My work has allowed me to meet many physicians in the small and midsize practice space over a number of years in a variety of specialties. In my experience, they all have very specific things in common including that they studied medicine, not business. Additionally, these practice owners all have operational headaches. Healthcare is a business, after all, and no physician’s practice is immune to the challenges that running a small- or medium-sized business presents. While many physicians make great business owners, the back office is not where they want to focus their time, so finding smart solutions to help is the key.
Working Smarter, Not Harder
We can pinpoint two very specific areas where physician’s practices most often “leave money on the table,” as we say, or rather, where money goes uncollected:

1. Denied or unpaid insurance claims; and
2. Patient copays or remaining balances.

When it comes to unpaid insurance claims, relentless outreach to insurance companies can cost physicians and their staff precious time and money, and take a considerable toll on productivity. Instead of giving up on the collections, or putting too much time to the process, the third choice is to work smarter, not harder.

Four Characteristics of an Ideal Collections Partner
One solution is outsourcing collection to businesses knowledgeable in the space. If you do your homework and find a company that you’re willing to work with on accounts receivable specifically in regards to insurance claims, there are a few things you should look for:

• Do they handle electronic and paper/HCFA claims? As paper claims seem to taper off with the speed of technology adoption, be sure that whatever company you choose to spearhead your accounts receivable follow up can handle both appropriately.

• Are they speedy? Electronic claims should be followed up on no less than 10 days after they are submitted to the insurance company. Any less time, and it’s likely the claim hasn’t been reviewed and filed appropriately. Any more time, and the likelihood of the claim getting “lost” or being perhaps incorrectly denied increases greatly.

• Do they have numerous avenues for follow up? If the company doing follow up only has one way of contacting the insurance company, do you think they will be aggressive in collecting what is owed to you in a speedy fashion? Probably not. There should be online, phone, and other interactive ways of reaching insurance companies to get to the bottom of why a claim has been denied or unpaid.

• Once a claim is addressed, yet still unpaid, can this company do what is needed to achieve a positive end result? Can the company fix an error or modify a claim and resubmit? Can they also address the patient’s responsibility owed for in-network deductibles or non-covered benefits?
Once you’ve settled with the insurance company, collecting past-due balances from patients is an important component of the revenue cycle that physician practices must actively manage. Much easier said than done, efforts dedicated to collecting money due from patients is time consuming and labor intensive and only a relatively small percentage of efforts result in successful collection.
Back-office staff can take measures such as reporting debts to credit bureaus and taking legal action. But every dollar spent trying to gather owed money is one less dollar of profit for a practice. Not to mention, quite often the cost invested in gathering owed funds can exceed the past-due balance. If practices decide to forgo such collection measures, even small amounts owed can add up to hundreds of thousands.

Outsourcing Your Collections
If you’re looking to outsource such services, look to companies that will accomplish or offer the following:

• Efficiency. Not unlike in insurance company follow-up, the longer a claim sits unanswered with a patient, the lower your chances are of collecting money owed. Don’t wait until it’s too late to engage a helping hand in this arena of your practice.

• Persistent, not pestering follow-up. Collection is all about balance. It’s imperative that you collect money owed to you, but not at the cost of a perturbed patient, a damaged reputation and lost potential referrals.

• Knowing how to reach patients. Knowing the best way to reach your patients will pay off big when it comes to collecting owed money. You will better your chances of a successful collection if you reach that patient on their terms. Is it via text? Perhaps e-mail and voicemail?
By implementing outsourced collection processes, not only will physicians stop “leaving money on the table,” and enjoy greater financial reword, but they can also focus on patient care and not on back office paper work.

By: Vishal Gandhi

– Source: http://www.physicianspractice.com/medical-billing-collections/getting-money-door-streamlining-patient-collections#sthash.QGjID6tI.dpuf

With the extended deadline of ICD-10, medical practices now have time till October 1, 2015 to train and test their capabilities with the new coding system. This delay has given another year to the providers to gear up for the new coding standard, but it has also affected the healthcare industry as a whole.
Effect of ICD-10 Delay on Vendors
Many EHR vendors have welcomed this year long delay in ICD-10 compliance deadline. This is because of the increased workload and the pressure to meet the new 2014 criteria for certifying EHR technology. Practices report to not been given adequate time for their developers to ensure ICD-10 readiness for their products. Some vendors were prepared for the original deadline though, but others remained unprepared. Since many practices use small vendor products, another year will surely help everyone come on the same page in 2015.
How has the Delay Affected Providers?
In order to prepare for ICD-10, providers had to deal with costs related to overhauling of IT departments and training coders. They had to overcome various hurdles associated with the implementation of the new coding system. Now that the deadline has been extended, they are faced with additional costs to either maintain the ICD-10 transition process or to stop and restart the process when nearing the deadline in October next year. Since these are operating costs, providers are not likely to be reimbursed for this expenditure.
Readiness of stakeholders, including payers, clearinghouses and vendors has also been one of the largest concerns for providers. The healthcare industry loses a lot of money every time ICD-10 is delayed.
The delay has affected stakeholders who had already spent thousands of dollars and sizeable time preparing for ICD-10. It has affected the health care educators, students of coding and Health Information Management (HIM) programs along with HIM professionals who were prepared for the new system. It has also affected the job prospects for students who learnt to code exclusively for ICD-10.
It is difficult to decide whether the effects are positive or negative, but the delay surely has had its presence felt even before its implementation in the healthcare industry in the US.
 According to American Medical Association, the delay in ICD-10 implementation will give the providers an extension to the timeline when sizeable amount of time and money is being spent by them on multiple government initiatives such as pay-for-performance initiatives or the Meaningful Use program
In order to sail through the reimbursement challenges and ensure readiness for the new coding system, many practices are outsourcing their billing and coding requirements to companies like MedicalBillersandCoders.com. MBC has a team of well-trained, certified coders and billers who are experts at maximizing revenue and strengthening the revenue cycle. By outsourcing their billing needs to MBC, physicians have been able to eliminate costs related to hiring and training coders and on implementation of health information technology.
HIM experts at American Health Information Management Association are of view that ICD-10 delay has affected the healthcare industry because the switch to a more specific and modern coding system has been prolonged too much. According to them, ICD-10 should be implemented by the next year as it will play a vital role in improving healthcare provision and healthcare reporting.

By: Jacob Thomas

– Source: http://www.medicalbillersandcoders.com/blog/what-percentage-of-healthcare-industry-is-affected-due-to-icd-10-delay.html#sthash.ECcavGmA.dpuf

CPT® released three new E/M services in 2011, to be used for the second and subsequent days that a patient is in observation status in the hospital.
The codes are 99224–99226 and they are out of sequence in the CPT® book. They require the same level of documentation as the three subsequent hospital visits.
99224 requires 2 of 3 of a problem focused interval history, problem focused exam and straightforward or low medical decision making. The typical time is 15 minutes and it carries .82 RVUs.
99225 requires 2 of 3 of an expanded problem focused interval history, an expanded problem focused exam and moderate medical decision making. The typical time is 25 minutes and it carries 1.45 RVUs.
99226 requires 2 of 3 of a detailed interval history, a detailed exam and high complexity MDM. The typical time is 35 minutes and it carries 2.17 RVUs.
An interval history means that no past medical, family or social history is required.
CPT® is instructing all clinicians (admitting and other treating physicians) who see a patient in observation status to use these subsequent observation visit codes. However, as of this writing, some CMS contractors are indicating that only the physician who admitted the patient to observation status should use these codes. Physicians other than the admitting physician who see Medicare patients in observation status should bill with office/outpatient codes (99201—99215).

As of Jan. 18, 2011, it looks like we’ll have different CPT® and CMS rules for using these new codes.

Author: Codapedia Editor

- Source: http://www.codapedia.com/article_521_Subsequent-Observation-Services.cfm#sthash.j9XbgW4z.dpuf

I can count on two consistent issues in coding audits. Doctors report that their patients are, in general, sicker than patients in other practices. Coders report that their physicians are, in general, worse documenters than physicians in other practices and select codes that are too high based on the volume of the documentation without considering the medical necessity for the visit. Because medical necessity is hard to define, some compliance policies mandate that medical decision making be used as a substitute for medical necessity. As a frequent arbiter to these discussions and an experienced E/M auditor, I am uniquely positioned to comment on this topic.
The most often quoted reference in the discussion comes from the Medicare Claims Processing Manual, Chapter 12 Section 30.

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.

It is brief and to the point, but provides no mechanism to operationalize the guidance. It relies solely on physician’s or coder’s judgment. For this joint pain, how much of an exam was needed? For that throbbing headache, what systems needed to be reviewed? What part of the volume of the detail was medically necessary for the physician to document and what part of the volume of detail was simply the doctor aiming for a higher level of code? Or just using the tool–the electronic health record—provided? The spirit of the guidance is clear but the interpretation is based on judgment.
The Documentation Guidelines themselves and the audit tools that sprang up after the guidelines were released provide a more objective tool in auditing an E/M note. Using these tools, the level of service is based upon the key components of history, exam and medical decision-making. Some codes require all of the three components and audit to the level of the lowest component. Some services require only two of the three key components. Of course, the CPT® book defines an E/M service as having seven components (history, exam and medical decision making are the three key components; most audit sheets have time as the fourth. Counseling coordination of care, and the nature of the presenting problem are the final three components.) The CPT® book includes charts for all E/M services in which the nature of the presenting problem is listed. It also states that counseling coordination of care at the nature presenting problem are considered “contributory factors in the majority of encounters.”
The CPT® book devotes a section to describing the five types of presenting problems, which are defined as minimal, self-limited or minor, low, moderate or high. Within the Tabular listing of E/M codes, CPT® assigns a type of presenting problem to each level of service. For example, for 99203, usually the presenting problem (s) are of moderate severity. CPT® describes moderate severity (in the E/M Services Guidelines section of the book) as “A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.”
The medical necessity for performing the key components of history and exam are determined by the nature of the presenting problem, the patient’s own personal history and the clinical judgment of the provider. The medical decision making, that is the diagnostics ordered, the assessment and the plan are formulated as a resultof the nature of the presenting problem, the patient’s past medical history, and the history and exam performed at that visit. Medical decision-making is the outcome of the visit and is not a substitute for medical necessity. If CMS had wanted medical decision making to be that substitute then the Medicare Claims Processing Manual would read, “medical decision-making is the overarching criterion in selecting an E/M service” instead of medical necessity. If CMS had wanted medical decision making to be a substitute for medical necessity than either medical decision-making would be required in determining the code or all codes would require all three components.
Physicians do need to use their electronic health records in a way that more clearly documents what happened at the visit. In most cases that means document what would have been dictated, and be prudent in copying and clicking. Length of note doesn’t win a prize. Coders need to recognize the difference between the medical necessity of performing a history and exam based upon the nature of the presenting problem and the patient’s condition and medical decision making that is the clinical outcome of the encounter. Organizations should seriously consider how policies and incentives are effecting coding for E/M services.

Author: Codapedia Editor

- Source: http://www.codapedia.com/article_559_Medical-Necessity-is-not-Medical-Decision-Making.cfm#sthash.PdPzONGd.dpuf

Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims.

When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing provider, date of service and billed codes, processing of the service is going to be stopped cold. You’ll see CO18 on the remittance advice, which is the code for a duplicate claim.

Providers typically don’t intend to re-bill the same service, but the MACs and CMS alike have expressed their frustration with the clogging of the processing system with duplicates. To put it in perspective, in one quarter alone in 2010, Cahaba received 489,738 duplicate claims in Alabama, Georgia, Mississippi and Tennessee.

Filing a lot of duplicate claims exposes you to some risk, as the MAC can see you as either an abusive biller or unfocused on provider education. At the worst, your practice could leave a perception that it’s trying to game the system.

Here are some causes of duplicate claims and ways to solve them:
• Initial claim not yet processed: If a claim is suspended for medical review or delayed in processing, it’s possible you’re submitting a claim that is still being processed. Or your software may be set up to automatically refile claims that haven’t yet been paid by all payers. If you know you’ve already filed a claim, check to see if it’s been adjudicated and posted either as a payment or a denial before simply re-filing. When it hasn’t been paid, address the reasons it hasn’t been paid before trying to resubmit. Set your software not to automatically refile Medicare claims.
• Only submit corrected claim lines: When you get a partial payment on a claim with multiple lines and you want to correct and resubmit the line(s) that were not paid, submit only those lines. Never resubmit a claim line for which you’ve already received a payment.
• Don’t split claims for resubmission: When you get back a claim with multiple lines that was denied entirely, don’t try to split it into two claims and send it back to the MAC. It’s only going to get denied again and raise the same red flags with the MAC.
• Only one E/M service per physician or physicians of the same specialty within a group practice per day: You can’t bill more than one E/M service for the same date of service for the same physician, or physicians of the same specialty within a group. Combine all of the work into one E/M service for that day. The only exception is for unrelated problems, but if the problems are unrelated the claims won’t be duplicates.
• Claims resubmitted when no payment is made: A claim may be adjudicated in your favor, but because the patient hasn’t met his or her deductible yet, no payment is posted. Those balances are collected from the patient, not from Medicare. Because Medicare applies the deductible at the adjudication stage, you can’t sit on an already processed claim in the hope that the patient addresses the deductible with services rendered by other providers.
• Make sure a claim is not pending based on additional information needed: Medicare denies a claim when the claim is able to be processed, but based on the information provided the MAC does not believe it is a payable claim. When data are missing or incorrect, such as the patient’s name or address, the claim will be rejected until the payer gets that information. Check the status of these claims via the remittance advice or the MAC’s interactive voice response system before just re-filing it.

Author: Scott Kraft

- Source: //www.codapedia.com/article_646_6-ways-to-stop-filing-duplicate-Medicare-claims.cfm#sthash.8p3dffIv.dpuf

Four new CPT® codes that got some attention when the 2014 CPT® changes were released late last year were a new E/M code series, 99446-99449, designed to be reported when a consulting provider offered a telephone or Internet E/M service that included a verbal and written report back to the patient’s requesting physician.

The delivery of physician services may be getting close to a technology tipping point – after all, a recent Information Week report suggests even telemedicine will be a $27 billion business by 2016.

But these new codes are likely to be another instances where the technology – and the availability of the codes for billing and tracking – is ahead of the world of payment. So far, Medicare slapped the new codes with a payment status indicator of B – making them bundled into all other services – and there is no evidence that any other payers see them any differently.

It’s unclear whether the time spent on these service could truly be “bundled” into a face-to-face encounter, given Medicare’s refusal to pay for non face-to-face care. At least not yet.

The four codes are based on the amount of time spent on the service, and are intended for use by the provider being consulted. 99446 is for between 5-10 minutes of time, 99447 for 11-20 minutes, 99448 for 21-30 minutes and 99449 for more than 31 minutes.

The time counted toward the services are medical consultative discussion and review time spent by the specialist. These new codes are different from the 99441-99444 set created in 2008 for phone or Internet E/M services with the patient because they are intended to cover discussions between providers.

If a payer allows you to bill these codes, or to consider the time spent as part of a bundle into a different E/M face-to-face encounter, remember these rules that govern their use:
• Discussions of less than five minutes are not reportable.
• The patient may be a new or established patient to the specialist, but must not have seen the specialist face-to-face in the previous 14 days or the following 14 days.
• Discussions initiated to facilitate a known transfer of care may not be counted.
• If more than one phone conversation is needed, the calls are bundled into a single code for reporting purposes.
• Like a consult, the request for the specialist’s opinion and the ultimate report back needs to be documented in the patient’s record.
• These services are intended for urgent or complex cases where a face-to-face visit with the specialist may not be possible.
• This service should not be reported more than one time per patient over a seven-day period.

Author: Scott Kraft

– Source: http://codapedia.com/article_715_Don%E2%80%99t-expect-to-see-payment-any-time-soon-for-%E2%80%98telephone-consults.cfm#sthash.n4HT6fRv.dpuf