ACOs: An Introduction for Medical Billing Personnel

Kathy McCoy, MBA May 31st, 2011

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Even in the medical billing office, today’s buzzword about healthcare is “accountable care organization,” or ACO. There is little doubt that you’ve heard about ACOs, and just as likely in negative terms as in positive. The main thing to know about ACOs is that they are coming. So, what are they? What do they mean for the U.S. healthcare system and more importantly, for your practice or billing service? Why are they coming? What changes can we expect? How does all this impact medical billing?

First and foremost, the notion of ACOs and their impact on all aspects of healthcare is an enormous and complex topic. It’s also an important one, with wide-reaching implications for everyone in healthcare, including medical billing staff. So, we’ll be tackling this subject in a series of blog posts. But let’s start off simply.

This table from Health Reform Watch shows a comparison of payment reform models, including ACOs

What is an ACO?

An accountable care organization is a new type of healthcare group resulting from specific financial incentives offered to healthcare providers for the purpose of improving coordination, efficiency and quality of care while reducing the costs associated with that care. ACOs are a network of physicians, hospitals and other types of providers that pool resources specifically to make these improvements to quality and cost of care.

Why are ACOs coming?

ACOs are coming because providers have financial incentives to participate in them. Healthcare reform offers financial reward for ACOs that improve care while saving money. (It’s no secret in the medical billing world that practices are looking for revenue wherever they can find it!) The primary reward is a share of the money the ACO saves by pooling its participants’ resources.

What is the Shared Savings Plan?

The main driver for the move to an accountable-care healthcare model is the opportunity providers have to add to their bottom lines a share of the money they helped save. Physicians, hospitals, long-term care facilities and other types of providers who participate in an ACO could be eligible for a portion of that ACO’s share of the savings it provided. That lure of a reduction of the bottom line has already started providers scrambling to make the changes necessary by the start date of January 1, 2012.

What are the necessary changes and requirements for ACOs?

The changes that have providers scrambling and healthcare buzzing are too numerous for this introduction. But the three big ones have already been discussed:

1.   Providers must organize into ACOs

2.   The quality of care, meaning outcomes, must improve

3.   Healthcare must cost less.

Obviously, this is no small feat. The reason everyone, including medical billing staff members, are talking about ACOs is that they represent a huge set of changes… to healthcare in general, to how practices operate and interact and to how they approach patients’ health.

Stay tuned for more on ACOs and their impact on medical billing today and the near- and long-term future. We have only scratched the surface with this post.

In the short term, here’s an interesting set of articles on ACOs on the Health Reform Watch blog.

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Medical Billing Software Update: News and Ideas from Industry for May 27, 2011

Kathy McCoy, MBA May 27th, 2011

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The latest news in medical billing and medical billing software for this week includes predictions of a bleak future for Medicare, continued debate over Medicare pay cuts for physicians and ACOs, and more. Subscribe now to receive our monthly newsletter filled with tips on improving your medical billing results.

Medicare Trustees Paint Bleak Financial Picture

Charles Fiegl, Amednews, May 23, 2011

Physician spending will consume an increasing portion of GDP even if pay cuts take effect. Part A will be insolvent in 2024. The trustees tasked with keeping an eye on Medicare’s finances again warned that it is on an unsustainable fiscal path… Read More

Congress Eyes New Medicare Payment Models

Charles Fiegl, Amednews, May 23, 2011

Key lawmakers are expressing support for transitioning away from the current Medicare payment system toward several different pay models, including pay systems based on quality of care. On May 12, the House Ways and Means health subcommittee held the first in a series of hearings on physician payment in the Medicare system… Read More

Medicaid Physician Pay Swept Up in Battle Over Funding and Access

Doug Trapp, Amednews, May 23, 2011   

An administration rule might make it harder to reduce pay rates. But Republicans say unless states can cut Medicaid rolls, payment may have to decrease. Even as House Republicans started moving a bill that would give cash-strapped states more flexibility to roll back Medicaid eligibility standards, Obama administration officials were proposing new standards for states to maintain access to care for enrollees. The rule could create an obstacle to states that want to reduce Medicaid physician pay… Read More

NIHCR Report: ACO Improvements Effective, Hard to Justify Financially

Rev DiCerto, Diabetes Options, May 2011

Accountable care organizations (ACOs) have been prominent among emerging new models of care delivery in the wake of the March 2010 adoption of the Patient Protection and Affordable Care Act (PPACA). PPACA provides incentives for the formation of ACOs in coming years. Despite the attention the model has received, there remains little agreement as to how ACOs are to be formed… Read More

Common Coding Myths May Put Profits and Practices at Risk

Mary Service, Diabetes Options, May 2011

Correct coding has significant consequences for physician billing and practice. There are a number of coding myths, however, that can jeopardize practices and reduce the amount of revenue for which they can bill. Given the zeal shown by federal agencies and health insurance companies to recover improperly paid bills, it is essential that medical professionals are careful and correct in their coding practices… Read More

How Big a Challenge is ICD-10? Ankle Sprain = 72 Codes

HDM Breaking News, May 24, 2011

Donna Stewart, compliance manager at Children’s Hospital, Norfolk, Va., summarizes this transition to ICD-10 this way: “If successful, the data we’ll extract will be incredible for medicine.” To be sure, it’s a big “if,” yet Steward’s main point about the forthcoming diagnosis and procedure classification system is on point… Read More

Senators Ask HHS to Rewrite ACO Rule

HIMSS News, May 27, 2011

Seven GOP members of the Senate Finance Committee this week sent a letter to HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick expressing their “serious concerns” over the proposed rule for accountable care organizations (ACOs)Read More 

Survey Explores Greatest Challenges with ICD-10 Conversion

HIMSS News, May 24, 2011

Greatest Challenge Associated with ICD-10 Conversion

HIMSS Vantage Point ICD-10 survey reveals healthcare providers' biggest concerns about ICD-10

An HIMSS April Vantage Point survey reveals healthcare providers’ ICD-10 preparedness. Nearly half of respondents noted that their greatest concern related to meeting the ICD-10 implementation guideline is a revenue loss due to a bottle neck of coding issues. One-third of respondents noted that the greatest challenge organizations face as they undertake ICD-10 conversion is a lack of staffing resources…  Read More

Co-Pay Or No Co-Pay? That is the Confusing Question

Emily Berry, Amednews, May 23, 2011

New rules about when to collect confound practices and patients alike. But there are ways to get paid when a practice is supposed to… Read More

Assembling a Robust Revenue Cycle Team: How to Hire and Retain Great Billers, Coders and Collectors

Leigh Page, Becker’s ASC Review, May 27, 2011

Although focused on ASCs, this article offers 14 tips for assembling the best revenue cycle team that apply to most practices, including 1) Hire an adequate number of staff, 2) Pay revenue staff well, 3) Make sure they are IT-savvy, 4) Allow coders to specialize, and more… Read More

10 Ways ASC Coders Can Keep Up with Coding Rules at Little or No Cost

Leigh Page, Becker’s ASC Review, May 23, 2011

Paul Cadorette, director of education for mdStrategies in Houston, cites 10 ways coders for ambulatory surgery centers can stay up-to-date on changes in CPT codes, even on a small budget… Read More

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Medical Billing Update: Navigating the ZPIC Audit and Appeals Process

Kathy McCoy, MBA May 25th, 2011

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ZPIC Audit and Review Process Chart helps you protect your practice during a CMS audit of your medical billing

In medical billing, Medicare audits can be a frightening and foreign threat. What happens? What do I need to do? That’s why I was happy to find this useful chart of the process, developed by Robert W. Liles, Managing Partner of Liles Parker, a law firm specializing in Medicare overpayment matters and cases.

Zone Program Integrity Contractors (ZPICs) have established themselves as the preeminent audit tool of the Centers for Medicare and Medicaid Services (CMS), surpassing both Recovery Audit Contractors (RACs) and Medicare Administrative Contractor (MAC) Benefit Integrity units, explains Mr. Liles.

RAC and ZPIC appeals follow the same general procedures, Liles says, but it is important to learn these procedures regardless of whether you engage counsel. Timeframes, both for recoupment and filing appeals, are very strict, and you should ensure that you meet these deadlines.

For more information and a full size view of the chart, please review the Liles Parker “ZPIC Audit and Appeals Process” Chart.

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Medical Billing Software Update: ICD-10 Category Code Details – Look, Read, Understand and Apply

Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT May 24th, 2011

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Learn how to prepare for the ICD-10 conversion in medical billing with expert Nancy Maguire

“The devil is in the details”!  The “Random House Dictionary of Popular Proverbs and Sayings” shows this phrase as a variation of “God is in the details,” meaning that whatever one does should be done thoroughly; details are important. The saying is generally attributed to Gustave Flaubert (1821-80), who is often quoted as saying, “Le bon Dieu est dans le detail” (God is in the details).

This expression refers to a catch or mysterious element hidden in the details and implies that overlooking the smallest detail might cause failure. Even the most complex project depends on the success of the smallest components.  ICD-10 diagnosis coding will build on details we are familiar with and new code detail and guidelines we have not previously encountered.  Small things in your strategy plan, if overlooked, can result in big problems later on. 

The ICD-10 is copyrighted by the World Health Organization (WHO), which owns and publishes the classification.  On December 22, 2010, the Center for Medicare and Medicaid Services (CMS) posted the updated ICD-10-CM code set to their website.  The ICD-10 codes are currently in draft form and there will be changes and additions prior to the final live date on October 1, 2013.  It would be prudent to obtain a draft ICD-10 diagnosis manual to familiarize yourself with the guidelines, structure and conventions. 

Additional detail may also be found under the ICD-10 category codes in the tabular list

Additional detail may also be found under the ICD-10 category codes in the tabular list as an “includes” note.  An example of this convention is category I21, acute myocardial infarction, which states “includes a myocardial infarction specified as acute or with a stated duration of 4 weeks (28 days) or less from onset”.  This differs from ICD-9 where category 410 states “an acute MI is acute for 8 weeks”. 

For example, code I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery translates to an acute MI.  If the patient is seen post-discharge from the hospital at 18 days from onset of the heart attack, it is still considered an acute MI.  If the patient is seen on day 29 following an acute MI, with no additional complaint or complication, the ICD-10 code would be an old MI code I25.2 (healed myocardial infarction).

Category I22  Subsequent ST Elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction. This category has the following instructional note:  “A code from category I22 must be used in conjunction with a code from category I21. The I22 code should be sequenced first, if it the reason for encounter, or, it should be sequenced after the I21 code if the subsequent MI occurs during the encounter for the initial MI”.  For example: code I22.0, Subsequent ST elevation (STEMI) myocardial infarction of anterior wall.

Category I23 Certain current conditions following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (within the 28 day period).  There is a note under this category code stating: “A code from category I23 must be used in conjunction with a code from category I21 or category I22. The I23 code should be sequenced first, if it is the reason for encounter, or, it should be sequenced after the I21 or I22 code if the complication of the MI occurs during the encounter for the MI”.  Code I23.7 describes postinfarction angina, as an example of a complication.

The ICD-10 code sets have significant changes in structure and concepts that make them very different from ICD-9. The category codes for a heart attack (myocardial infarction) are an example of these differences. It is important to develop a preliminary understanding of the changes from ICD-9 to ICD-10 diagnosis codes.  If unfamiliar with clinical terms, such as STEMI or NSTEMI, the professional coder should query the physician or research the definitions. 

STEMI (ST segment elevation myocardial infarction) indicates the patient has signs of a heart attack.  If a portion of heart muscle was damaged, the electrocardiogram (ECG) tracing shows an elevation of the ST segment, and this “ST Elevation” is considered an indication of a heart attack.  In the case of a non-ST elevation heart attack (NSTEMI), the symptoms of chest pain can be identical to that of a STEMI, but the important difference is that the patient’s electrocardiogram does not show the typical ST elevation changes traditionally associated with a heart attack.

Diagnosis codes are to be used and reported at their highest number of digits available

Diagnosis codes are to be used and reported at their highest number of digits available. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 digits. Codes with three digits are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater detail. A three-digit code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.

Chapter 15 of ICD-10 (Pregnancy, Childbirth and the Puerperium O00-O99) includes greater detail than similar conditions in the ICD-9 coding classification.  These codes are used only on maternal records, never on a newborn’s record.  In ICD-9 many codes in Chapter 11 (Complications of Pregnancy, Childbirth and the Puerperium) required a 5th digit to denote the episode of care (antepartum, postpartum, delivered).  ICD-10 replaces “episode of care” with “trimester”. Trimesters are counted from the first day of the last menstrual period. They are defined as follows: 1st trimester – less than 14 weeks 0 days; 2nd trimester – 14 weeks 0 days to less than 28 weeks 0 days; 3rd trimester – 28 weeks 0 days until delivery. Code O24.112 describes, Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester.

Chapter 15 requires 7 digits in many code definitions.  An example of this is an encounter with the mother for disproportion due to an unusually large fetus (O33.5).  This diagnosis could be the reason for observation, hospitalization or other obstetric care of the mother, or for cesarean delivery before onset of labor.  A 7th character is to be assigned to each code under category O33. The 7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category O30 (Multiple gestation) must also be assigned when assigning a code from category O35 that has a 7th character of 1 through 9.  If the patient presents with a single gestation the appropriate 7th digit is 0 (O33.5xx0).  Subcategory O33.5 does not have a 5th or 6th digit but requires a 7th digit.  In this case, it is necessary to use two placeholders (xx) in the 5th and 6th place followed by the 7th digit of 0 to denote a single gestation.

If the patient presents in the third trimester with twin gestation and disproportion involving fetus 2, the appropriate code assignments would be: O33.5xx2 and O30.003 (twin pregnancy, unspecified, third trimester).

The devil is in the detail when assigning ICD-10 diagnosis codes.  Documentation must support the condition(s) coded and physicians must be educated on the detail required.  This is a new way of doing business and everyone involved must be prepared, patient, and willing to adapt.  Resistance will yield frustration and accomplish nothing meaningful on the path to compliance.

Nancy Maguire, an expert on coding and ICD-10, teaches you how to prepare for the transition in medical billing
Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT, author of The Nancy Maguire GPS to ICD-10-CM Planning and Implementation Guide, is a nationally-renowned procedural and diagnostic coding instructor, bootcamp trainer, and workshop leader. She has spent more than 30 years as a hands-on coder and has authored countless coding articles and presentations. In her expansive career, she has transitioned from nursing, to coding, to practice management, auditing and consulting. Nancy served as Director of Coding and Reimbursement at UTMB in Galveston Texas for four years. She served the first two terms as president of AAPC in the early 1990s.

Nancy will be speaking in a complimentary webinar presented by Kareo medical billing software on “Preparing for ICD-10-CM: The Nitty-Gritty of Diagnosis Coding” on June 16th. Register now.

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Medical Billing Software Update: News and Ideas from Industry for May 20, 2011

Kathy McCoy, MBA May 20th, 2011

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The latest news in medical billing and medical billing software for this week includes the first Meaningful Use checks, debate over Medicare pay cuts for physicians and ACOs, and more. Subscribe now to receive our monthly newsletter filled with tips on improving your medical billing results.

Medicare Issuing Meaningful Use Checks

Joseph Goedert, Health Data Management, May 18, 2011

The Centers for Medicare and Medicaid Services this week started issuing the first Medicare incentive checks for meaningful use of electronic health records authorized under the HITECH Act. It could not immediately be determined how many checks are going out. Attestation of meaningful use started on April 18, and 150 providers successfully attested that day… Read More

AMA Unveils SGR Replacement Plans

Charles Fiegl, Amednews, May 16, 2011

The AMA calls on Congress for five years of positive pay updates while Medicare tests a range of payment models, including full private contracting. Members of organized medicine have offered Congress more specific alternatives to Medicare’s payment formula, which has physician pay in line for a 29.5% cut in 2012. House lawmakers heard testimony from physician organizations at an Energy and Commerce health subcommittee hearing… Read More

Business is Booming for Medicare Recovery Audit Contractors

Charles Fiegl, Amednews, May 16, 2011

A Centers for Medicare & Medicaid Services report reveals that Medicare recovery audit contractors, which recently began operating nationwide, have had great success this fiscal year in identifying overpayments to hospitals, physicians and others — and recouping the cash. In the past six months, RACs have more than tripled the amount of overpayments recovered in all of fiscal 2010… Read More

RACs Focus on Overpayments

Charles Fiegl, Amednews, May 16, 2011

Recovery audit contractors hired by Medicare have returned nearly $240 million in overpayments to the program in the last six months, more than three times the amount collected in fiscal 2010… Read More

Medicare Costs Slow Dramatically, Unlike Commercial Sector

Ron Shinkman, Fierce Healthcare, May 20, 2011

The cost of delivering healthcare in the hospital setting is continuing to rise, but the sector’s inflation has been strongly muted, according to data from the S&P’s Healthcare Economic Indices. The slowdown in the hospital Medicare cost index was particularly dramatic… Read More

Specialists Question ACO Integration, Show Reluctance to Join

Ron Shinkman, Fierce Healthcare, May 20, 2011

Organizations representing oncologists and other specialty physicians are expressing some concerns about how accountable care organizations will be regulated, reports AIS HealthRead More 

Tactics for Tight Times: How to Keep Your Practice Afloat

Victoria Stagg Elliott, Amednews, May 16, 2011

When a physician practice’s cash flow slows, there are many strategies for coping until the stream begins running again. In 2008, the cash flow of the medical practice of Daniel Lensink, MD, an ophthalmic plastic surgeon in Redding, Calif., slowed to a trickle. He had plenty of Medicare patients to fill up his schedule, but as expenses went up, Medicare pay rates stayed flat. “When I entered medicine, there was a promise that if I took care of everybody who came my way, I could make a living,” said Dr. Lensink, who has a solo practice with three full-time employees. “I didn’t realize I could be busy and go broke at the same time”… Read More

Insurer-Owned Clinics Bid to Offer More Patient Care

Pamela Lewis Dolan, Amednews, May 16, 2011

Major health plans are expanding direct care to control costs and put their names in front of potential individual insurance shoppers. The company that found the Food City grocery store in Phoenix so attractive for an in-store clinic isn’t a typical retail clinic operator. It’s Cigna, one of many health plans moving aggressively to expand its operations into treating patients… Read More

HHS OIG Raises Concerns About HIT Security Standards

HIMSS News, May 20, 2011

The HHS Office of the Inspector General (OIG) conducted an audit of information technology security included in health information technology standards, finding that “there were no HIT standards that included general IT security controls”… Read More

Medical Liability Reform Awaits Vote in House; ASC Association Maintains Support

Rob Kurtz, Becker’s ASC Review, May 19, 2011

The Help Efficient, Accessible, Low-Cost, Timely Healthcare (HEALTH) Act of 2011 awaits a vote in the House of Representatives after it was voted out of committee by the House Energy & Commerce Committee, according to the Ambulatory Surgery Center Association’s Government Update. According to the Government Update, the proposed legislation would… Read More

5 Surgery Center Coding and Billing Tips

Rob Kurtz, Becker’s ASC Review, May 19, 2011

Here are five ambulatory surgery center coding and billing tips from the team at National Medical Billing Services: 1. Use modifiers that meet payor guidelines. Ryan Flesner, direct of A/R for NMBS, says certain carriers have different preferences when it comes to modifiers… Read More

Subscribe now to our monthly e-newsletter to receive additional articles and news on improving the profitability of your medical billing.

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Medical Billing Video Update: Top 3 Ways to Improve Your Medical Billing

Kathy McCoy, MBA May 19th, 2011

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Many of you have enjoyed the webinars we’ve conducted featuring Elizabeth Woodcock, MBA, FACMPE, CPC, a leading expert and author on medical practice management and medical billing, so we asked Elizabeth to record a short video featuring her top 3 tips for improving your medical billing. Here is what she shared with us:

For more information on improving your medical billing, watch these archived webinars featuring Elizabeth Woodcock:

Learn how to improve your medical billing results with denial management
Denial Management:  Strategies to Improve Cash Flow in Medical Billing


Learn how to incentivize your billers for optimal performance in your medical billing
Best Practices in Medical Billing: How to Incentivize Your Staff for Optimal Performance

Learn how to use key performance indicators to improve your medical billing results
Key Performance Indicators in Medical Billing: How to Make 2011 More Profitable for Your Practice than 2010

Learn the best practices in medical billing that will make your practice more profitable
Best Practices in Medical Billing: What the Most Successful Practices Know that You Don’t

We hope you find these resources useful. Please let us know what subjects you would like covered in future webinars.

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Medical Billing Update: Protect Your Practice with a Good Compliance Program

Kathy McCoy, MBA May 18th, 2011

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CMS webinar presented guidelines for making sure your medical billing is compliant with CMS policies

I watched part of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) Provider Compliance Training offered by CMS this morning, and found it to be interesting, to say the least. First, I was amused that they offered the training from 5:30 AM to 10:00 AM Pacific Time.

Really? You want me to watch a webinar for four and a half hours? Kareo offers webinars on a regular basis, and the longest one we’ve done was about an hour and a half. We recognize that people have lives…and work to do. And that’s ignoring the fact that it started at 5:30 AM my time.

Next there were the technical issues…in the middle of the section I watched, we were suddenly treated to part of a clinical presentation on Job’s syndrome. What that has to do with compliance, I don’t know. After a few minutes, the previous (and scheduled) presenter reappeared. Then, the webinar ended in the middle of the last presenter’s talk.

Jacqueline Franklin, Supervisory Criminal Investigator of the Medicaid Fraud Control Unit of Washington, D.C., I’m sorry I didn’t get to hear what you had to say.

All told, it made me think of that famous saying by Ronald Reagan: that the most frightening words in the world are, “We’re from the government, and we’re here to help.”

These are the people who are in charge of the hen house, and I find that more than a little unsettling.

A group that can’t run a webinar without technical issues is now crunching data and using “analytics” to find healthcare fraud. Does that make you nervous? (And now I’m wondering if my taxes will be audited, having written that.)

The good news: Nick DiGulio, Office of Investigations, Special Agent in Charge, OIG/HHS, said that his office is using analytics so that they can be “truly targeting the bad guys.” Mr. DiGulio said, “We vet all complaints that come into our office. We take our job very seriously, and we look for false positives.” He assured us that just because a practice sets off all the bells, it doesn’t mean that they will automatically be prosecuted. Feel better?

But in spite of my doubts, the webinar did provide some useful information. It was recorded, so if you have several hours to kill (and even if you don’t, it’s best if you assign someone to watch it) you can review the material. You can find it at “on or before May 31, 2011″ according to the OIG website. There are a number of resources posted there as well, including the slides from the webinar.

As an example of those resources, here is an outline provided by Tony Maida, Administrative & Civil Remedies Branch, Deputy Branch Chief, OIG/HHS, that you may find useful in setting up and or/managing your own compliance program:

Operating an Effective Compliance Program

Policies and Procedures
- Regularly review and update with department managers and Compliance Committee.
- Assess whether they are tailored to the intended audience and their job functions.
- Ensure they are written clearly.
- Include “real-life” examples.

Measuring Effectiveness
- Develop compliance program with benchmarks and measurable goals.
- Set up a system to measure how well you are meeting those goals.
- Involve the Board in creating the program and regularly update the Board regarding compliance risks, audits, and investigations.
- If one or more goals are not met, investigate why and how to improve in the future.
- Assess whether the compliance program has sufficient funding and support.

Train your medical billing and other staff on compliance

- Regularly review and update training programs. Try different approaches. Use “real-life” examples.
- Make training completion a job requirement.
- Test employees’ understanding of training topics.
- Maintain documentation to show which employees received training.
- Train the Board.
- Train yourself and your compliance staff. Attend conferences and webinars, subscribe to publications and OIG’s email list, monitor OIG’s website, and network with peers to stay up-to-date and get ideas.

Lines of Communication
- Have open lines of communication between you and employees.
- Maintain an anonymous “hotline” to report issues to you.
- Enforce a non-retaliation policy for employees who report potential problems.
- Establish a direct line of communication between you and the Board.
- Use surveys or other tools to get feedback on training and on the compliance program.
- Use newsletters or internal websites to maintain visibility with employees.
- Regularly meet with the Board and brief them on the compliance program.

Develop an audit plan to insure your medical billing is in compliance with CMS policies

Internal Auditing
- Perform proactive reviews in coding, contracts & quality of care.
- Create an audit plan and re-evaluate it regularly.
- Identify your organization’s risk areas. Use your networking and compliance resources to get ideas and see what others are doing.
- Don’t only focus on the money – also evaluate what caused the problem.
- Create corrective action plans to fix the problem.
- Refer to sampling techniques in OIG’s Self Disclosure Protocol and in CIAs to get ideas.

Enforcement of Policies and Procedures and Prompt Response to Compliance Issues
- Delegate/empower teams closest to the issues to perform reviews, but be careful of possible conflicts or personal relationships that may interfere with getting an objective review.
- Act promptly, and take appropriate corrective action.
- Create a system or process to track resolution of complaints.
- Enforce your policies consistently through appropriate disciplinary

My point in all of this is that while it is a little frightening that the government is combing through data looking for malfeasance, practices need to do what they can to keep CMS out of their offices. An ounce of prevention is worth a pound of cure, as the old saying goes. So as was recommended in the webinar, make sure that you have a compliance program in place, be proactive and keep your employees trained. If you have an issue, report it yourself rather than trying to hide it.

Exclusion is a very painful thing, and certainly won’t do a thing for your medical billing.

Did anyone else attend? What do you think about this program?

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Medical Billing Software Update: News and Ideas from Industry for May 13, 2011

Kathy McCoy, MBA May 13th, 2011

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We want to help you make the most of your medical billing software and improve your practice profitability. That’s why you’ll find a section of news and ideas from the medical billing industry in each issue of our monthly newsletter. Since these news items are often extremely popular with our readers, we are now bringing them to you on a more frequent basis so that you can stay up to date on the latest in medical billing and medical billing software. We hope you find these items useful. Subscribe now to receive our monthly newsletter filled with tips on improving your medical billing results.

OIG Offers Free Compliance Training Webcast May 18

OIG, May 12, 2011

The Office of the Inspector General (OIG) is offering a free webcast of its HEAT Provider Compliance Training on May 18 at 8:30 a.m.–1:00 p.m. Eastern Time. Attendees will learn about the fundamentals and best practices of health care compliance…  Read More

The Cost of Moving to ICD-10: 20 Statistics for Physician Practices

Rachel Fields, Becker’s ASC Review, May 3, 2011

Here are 20 statistics about the cost of ICD-10 for physician practices, based on 2008 data released by Nachimson Advisors, LLC, on behalf of various healthcare organizations. Costs for a typical small practice… Read More

ACO Regs Are “Overly Prescriptive, Operationally Burdensome,” Docs Say

Ron Shinkman, Fierce Healthcare, May 13, 2011

The American Medical Group Association has pushed back on the Obama Administration’s recently released regulations on accountable care organizations, claiming they are too costly and complex to administer and enforce, reports the Associated PressRead More

Beware Physician Compare: Medicare Site Inaccurate, Say Wronged Practices

Charles Fiegl, Amednews, May 9, 2011 

Doctors and other health professionals have been disheartened with what they’ve found out about themselves on Medicare’s Physician Compare website. Doctors say if CMS can’t get simple biographical information right, expanding the website to include quality scores by 2013 might not produce a trustworthy resource. Name misspellings, locality mistakes and other errors have physicians questioning the integrity and accuracy of the information on the site and wondering… Read More

GOP Urges Obama to Repeal — Not Expand — Medicare Pay Board

Charles Fiegl, Amednews, May 9, 2011 

Republican leaders in Congress have blasted President Obama’s plans to strengthen the upcoming Medicare Independent Payment Advisory Board as a way to cut spending growth and extend the solvency of the program… Read More

Denial-Management Programs Get Claims Paid

 Victoria Stagg Elliott, Amednews, May 9, 2011 

Deanna Brown, practice manager at Tennessee Valley Urology Center in Cleveland, Tenn., established a claims denial-management program when she began working there eight years ago. She had seen the bottom-line importance of such programs at the practices where she previously worked… Read More

Two More Senators Introduce Bills To Publish Medicare Claims Data

Charles Fiegl, Amednews, May 9, 2011 

Two additional senators have proposed separate bills to open Medicare claims data to the public, a move that doctors organizations have opposed on privacy and anti-fraud grounds… Read More

Subscribe now to our monthly e-newsletter to receive additional articles and news on improving the profitability of your medical billing.

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Medical Billing: Know When to Outsource Delinquent Accounts to Third-Party Collections Professionals

Kathy McCoy, MBA May 12th, 2011

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Improve your medical billing results by knowing when to outsource collectionsA key premise behind medical billing — and medical billing software specifically — is that for some practices there are distinct advantages to keeping billing services in-house. And some of these advantages extend to the efforts to collect on delinquent accounts. But the reality is that some of your accounts will need to be outsourced.

First, a reality check.

Let’s review some of the most basic truths about medical billing and delinquent accounts:

•     There will be late-paying and non-paying accounts. It’s a sad but unavoidable fact.

•     Practices must have — and stick to — a realistic and effective debt-recovery plan.

•     The longer an account is delinquent, the lower the likelihood of collection… and the greater the costs and challenges of collection.

•     Part of your practice’s debt-recovery strategy should be to outsource certain accounts to debt-collections professionals.

The big question: When to outsource a delinquent account?

Every practice is different, but there is a simple answer: Your medical billing team should be outsourcing accounts that are delinquent and unpaid for two or three months. But be clear: These three months should consist of multiple contacts and collections attempts consistent with your practice’s written, vetted, always-followed policy for debt collections.

Before outsourcing, make a serious effort to collect.

Remember that the value of an account is said to depreciate about 15% with each month that passes, so your staff needs to be expending effort. Remember, too, that in-house staff can begin the collections process as soon as the account becomes delinquent. Your billing professionals also have the advantage of being part of the trusted medical provider’s caring, dedicated staff. This can improve the chances of collection, but it’s also essential to maintaining the patient’s loyalty and trust. The object is to both collect the delinquent amount and keep the patient.

After three months, rely on the professionals.

But after three months, the die is pretty well cast: You’ve got a difficult account. It’s a benefit, of course, that staffers bring a level of personal compassion and understanding. Yet, drawing a “hard line” of three months makes it easy to be more dispassionate, a trait that, frankly, is warranted and appropriate for seriously delinquent accounts. (Also, dispassion is what is coming from the third-party collections professionals.)

It’s a simple rule; a quarter of a year is long enough. You can’t pursue a lost cause (at least, lost to your internal staff) at the expense of labor that is needed for the practice to fulfill on its primary healthcare mission.

Outsourcing collections is best when done wisely.

It is a very simple premise: To get professional results, hire real professionals. There is no shortage of agencies to choose from to collect on your delinquent accounts. There are so many, in fact, that you could get all manner of outcomes, not all of them positive. So, like anything else, your medical billing manager or practice leadership must choose a collections vendor carefully. Here are some key considerations to keep top-of-mind when selecting a debt-collections agency:

•     Dedication – You want more than a vendor that specializes in debt collections; you’ll want one that specializes in medical debt collection. The more narrow and specific to what you do, the better.

•     Experience – There is no substitute. Remember that you’re outsourcing these accounts to a team with collections as the core competency. That logic extends to selecting a team with more of that core competency, which amounts to a greater breadth and depth of experience.

•     Licensure – Collection agencies are only allowed to collect in states where they have been licensed. Licensure means they know the laws and regulations, and that’s critically important.

•     Reputation – In addition to wanting a reputable agency, you want one that will represent and act on behalf of your practice in a way that won’t negatively affect its/your reputation. Choose a collections team that will be resolute, consistent and effective without being hostile, unprofessional or insensitive.

Ultimately, knowing when to outsource collections for delinquent accounts is easy: After three months of good effort by in-house medical billing personnel. The more significant task is to find that vendor most likely to be successful while making sure to represent your practice well and act in its best interests. Follow these guidelines, and you will avoid many of the common errors.

What suggestions do you have for practices struggling with collections? Do you have a good or bad experience to share?

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Work with Medical Providers to Maximize Your Medical Billing

Kathy McCoy, MBA May 11th, 2011

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Work with your medical providers to maximize your medical billingThere is no question that physicians are busier than ever these days, seeing more patients and often making less as reimbursement continues to decline. That is why it is so important for billing professionals to work closely with health care providers to ensure that medical billing reflects the full scope of services that they provide.  Medical billers also need to ensure that they include all allowable supplies as they submit claims to payors. Because codes change or are updated periodically, physicians may not be up-to-date on what the definitions of allowable services and supplies really are. It is in everyone’s best interest to keep medical providers current on how they can maximize their reimbursement via medical billing.

 I came across a good article in Physicians Practice recently that provided a good overview. Here are some of the common pitfalls they offered that may be limiting your practice’s cash flow:

Downcoding Visits – There is a difference between having a conversation with a patient about his progress and actively managing the condition. Documentation of a problem-focused visit (99212) would look something like this: “Mr. Smith is being seen today for his elbow injury last month. He has been regularly attending rehabilitation and has no complaints. We will see him again in another month.” It’s much more likely that the physician reviewed the prescribed treatments, such as continued rehab while icing the elbow and using a brace, and recommending over-the-counter medications as needed for pain. Even with no complaints from the patient, this would qualify for an evaluation and management visit (99213). It’s all in the details.

Failing to document negative findings – Evaluating a patient entails much more than an examination of his or her chief complaint. Ruling out what’s not involved in an illness or injury is a fundamental part of the diagnostic process. But many physicians fail to bill for it. Medical billing should reflect what the provider looked for related to the condition but didn’t find, as well as what he did diagnose. For instance, consider a patient presenting with knee pain and limited range of motion. The physician may take a pulse and look for lesions or rashes, signs of injury, neurological impairment, or pain to the touch. But stating in the record he only evaluated knee pain and limited ROM equates to a problem-focused exam covering just one organ system, which is a lower-level code. By fully documenting both positive and negative findings, that same provider shows he examined three or more organ systems — a detailed exam under the 1995 rules or an expanded exam under the 1997 rules—and both a higher code. Why not get paid for that?

Not reflecting the treatment thought process – Physicians may also fail to bill for the scope of an assessment and medical plan that is based on other physicians’ records or diagnostics they have ordered for the patient. An assessment and medical plan in the patient’s record should state the diagnosis and the rationale for the treatment plan, test, therapy, or other orders. The record should also reflect if the provider discussed options with the patient or what the prescribed next steps are, such as therapy, watchful waiting or surgery.

Billing professionals should be sure to review any new or changed codes as they relate to the PCP or specialists within the practice. By staying diligent and communicating potential opportunities for enhancing reimbursement through medical billing, everyone wins.

Learn more about maximizing your medical billing and medical billing software now.

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