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.

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.

OMNI 3750 terminals to be deactivated on March 31, 2013

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SSI Adds “Swipe Card Technology” to PC-MVS Product Line

 Synchronized Systems, a software development company based in Patchogue, New York has announced it has added “Swipe Card Technology” to its existing PC-MVS Medicaid Verification System product line. At press time, one of the staff members at Synchronized spoke to us about what the “Swipe Card Technology” will offer existing customers that license the product. “Our customers already use the product to batch enter, or batch import, Eligibility data and can get results in Real-Time. They have been waiting for this add-on technology, so that they can move the PC-MVS product line onto computers located at the front desk of clinics and day treatment centers across the city” stated Peter Rabolt, a senior developer for the company. Peter goes on to say “The swiping capability marries with the current PC-MVS software, providing a virtual, as well as cost effective replacement of the current EMEVS terminals (OMNI 3750 terminals to be deactivated on March 31, 2013)”

 Synchronized can back up its knowledge and experience in this area with a powerbase of over 700 licenses sold to Medicaid Providers across NY State.  The new PC-MVS Scan Option allows customers to slide a NY State client benefit card through the SSI approved Slide Card Reader. After decoding the information on the card, the system adds all the necessary information to the database, and performs a Real-Time eligibility check and printout with no other input from the user. “Other useful options could be to scan and save all pertinent information to the database, then at a later time, send the entire batch for real-time results. This is a flexible batching feature that is unique to the PC-MVS product line, and a capability that the EMEVS box sorely lacks”, said Neil Petillo, another company representative.

 Using software that never physically “breaks down” could change the way many hospitals, clinics, and medical centers perform these vital billing related functions. It will be interesting to see what impact this technology has on the current base of EMEVS terminals that exist out in the field. 2 large medical providers have already signed on to beta test the new technology from SSI, which will eventually replace a total of  35 EMEVS boxes with this flexible software solution.

For more information on this product or any other EDI related problem or project, contact Peter Rabolt (“The EDI Guy”) at Synchronized Systems

PH: (631) 207-4221  Email: synchsys@rcn.com  Website: www.ssi-ny.com

Top Ten Signs of a ‘Buttoned Up’ Medical Practice

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Is your medical practice ‘buttoned up’ ?

I work with medical practices all the time, and they don’t always seem to have all their bases covered.  This means they are spending their days fighting fires, while they provide patient care, but they are not able to spend their time proactively thinking about how to make things better.

Here are some questions you should ask yourself to see if your medical practice is performing at the top of your game:

  1. Do you have command of your numbers?  And do you know what those numbers mean?  Between your accountant, and your practice management and billing systems, you should be able to know all kinds of metrics about your practice.
  2. Do you know where your patients come from, and do you know which patients you’d like to have more of?  Less of?
  3. What is your internet presence, and what do patients who are looking for your services, or looking into your practice, find when they do a search?
  4. Are your contracts and fee schedules all up to date, and have you negotiated the highest reimbursement from your payors?
  5. Are all your forms, superbills, EHR templates, billing reports up to date so you can maximize your capture of the most current documentation, coding, billing and remittance information?
  6. Are you providing only those services you’ll get paid for, and referring patients to other specialty providers when their insurance plan won’t pay you?  For example, many insurance companies today don’t pay for imaging services in the office and require patients to go to specially contracted imaging centers.  Many providers have the equipment and figure it doesn’t really cost more to do it themselves, however, have you really done a return on investment analysis?
  7. Are you documenting and coding and billing correctly for all the services you DO provide?  Many providers are so wary of being accused of over billing or over coding that they are cheating themselves.
  8. Are you getting paid, and paid correctly, for all services you do provide?  If you use an outside billing service, how do you keep track of this?  What do you do when reimbursement falls short?
  9. Do you perform regular internal audits of your entire revenue cycle to identify any areas in need of improvement?
  10. And, this is a new one over the past couple years.  Are you KEEPING the payments you do get?  Every insurance company, especially the governmental payors like Medicare and Medicaid, have hired outside firms to work on a CONTINGENT FEE BASIS to identify ‘fraud and abuse’ and recover payments already made to providers, and many times these are for services provided YEARS AGO!  These companies cast a wide net looking for any potential discrepancies and many providers are so afraid of getting onto the radar of the government in any way that they may actually be doing themselves a disservice by not assertively responding to these refund requests.

 

I met with a practice yesterday that had met just about all these criteria, and it was so refreshing!  With so many practitioners being challenged by all the change going on in the healthcare arena, it is inspiring to see that it isn’t getting to everyone.

How about you?  If your practice needs a tune up, or if you’d like an assessment of the most cost effective improvements for your particular practice, contact us for a free consultation at info@HabaneroInc.com

Healthcare and the Internet

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Patients and providers alike should be utilizing the internet in their pursuit of healthcare.  The first point of connection – the patient and the provider meeting – might be the most important for both parties.

keyboard_stethoscopeIf you are a patient, and you need to connect with a provider for a particular condition, how do you choose from the many providers out there?  If you’re a provider and you want to be able to connect with new patients, how do they find, and then select you?  Here are just a few options:

Insurance Company Lists

If a patient is fortunate enough to have access to health insurance, the insurance company maintains a list of providers who participate in their insurance plans.  These lists may be available in hard copy form, or more commonly, on the insurance company’s website.  Patients can use these lists to narrow down their choices based upon name recognition or geographic location.  Providers should regularly confirm all their practice locations are properly listed for all the insurance companies with whom they participate, and promptly update any inaccurate or insufficient listings.

Internet Searches

There are MANY sources of provider information available online.  Patients today can post their experiences, both good and bad, on one of dozens of healthcare opinion and experience websites, such as healthgrades.com, vitals.com and ratemds.com, to name just a few.  Providers, what information is prospective patients seeing about YOU when they do an internet search?

Word of Mouth

Often the first choice for a patient is a provider who comes with a glowing recommendation from a friend or family member.  Sometimes, the recommendation is so compelling, the patient doesn’t care if the provider is in their insurance network or not, and they are even willing to pay out of pocket and seek reimbursement from the insurance company after services are rendered.  The same word of mouth system can have the exact opposite effect, where a bad experience can steer a patient away from a prospective provider.  Providers, ask yourselves honestly, what are your current and prior patients telling their friends and family?  And keep in mind, unsatisfactory experiences with office and billing staff can negatively reflect on otherwise good medical care!

Please direct your health care reimbursement questions or topics you would like to know more about to Sue@HabaneroInc.com.

Telehealth – Great Concept, But Can You Get Paid?

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I’ve always got interesting stuff coming across my desk.  This week it’s Telehealth Services.  The idea is not new, but insurance plans potentially paying for the service is.

telehealthThe concept of Telemedicine is that the health care system could save considerable money, and patients could experience a heightened level of support for particularly delicate conditions, if the patient could be accessed remotely by the provider.

Obviously, this won’t work well for physical therapy and other hands on healthcare modalities, but certain treatments and conditions, such as continuous oxygen, patient history of non-compliance, high risk of emergency care interventions, medication management, etc. lend themselves to this new technology.

As technology has gotten more sophisticated and less expensive to deploy, telehealth services have become more appealing to all parties – patients, insurance companies and providers of healthcare services.

Medicare has issued very comprehensive guidelines, and many Medicaid agencies have adopted CMS’ guidelines as well.  Commercial insurance carriers address it in their provider manuals, but always with a litany of caveats as to when, if and how much they might pay.  And the documentation, coding and reimbursement rules are likely to trip up providers as they attempt to participate in this new healthcare delivery system.

The good news is that if this technology is able to deliver as promised, we could be welcoming a new breed of medical monitoring devices in our homes in the very near future.

 

Why patients AND providers should care about insurance appeals

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My guest in August 2011 was Thomas Force, Esq. of the Patriot Group.  Habanero Tom Force Interview August 2011We discussed the importance of appealing medical claims from both the patient and the provider perspective.  It runs 36 minutes.

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