, some of these things are very well implemented … and in other parts of the country they’re just barely getting off the ground.”
To hear one physician discuss how her practice transitioned to a medical home, visit bit.ly/PCMH-transition.
Shared savings models
While not all payers are offering incentives to medical homes, transitioning to that model of care has other perks. Cook says it’s a great way for practices to gain experience delivering value-based care, and it’s also a great jumping off point for successful ACO participation.
In ACOs, groups of providers, including physicians, practices, hospitals, and/or larger healthcare systems, partner to improve the quality of care and reduce the cost of care provided to a particular patient population. If successful, the participants share in the cost savings with their payer partner. If not, in some arrangements, participants share in the losses.
Over the past two years, hundreds of ACOs have cropped up across the country. One is Coastal Carolina Quality Care, which has participated in Medicare’s advanced payment model ACO program since 2012.
“We felt that it would help us better focus and prepare for the future,” says Stephen Nuckolls, chief executive officer of Coastal Carolina Health Care, P.A., the multi-specialty medical group that formed the ACO. “We feel this type of aligned incentives is the way that medicine is moving and we wanted to go ahead and get some experience with that,”
Due to its ACO participation, Coastal, which is located in New Bern, N.C., has stepped up its focus on population health management, care coordination, cost control, and quality metrics, says Nuckolls. Those efforts may be paying off. Though CMS has not yet released Coastal’s first-year ACO performance report, Nuckolls says that the health system’s internal metrics are showing positive signs. “We are showing our emergency room utilization down year over year in excess of 30 percent,” he says. “We’re seeing hospital admissions down a little over 10 percent.

By: Aubrey Westgate

– Source: http://www.physicianspractice.com/medical-billing-collections/getting-paid-value-defining-new-reimbursement-models/page/0/2#sthash.eSREQ1EQ.dpuf