Ensure Billing/Reimbursement is Maximized & Compliant

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All providers in all specialties want to maximize their revenue, while maintaining compliant practices.  There are constant state by state, payor by payor, evolutionary changes in most areas of medical practice.  One of the challenges is to be able to keep up with these changes at all levels of the organization.You may have a collection of Stand Operating Procedures (SOPs) or employee manuals, which is a good starting point.  But how do you keep up?It requires not only an understanding of the changes, but also an effective mechanism for implementing these changes.When changes or vulnerabilities are identified, they should be addressed immediately.  You will want to ensure there is a mechanism in place to very quickly translate any findings into action items – updating any forms or reports; training staff all along the revenue stream on any corrective measures; determining if any retroactive corrective action is required; updating SOPs; etc.

Some ideas for how to keep up include:

External audits or reviews.  These provide an excellent starting point for reviewing potential issues with coding, reimbursement and compliance.  If there is an audit or review in progress, there is the potential to support a positive outcome (or mitigate a negative outcome).  If there have been adverse findings in prior external audits, it is important to ensure corrective action has been taken.  These also provide concrete examples useful for staff training.

Denial reviews.  Review of claims that have been denied are an excellent opportunity to identify and remediate revenue leaks.  Examples of findings from this exercise include (where appropriate):

  • not providing an unbillable service in the first place
  • improving documentation to better support medical necessity
  • updated forms, codes or other information or processes to ensure payment upon first presentation of claim, thereby improving cash flow and lessening staff time to process denials
  • identifying opportunities for streamlining appeals processes

Internal review.  There are a many variations of internal review, but an excellent opportunity to identify revenue leaks is to take a sample of cases from start (making an appointment) to finish (payment received and posted).  This process avails the reviewer of a glimpse into every step of the life of a service, and further allows for a time study aspect to identify any bottlenecks in the process, including any potential violation of state prompt payment laws by certain payors.

Contract review.

  • Identify any currently participating payors who may offer enhanced rates or be open to contract rate negotiations due to panel openings or deficiencies
  • Understand all fee schedule and reimbursement guidelines by payor (can lead to identification of additional billable services)
  • Identify payors who may be good candidates for network participation
  • Identify payors for termination of participation due to excess headaches or fees so low they don’t cover your costs

Most medical practices don’t have the resources to tackle these issues.  Either their staff is already overworked, they don’t have the Project Management skills to process and implement these changes, or the personnel dynamics are not conducive to these higher level changes.

Consider bringing in a consultant for these types of special projects.  We can tailor our projects to meet your time and budget.  Our consultations are complimentary, so give us a call today.

Ebola was MORE than a Healthcare Crisis!

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How important are solid policies and procedures, including clinical best practices? This is something that became very popular in the news with the identification of three cases of Ebola here in the US. But it’s also something that I’ve encountered personally over the summer as my mother had her knees replaced, my brother experienced a cardiac scare, and I prepared for a procedure.

While you probably don’t have to worry about contracting the Ebola virus in your office, the situation in Texas demonstrates that you never know when you’ll be hit with an unexpected crisis.  How will you and your staff respond?
I received this link from one of my nursing friends. It’s an inside story from some registered nurses at Texas Health Presbyterian Hospital in Dallas who have familiarity with what occurred at the hospital following the positive Ebola infection of first the late Thomas Eric Duncan and then a registered nurse who cared for him Nina Pham.

We now know many more details of the Ebola story, but just because it’s out of the news doesn’t mean the headaches are over for that Texas hospital, or any other health providers who may find themselves in a crisis situation.
It has served as a wake up call to many that usable Policies and Procedures are not just a binder full of papers that sits on a shelf.
Another situation that occurred for me personally, that demonstrated the importance and efficacy of documentation, policy & procedure, and overall public and provider information regarding best practices in health care was when my brother experienced chest pains on the train. He recognized them, his seat companion responded appropriately when he noticed, the taxi driver who overheard him telling his wife he was experiencing chest pains sped his way to the hospital, and when he presented in the ER, as soon as he uttered the words ‘chest pain’ he was whisked off, stripped of his shirt, hooked up to an EKG and given an aspirin.
My mother had her knee replaced and every person on the medical team, from the surgeons to the housekeeping staff were obsessed with avoiding falls. Every piece of equipment, cleaning supplies, warnings, patient and staff awareness was riveted on making sure the patient didn’t fall and screw up that new knee.
I’m having a procedure done next week as an outpatient. One of the biggest risks identified has been infection, so there are many different protocols to follow to minimize the chance of infection.
We can extend this now to the recent Ebola hysteria. I’ve said this before – there is no doubt about it – I think if you had asked anyone where Ebola was likely to show up they’d say NY or CA. I highly doubt ANYONE would have expected it to show up in the middle of TX.

I was at Peconic Bay Medical Center recently, and they had a guard with a questionnaire at the front doors with big signs to attempt to identify anyone who may need medical screening for Ebola. So the message is getting across, and these best practice protocols are being put in place. 

The doctor in NY who was diagnosed was identified immediately because the best practice for Doctor’s Without Borders is to make sure health care workers who return from an Ebola area take their temperatures twice a day until they are past the incubation period. As a result, this doctor was identified, isolated and treated very quickly.
In the meantime, each one of us has an exponentially higher chance of dying from a bad egg/chicken (salmonella) or the flu or in a motor vehicle accident than even contracting Ebola, much less dying from it.
There is never a good time for developing protocols and documentation and delivering training. And 99% of the time, you’ll be fine. It’s that time when you really need it that people will start criticizing, condemning and blaming (and of course, since this is the good old US of A, lining up the lawsuits) YOU for NOT having prepared.
Where are the holes in your practice? Documented clinical protocols? HIPAA privacy training for your staff? Coding and billing errors by your physician, coders or billing team?
Put on your calendar to tackle these one at a time. Compliance is more than another set of pesky rules – it can be a matter of life and death!

Types of Chart Reviews

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So you’ve decided to implement an internal audit program for your practice.  Excellent!  There are so many external parties who can scrutinize your internal documentation, so it is a really good idea to see your practice from their perspective.  An internal audit/review is an outstanding and comprehensive tool.

The first decision is to determine what you want to get out of your audit/review.  Here are some examples of reasons to perform an in-depth, structured, peek into your own medical records:

 · “How are we doing?” review.  This is an excellent way to initiate an internal review process when you don’t have a lot of time, money, resources and have no reason to think there is anything specifically wrong.  Depending on the size of your organization, you select a very small sample:

  •  1-5 records from each provider
  •  representing a variety of services performed by that provider
  1. E/M
  2. Surgery
  3. office procedure
  4. studies
  • every piece of documentation that supports the service

 ·  Formal compliance review.  This process would follow the detailed description contained in the practice’s formal Compliance Plan.  Don’t have a Compliance Plan?  Well, that’s another blog post for another day.

 · “Someone else we know had a problem” review.  A news report or a colleague reports an awful experience with a payor or other oversight entity.  Your initial response is panic, then denial.  Eventually you realize the best path to peace of mind is to perform an internal audit/review to make sure you don’t have any of the same issues in your practice.

 · “We think we have a problem” review.  Somehow it’s been brought to your attention that one area in your operation may have documentation or compliance concerns.  An internal review can be a solid first step in determining if the problem does exist, and to determine the extent of it.

 · “We KNOW we have a problem” review.  At this point, an internal review should only be one component of a larger strategy.  Coordinating efforts with your Compliance department, and potentially Legal counsel, is imperative.  Once you’ve been alerted to a problem, the steps taken and the speed with which you correct the problem can be instrumental in mitigating consequences.

If you’ve got any questions about chart reviews, we can help.  Contact us at sue@habaneroinc.com.

What’s the Difference Between an Audit and a Review?

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So you’ve selected which type of internal audit/review you’re going to conduct for your practice.  Now you need to determine if you’re going to do an audit or a review.  What is the difference you may ask?

Audit

An audit is conducted after claims have been submitted to a payor.  The advantages are that a claim has gone through the entire process, and the analysis can include how the payor adjudicated the claim.  It allows for a complete picture of the results of the service delivered by the provider.  This will let you know which services a payor:

·        bundles or unbundles

·        up or down codes

·        pays, and how much

·        denies, and for what reason

A primary disadvantage to performing a claims audit is that if problems are discovered, they have already been submitted to the payor so you may need to:

·        submit voids or adjustments to correct billing errors

·        self-report compliance errors

Review

A review is performed before any claims are submitted to the payor.  It allows for the discussion and research of any issues that arise, and the capture of any additional supporting documentation that may not have been included in the initial submission.  Of course, care must be taken to ensure documentation is not improperly supplemented.  Provider notes may not be altered, studies that were not reviewed by the provider at the time of service are not admissible, etc.

Performing a review enables you to make any coding or billing corrections prior to submitting claims, avoiding the need to submit claim corrections.

A review also offers the practice an opportunity to discuss any issues identified to determine the course of action to take.  This is particularly important when documentation deficiencies deem a service unbillable, or when a compliance issue is identified.

A disadvantage of performing a review instead of an audit is that you don’t have a full picture of the impact of the service provided on the practice.  Without seeing how the payor adjudicates the claim, valuable insights into the bottomline net results are missed.

 

Which type of process makes the most sense for your practice?  Weigh the pros and cons of each, and give us a call

If you’ve got any questions or need help selecting a chart review method.  Contact us at sue@habaneroinc.com. 

The RAC Attack

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Many medical practices are feeling the impact of the Medicare Recovery Audit Contractor (RAC) process, especially as non-Medicare payors have gotten on the band wagon.  It is difficult enough to submit claims and receive payment for all the services you provide, but now they want to take back payments – sometimes years later!

What can be done to keep as much of these payments as possible?  The key is to have a formal process in place, and to be diligent about time limits and attention to detail.

What is a RAC?

Medicare began recovering overpayments from hospitals via RAC in 2005.  It began witha demonstration project in four states, and was rolled out to all providers in all 50 states in 2009.  The RAC is paid a contingency fee — a percentage of the money it recovers for the CMS.  Therefore, it is in the Contractor’s interest to cast the widest net possible.

What types of audits/reviews are there?

There are many categories of insurance recoveries.  Upon receipt of a letter from a payor, your first step is to determine the type of request.  Examples of some types of audits/review are:

  • RAC – The Recovery Audit Contractor for Region A — which includes New York — is Diversified Collection Services, Inc.
  • COB – Coordination of Benefits, where the insurer believes another party was responsible for payment of the claim.
  • Global reviews – Medicare implements a global review when sample reviews identify gross provider errors for a particular procedure code.
  • Targeted reviews – insurers and/or their contractors perform sophisticated data analyses to determine certain provider’s billing practices are outside the norm.

What should I do?

The most important thing to keep in mind is that there are very strict timeframes for responding to insurance recovery requests.  Penalties for not responding can be significant, including charging interest, and sending unpaid requests to a collection agency.

There are two schools of thought regarding a response strategy.  The first is to challengeeverything, and the second is to only challenge those cases where responding is cost justified.  There are valid arguments for each position.

Even if you do not intend to challenge each insurance recovery request, it is essential to keep copies of all letters received, and any checks or other responses submitted.  It is also recommended to keep a log of all recovery requests for quick reference.

– As published in GEM Magazine, Author: Susan Montana

Habanero, Inc., based in Patchogue, NY provides healthcare reimbursement consulting services to medical practices – helping them maximize reimbursement, maintain compliance and optimize operational efficiency. Ms. Montana may be reached at 631-244-5661 or SMontana@HabaneroInc.com.

Private Practice #1 Target for HIPAA Compliance

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Yikes!  Want to know why all this HIPAA stuff is so important for medical practices?  Look at who is Number One on the hit list – private practices. Are YOU in compliance??? 

Here’s what HHS says: 

“Since the compliance date in April 2003, HHS has received over 90,001 HIPAA complaints. We have resolved 94% of complaints received through investigation and enforcement (over 22,026)! 

The most common types of covered entities that have been required to take corrective action, in order of frequency:

1.   Private Practices;
2.   General Hospitals;
3.   Outpatient Facilities;
4.   Health Plans (group health plans and health insurance issuers); and,
5.   Pharmacies.

The compliance issues investigated most are, in order of frequency:

A.    Impermissible uses and disclosures of protected health information;
B.    Lack of safeguards of protected health information;
C.    Lack of patient access to their protected health information;
D.    Uses or disclosures of more than the minimum necessary protected health information; and
E.    Lack of administrative safeguards of electronic protected health information.”

Habanero, Inc. has developed a basic HIPAA & HITECH Privacy Policy & Procedure product that is customized to YOUR practice, provides easy to follow instructions for your Privacy Officer, personalized set of HIPAA Privacy forms and documentation & training materials for your staff, including a staff assessment and acknowledgement process.  Call today at (631) 244-5661 to get your own and be prepared for HHS’  OCR Privacy auditors.