Accepting insurance at your practice and signing a contract does not mean that you’ve opened your arms up to assume that financial risk. It is important that patients understand this concept.
One way to ensure patients understand your requirements is to ask patients to sign a payment policy.
Here’s a sample policy to consider adapting for your practice:
As a courtesy, (your practice name), verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.
It is the policy of (your practice name) that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. The office manager at your location will explain this information to you prior to your first visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.
If you are covered by health insurance with (your practice’s specialty) benefits, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.
Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician’s referral and our verification of your insurance benefits are not a guarantee of payment.
We highly recommend you also contact your insurance carrier and check into your coverage for (practice specialty). Do not assume that you will not owe anything if you have more than one insurance policy.

By: Ericka L. Adler

– Source: http://www.physicianspractice.com/medical-billing-collections/sample-payment-policy-medical-practices#sthash.fudpO1sb.dpuf

I spent some time this week reviewing denials that came through on some of our EOBs (explanation of benefits). Although this is a very laborious process, what I have learned from this exercise is truly worth the time I invested.
I ran a report in our software system that showed all of the EOBs that came in electronically. By opening up each file, I made a tallied list of the denial codes supplied by the insurance company. After a month’s worth of data, I decided to drop everything into a spreadsheet and then sorted the data. It provided me a snapshot of where we are having billing issues and/or front-office issues.
Some of the problem areas that I found were:

• Claims were sent out with incomplete information
• Claims were sent out with incorrect or missing modifiers
• Charge codes were not covered under patients’ plans
• Multiple duplicate claims were submitted — the insurance company may see this as a red flag and start auditing all of your accounts
• Precertification or authorization status was not included with claims — does this mean it was not obtained or not entered into the system?
• Insurance was terminated before patient was seen
• Patient name, date of birth, or policy number does not match; Patient cannot be identified as insured
• Claims submitted with incorrect provider name
• Patient’s benefit maximum has been met
• Patient’s insurance plan changed midway through treatment
• Primary EOB was not included with claim to secondary insurance

Now that I have identified where the denials are coming from, I can work with the results to improve our billing processes and procedures. I can group these denial types into areas of responsibility. For example:
Front-office staff. Provider name incorrect, incorrect patient demographics, precertification/authorization not present — all of these are front-office or data-entry problems and can be addressed with those employees.
Physicians. Coding and modifiers are the physicians’ responsibility. Be sure they are fully trained or hold a modifiers and coding seminar to help educate them.
Office policy/manual. Patient benefit maximum met, insurance plan changed midway through treatment, patients plan terminated prior to visit. These are areas that need to be in your office policy stating that patients are fully responsible for the cost of their treatment.
Billing department. Claims sent out with incomplete information, duplicate claims, precertification/authorization not included with the claim; primary EOB not included with the claim to secondary insurance. These can all be addressed with your billing department. The only caveat would be that patients should also be responsible for coordinating their benefits.
Unless you ask the questions, you will never be able to fix the problems. Don’t be afraid of what you’ll find, instead understand that the results of your internal audit will help you solve multiple problems, and you can start getting paid faster and appropriately.

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/knowing-why-claims-are-being-denied-will-help-you-get-paid#sthash.vMkb5wkm.dpuf

Physicians and practice managers face pressure to increase performance and reduce costs in just about every area, and with the myriad of performance-based incentive programs, licensing and certification requirements, and reporting obligations, it’s no wonder many are overwhelmed and confused.
There is much to deliver on, and expectations are high. One of those deliverables is patient experience, which focuses on the patient’s perception of care received. Because of its impact on patient health outcomes and financial efficiencies, patient experience is now viewed as a marker of quality patient care and is being measured through CAHPS surveys.
Here are six ways focusing on improving the patient experience might benefit your practice:
1. Maximize PQRS incentive. Reporting of CAHPS surveys may be used to meet one of the nine mandatory measures, and one of the three mandatory National Quality Strategy domains, under the PQRS program. Financially speaking, that’s one-third of the way toward meeting your Medicare Part B Physician Fee Schedule incentive. This is an easy way to fulfil PQRS requirements and avoid the 2 percent decrease in payment for unsatisfactory reporting in 2016.
2. Maximize Physician Value-Based Payment Modifier (VBPM) dollars. Reporting of CAHPS surveys counts towards at least 16.7 percent of the VBPM dollars, providing physicians and practices with a good opportunity to improve performance, and reimbursements.
3. Maximize shared-savings dollars. CAHPS surveys are used to measure the patient and caregiver experience in Medicare’s pioneer and shared-savings program accountable care organizations (ACOs). This makes up 25 percent of the overall quality score used to determine an ACO’s share of cost-savings (or losses for those in the two-sided shared-savings model).
4. Meet the new Maintenance of Certification requirement. ABIM now requires all board certified physicians to participate in the completion of CAHPS surveys by the end of 2018, and every five years thereafter.
5. Gain Patient-Centered Medical Home certification. Measuring CAHPS domains will earn points towards Level 1, 2, or 3 of medical home certification under the National Committee for Quality Assurance.
6. Improve your reputation. Medicare’s Physician Compare website now includes quality of care ratings for group practices.
Many of the CAHPS survey questions require factual responses about the patient’s contact with the office, such as how quickly patients are able to schedule an appointment, or how long they wait. These questions require straightforward responses, and practices can improve performance by examining their current processes and making efficiency improvements.
Other survey responses inquire about the cognitive aspects of the physician-patient interaction, and identify how patients feel throughout the encounter.
For example:
• How often did this provider explain things in a way that was easy to understand?
• How often did this provider listen carefully to you?
• How often did this provider show respect for what you had to say?
• How would you rate this provider?
Most physicians believe they will perform well on these questions, however, research suggests that this is often not the case.
A 2011 study found that patients do not express their health concerns, expectations, or opinions in up to 75 percent of physician visits, principally because they are not asked. A report from leaders at Elmhurst Memorial Healthcare, Hackensack University Medical Center, Piedmont Healthcare, Griffin Hospital, and Sharp Healthcare noted that more than 50 percent of patients leave their appointment not understanding what they were told, how to take their medication, or in fact, why they need to take their medication at all.
Good interpersonal skills and the ability to create a good patient experience is not something that just “comes naturally” to all doctors. Just like any other evidence-based clinical competency, it requires teaching, practice, and evaluation.
In my next post, I will provide you with simple techniques to help ensure you are doing all you can to improve the patient experience at your practice.
Sue Larsen is president and director of education of Astute Doctor Education, Inc, a provider of online education and resources specializing in physician interpersonal skills. Larsen has over 10 years experience in medical education, and understands how to turn clinical evidence into practical, technique-based learning events. E-mail her here.

By: Sue Larsen

- Source: http://www.physicianspractice.com/physician-compensation/six-ways-patient-satisfaction-could-impact-your-practice-finances#sthash.IpZVW1mU.dpuf

Appending modifiers on a claim form is like playing Monopoly. Use the right modifier in the right situation, and it is like “passing go,” and collecting $200. The claim sails through the claims processing system on the first pass, and the insurance company deposits money in the practice’s account. However, use modifiers incorrectly, and you will receive payment denials or worse. Not unlike picking a “Go to Jail card,” incorrect modifier use puts your practice at risk for a payer request for a refund.
Modifier 24 is appended to an evaluation and management service (never to a procedure) to indicate that an unrelated E&M service was provided by the same physician during a postoperative period. Other, “same-specialty physicians” are included in the definition of “same physician.” That is, if a surgeon is covering post-op patients for her partner, the covering surgeon is considered the same physician and does not bill for it. Remember, modifier 24 is used for an unrelated E&M service.
The following are three examples where you could use modifier 24:
• A surgeon performs a hernia repair on May 20. The procedure has a 90-day global period, so all related post-op care is included in the payment for the hernia. But, on July 1, the patient returns to have a breast lump evaluated. Report the E&M service with modifier 24 attached and use the new diagnosis — breast lump — as the reason for the visit.
•An orthopedist treats a hip fracture on Dec. 15, and the patient returns with shoulder pain on Jan. 10. The Jan. 10 visit is separately reportable with modifier 24.
• A surgeon who is managing immunosuppressant therapy during a post-op period for a transplant may use also modifier 24 for the E&M services and be paid separately for these.
The Medicare and CPT definition of the post-op global package are slightly different. Medicare states that unless a return trip to the operating room is required, all medical and surgical post-op complications are included in the global payment and may not be separately billed. Also treatment of wound infections or other complications may not be reported to Medicare.
However, the CPT definition of the surgical package is “typical” post-op care. This is found in the introductory material to the surgical section in the CPT book. This raises a question: If a payer follows CPT rules and not Medicare rules, can a surgeon report atypical post-op care for complications? Yes. How? Some practices use modifier 24 in this instance for E&M services for medical complications. Use the complication diagnosis code first on the claim form. However, it is critical that you check with your payer to be sure this follows its rules, because the definition of modifier 24, as developed by the AMA, is for unrelated care.
Other physicians who see the patient during the global period do not need to use modifier 24. If a patient in a surgical post-op period sees an internist, the internist does need to append a modifier to the E&M service. Only the operating physician, and his or her same-specialty partners or covering surgeons, need to use modifier 24.
Review the official definition of each modifier in the CPT book annually. It provides the definitive answers to your questions, so that applying a modifier goes from a game of chance to a sure thing.

By: Betsy Nicoletti

– Source: http://www.physicianspractice.com/medical-billing-collections/using-modifier-24-understand-rules-game#sthash.PVMrXYiq.dpuf

Physicians and their practices have a little more breathing room when it comes to meeting the requirements of the EHR incentive program.
CMS recently released a new rule allowing flexibility in certified EHR technology for meeting meaningful use in 2014. The rule also finalizes the extension of Stage 2 through 2016 for certain providers, and it announces that Stage 3 will now begin in 2017.
Here’s more on the key elements of the final rule that physicians and their practices should be aware of:

1. Greater flexibility. Eligible providers will now be able to use 2011 edition certified EHR technology (CEHRT), or a combination of 2011 and 2014 edition certified EHR technology for an EHR reporting period in 2014. In 2015, all eligible professionals will be required to use the 2014 edition CEHRT.

One reason CMS may have added more flexibility to its requirements? By the end of July, only about 1,900 eligible providers had attested to Stage 2.

“We listened to stakeholder feedback and provided CEHRT flexibility for 2014 to help ensure providers can continue to participate in the EHR Incentive Programs forward,” Marilyn Tavenner, CMS administrator, said in a statement regarding the final rule. “We were excited to see that there is overwhelming support for this change.
In an article following the release of the final rule, practice consultant Elizabeth Woodcock wrote that, with many vendors failing to deliver fully functional 2014 certified EHR technology, “this August 29 final rule was the last hope for successful reporting in 2014.”
Later, she told Physicians Practice via e-mail, “I do believe that the flexibility will allow [eligible providers] to participate, given the medley of options.”
Practice consultant Owen Dahl agreed with Woodcock. He told Physicians Practice via e-mail that the added flexibility “takes some burden off” eligible providers and makes attestation more of a “reasonable” possibility.

2. Long reporting period. While more flexibility for providers may be a step in the right direction, the College of Healthcare Information Management Executives (CHIME), said more could be done to ensure that higher numbers of providers could satisfy the meaningful use criteria.

Prior to the release of the final rule, the organization, and many others, had pushed CMS to allow providers to choose any quarterly EHR reporting period to qualify for meaningful use in 2015, rather than requiring 365-days of reporting.
“CHIME is deeply disappointed in the decision made by CMS and ONC to require 365-days of EHR reporting in 2015,” CHIME President and CEO Russ Branzell said in a statement. “This single provision has severely muted the positive impacts of this final rule. Further, it has all but ensured that industry struggles will continue well beyond 2014.”
Dahl agreed that the 365-day reporting period could take a toll on many physicians. It “creates a problem or major area of concern as well,” he said.

3. Useful resources. A solid understanding of how the new rule applies to your practice’s meaningful use journey is critical. Here are a few helpful resources:

By: Aubrey Westgate

– Source: http://www.physicianspractice.com/health-it/new-meaningful-use-rule-good-news-many-physicians#sthash.NGxwcbPo.dpuf

Whether you are looking to sell to a hospital, grow your provider base, or partner with other practices to take advantage of strength in numbers, knowing the true value of your medical practice has become much more important. But knowing the value is one thing; boosting that value may be the more important piece.

Daniel M. Bernick”Value is an important thing to keep in mind, even if you don’t have an immediate desire to sell your practice,” said Daniel M. Bernick, a principal at Plymouth Meeting, Pa.-based The Health Care Group and Health Care Law Associates.

For example, noted Bernick, if a practice is looking to bring on a new associate physician, it’s likely in the future that he will want to buy into the practice. You’ll want to know the value of your practice as the valuation will affect compensation during the buy-in period. Another consideration, added Bernick, is simply that “life is unpredictable and you never know when it might be to your advantage” to sell, perhaps to a hospital or other large entity.

“Because the market is changing and larger entities enjoy an advantage in terms of negotiating with payers, it may make sense for you to sell your practice to a larger entity,” he said. “If that happens, you are going to want to know what the value of your practice is.”

Bernick noted there are six areas where you can start boosting the value of your practice, starting today:

1.  Keep working.

Bernick notes this pertains to an older physician, as any potential buyers will want to see the financials prior to a deal. “If those financials show a declining revenue stream in the past few years it is very discouraging,” he said. “So you want to keep working and keep your revenue up so your practice continues to show good profit and is attractive to potential buyers.”

2. Maintain your “curb appeal.”

Just as you would put a fresh coat of paint on your walls before selling your home, do the same at your practice to spruce things up prior to a possible sale. And it is not just aesthetic items, Bernick noted, it is your practice website — which shouldn’t look “unprofessional or clunky” — and your financial reports on everything from aging of receivables to CPT volume. “To the extent you have professional-looking financials that look as though you are on top of things and are tracking the important aspects of your practice, that plays very well with potential buyers,” he said.

3. Maintain relationships.

Bernick said it is important to keep up relationships with referring sources to show patient base consistency and growth, with training program directors to ensure you have good access to qualified physician candidates, and with others, including your local hospital. “The hospital is an important player in your marketplace and may be a potential buyer for your practice,” he noted.

4. Utilize non-compete clauses.

While unenforceable in some states, Bernick notes that most states will allow a “geographically reasonable, properly drafted” non-compete clause for an associate physician, PA, or even nurse practitioner. Without such a clause, you are raising a red flag for potential buyers in terms of your patient base. “If the associate is not subject to a non-compete, the buyer will worry that your associate may, at the time of sale, go into practice on their own or right across the street,” he said. “If that’s a possibility, that will really depress the value of your practice.”

5. Hold off on major tech investments.

If you are considering a sale in the short term, hold off on long-term tech purchases, such as a new practice management system or EHR, said Bernick. One, there’s a good chance you’ll lose productivity during the adoption and integration of new technology, resulting in “a pretty big hiccup in your revenue flow.” Two, it’s likely that the buyer of your practice will have their own systems to integrate, rendering your new purchase — and the time and training involved — virtually useless.

6. Add ancillary services.

If it makes sense for your practice and you have the ability, ancillary services can be a boost to your practice’s value. “Some [services] are more expensive and some are within reason, so if you can add it reasonably and make use of the ancillary service, that’s going to help your profitability and help your curb appeal,” Bernick said

By: Keith L. Martin

– Source: http://www.physicianspractice.com/physician-compensation/six-areas-boost-your-medical-practices-value#sthash.iMNnE96U.dpuf

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

Question: My physicians would like me to retain patients after we send them to a collection agency; however, these patients must maintain a zero balance. Consequently, these patients must pay their copays, deductibles and coinsurances [at the time of service]. I would like to know if you are aware of other practices who have instituted a similar policy, and the result of [such a] policy. Could you share information on the ROI, labor hours associated with this [type of] policy? Additionally, the practice is pain management which means we serve a chronic population, and these patients will need frequent medication refills on a regular basis.

Answer: Being upfront with your patients is key in maintaining your patient balances. They need to understand that ignoring the monthly statements is not part of your practice’s policy. A good rule of thumb is to send three statements (one each month), and if the patient does not make a payment or set up a payment plan, then you should be sending a 15-day pay or go-to-collections letter. This can be a very simply stated letter that says if the practice does not receive payment, or the patient sets up a payment plan, then the result will be collections.

You will need to set up an easy process to monitor these letters. If you do not receive payment then placing patients into collections is your next step. A great collection agency is TransWorld. They have a high recovery percentage, much better than any other I’ve interacted with. The sooner you get patients into collections, the more likely you are to receive payment.

One thing that I’ve learned is that staff in the billing department are not bill collectors. They understand insurance and denials, not collecting monies from your patients. You really should leave that up to the professionals at the collection agency. They have been specifically trained in negotiating, communicating, and understanding the different types of debtors.

So, now you have placed a patient in collections, but they want to continue being treated at your practice. What do you do? Simply set them up on a payment plan. Contact your collections agency and tell them the patient wants to return to your practice for more treatment, and you have agreed upon a specific payment amount that they will pay weekly, bimonthly, or monthly. (See Payment Plan Example.)

I know that it is difficult at times to talk money with patients, but by setting the expectation up front, you are more likely to collect your copays, coinsurances, and deductibles from patients. Being consistent and following your own set policies will also show patients that ignoring your policies is not an option for them. If you tend to pick and choose who you impose your policies on, you will have a much more difficult time collecting patient balances

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/when-you-send-patients-collections#sthash.D9UtpVMb.dpuf

Increasing revenue and decreasing expenses in a medical practice are often misguided goals. Each is a proxy for the more effective goal of increasing net income, the difference between actual receipts and expenses, e.g., the money you actually get to keep. Here are three principles you can use to substantially and sustainably increase net income.
1. Plug the holes
Earning money can be a bad thing, if you don’t collect it. Providing services incurs expenses. If you never actually receive payment for those services, you have lost money. Revenue holes in a medical practice are regularly the result of failure to:
• Confirm insurance coverage
• Obtain prior approval for procedures
• Collect copays at the time services are provided
• Collect accurate and complete insurance information
• Adequately explain to the patient his financial obligations (Most offices have patients sign an acknowledgment of responsibility, but most patients do not read it and dollar amounts are seldom even estimated.)
• Take advantage of opportunities, through affiliation not buyouts, for better reimbursement schedules
Other revenue holes result from not getting it right the first time:
• Re-filing insurance claims because of errors and omissions in the original submission
• Choosing not to re-file short-paid claims because it is not worth the costs
• Re-filing short-paid claims for an increased payment that does not exceed the cost of the extra work
• Multiple billings and subsequent write-offs of patient balances
2. Reduce operational waste
Operational waste comes in the form of wasted money and wasted effort.
Wasted money comes from spending more than is necessary to get the required result. It is not a function of value, not price: An inadequate product or service is expensive at any price.
Any activity that does not affirmatively serve the objectives of the practice is waste. It can, therefore, be eliminated without negative consequences. The rule of thumb is that 30 percent of the work in any office, medical or otherwise, adds no value. Identify it, eliminate it, and increase the practice’s productive capacity by 30 percent.
Reduced operating costs are a natural side effect of reducing operational waste. The simplistic goal of reducing expenses often impairs both productivity and profitability.
3. Increase revenue
Increasing revenue is the last in the list because that is where it belongs chronologically. It is the best use of practice resources only after the holes have been plugged and operational waste has been minimized.
The practice can use its increased operational capacity to increase revenue by seeing more patients. It can also leverage that productivity by applying the additional capacity to more lucrative services.
More expensive services are not necessarily more lucrative. The net income attributable to a service is a function of both the difference between receipts and expenses, and volume. A high margin service with a small market often yields less eventual net income that a low margin/high volume service.
Be cautious about adding products and services not directly adjacent to current offerings. These always carry higher startup and operating costs because the practice is not already set up for them.
In improving financial performance, the real goal is to increase net income. Do not be distracted by popular proxies.

By: Carol Stryker

– Source: http://www.physicianspractice.com/physician-compensation/three-ways-increase-physician-income#sthash.XVmevDhC.dpuf