How You Can Improve Your Time of Service Collections

Kathy McCoy, MBA October 27th, 2011

Leave a Comment Latest by COMMENTOR NAME

Patients today are increasingly more responsible for a higher percentage of their total health care bills. In addition to co-payments, some patients may have deductibles that range as high as $2,500 to $5,000, notes Betsy Nicoletti, M.S., CPC in a new video produced by Kareo: How to Improve Your Time of Service Collections. Betsy is the founder of and is a well-respected authority in matters that pertain to practice management and medical billing. Kareo provides these videos with experts such as Betsy to help practice managers and medical billers achieve more success and better cash flow.

In the webinar, Betsy gives an excellent overview of assertive, proactive collection strategies in a video that lasts no more than five minutes. This blog will summarize her recommendations but cannot cover every salient point in Betsy’s informative presentation. To do that, view How to Improve Your Time of Service Collections now (or click on the video below). For the “Cliff Notes” version, keep reading.

Betsy stresses that the first important step in collecting what is due to you is knowing if the patient had insurance, what type it is, and if the deductible has been met. Some practice management systems will do batch verifications and eligibility, and will return information on any deductibles that haven’t been met. If yours does not offer this function, you will need to check the payors’ websites for this information on each patient.

Betsy also advises that each practice have a financial policy in writing that is given to each patient. There are many free examples on the internet. Use a welcoming tone but be sure it spells out that you expect to be paid.  If a high balance leads a patient to request a payment plan, don’t be a bank for long – try to limit the term to six months. Otherwise, you are giving free interest while carrying the balance on your books. And require that the arrangement utilizes a recurring payment system such as automatic debits to a credit card.

In today’s economy, it is increasingly common that some accounts will end up in collections. If that happens, be sure to change that patient’s status in your practice management system, noting the outstanding balance. If and when the patient opts to return, ask for the balance due and require cash going forward before accepting them back to the practice. Any balances that go to collections should be written off from your days in accounts receivables. Otherwise, those unpaid balances will skew your calculations on accounts over 120 days and make it difficult to trend your true A/R.

Kareo offers a powerful yet user-friendly solution to effectively handle your medical billing from appointments to payments and collections. Learn more about Kareo medical billing software and its unique capabilities aimed at generating more cash for your practice.

Betsy Nicoletti, M.S., CPC, is the founder of, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at You can watch an informational video by Betsy Nicoletti on Better Collections Through Improved Medical Coding now. Or, view her archived webinar on What You Can Do to Prepare for Medicare Payment Reductions.

Read More

MGMA Day Three: Patient Throughput Analysis, Payer Contract Language to Avoid, and More

Kathy McCoy, MBA October 25th, 2011

Leave a Comment Latest by COMMENTOR NAME

Another full day here at MGMA, with lots of informative sessions and last day of the exhibit hall. I was pleased to be able to sit down with some of our Getting Paid contributors while I was here: Betsy Nicoletti last night, and Sara Larch today. We discussed some new article ideas that will be coming your way in the Getting Paid newsletter that I think you’ll enjoy. If you have ideas you’d like us to write about, please share them with us in the Comments box or on our Facebook page.

We also enjoyed being able to give away a free iPad to a lucky winner: Carol Kristofix, who I understand recently lost her iPad to a thief. It’s nice to be able to balance the karma of the world while we make medical billing easy.

As far as the sessions, the first one I attended was “Conducting a Patient Throughput Analysis” by Frank Cohen, MBB, MPA. I wish his slides were posted on the MGMA site like so many others because they were extremely detailed and informative, but unfortunately not so. I have to admit that like many others, my eyes started to glaze over when he veered too much into statistical analysis. However, when he summed up by saying that by conducting the patient throughput analysis and improving the process to reduce the time required, the practice was able to see 9 additional patients per day and brought an additional $285,000 revenue to the practice, my eyes were opened along with the rest of the audience.

They achieved this by analyzing the time involved in each step of the patient intake experience and analyzing where delays existed, then testing solutions. One interesting solution was that they found the older patients had trouble reading the intake forms because they had forgotten their reading glasses—so Frank went out and bought 50 pairs of reading glasses for a $75 investment, shaving 7 minutes out of the wait time. Ultimately they saved the practice 22 minutes per patient, resulting in the revenue improvement.

Another interesting session was “The Evolving PQRS: Securing Incentive Payments, Avoiding Penalties and Maximizing Value” by Francis Campion, MD, FACP, which looked at the purpose and specifics of the PQRS program. It was a good overview; I particularly liked the PQRS Registry Reporting Options (see slide below).

PQRS Registry Reporting Options -- Campion

Finally, the absolute best session of the day (and possibly of the conference) for me was “Deal Breakers in Payer Contract Language” by Penny Noyes. Penny has a background on the payer side, and she promised to tell us “some things payers might not want you to know.” In my opinion, she delivered. First she provided an explanation of self-funded and insured plans, explaining that if a plan is self-funded, insurance laws don’t apply. This is extremely important when negotiating contracts, because it means that without specific contractual language prohibiting it, a self-funded plan can come back to you long after the usual 18 month recoupment limit (she has seen plans come back after 4 and 5 years).

Penny gave a thorough discussion of how to determine what your deal breakers are in contract negotiation, with examples of language you definitely don’t want to agree to, and some better alternatives. Some of the key points she mentioned include:


Deal Breakers--Any Practice--Noyes


The Long List of Payer Contract Negotiation Dealbreakers 1 -- Noyes

The Long List of Payer Contract Negotiation Dealbreakers 2 -- NoyesThe Long List 3 -- Noyes

  1. If a contract provides for 18 months recoupment for the insurer, you shouldn’t be limited to 30 days to correct errors. Push for 18 months for your practice as well.
  2. Make sure it’s specified which contract prevails. In negotiating a contract recently for an ACO, the contract they had agreed to was 4th in line; the practice had neither seen nor agreed to the other contracts, but were bound to them by language in the contract they did sign.
  3. Avoid “black box” language that requires you to agree to something that’s unspecified. This includes vague references to payment policies you’ve never seen and could be changed without your agreement. She said she hasn’t been successful in getting the payment policy language out completely, but to push to see the payment policies and to get the language out. Ultimately, she hopes to see that change.
  4. Don’t agree to recoupment through offsets—the payer should not be allowed to borrow from one patient to correct a problem with another patient. This obviously causes a nightmare for your bookkeeping.
  5. Don’t agree to a contract that automatically renews or allows for notification of rate changes without written notification and your signed approval.
  6. Make the payer spell out what rates are based on and what the fee schedule is. Don’t allow them to include some unknown “then current” or “prevailing year language.

Overall, Penny urged practices to require specificity in contracts, written notice of rate or term changes, and to push for equality in terms for timely payment, etc. As you can see from the few of her slides that I have included, it was an excellent session.

Now for the final day tomorrow—there are still some interesting sessions to go. If you’re here, I hope you’ve enjoyed the conference and have safe travels home.


Read More

MGMA Day Two: Washington Update, Maximum Performance and Women Leadership

Kathy McCoy, MBA October 24th, 2011

Leave a Comment Latest by COMMENTOR NAME

MGMA Women Business Leaders Reception

Today was an action-packed day at MGMA, filled with informative sessions. I didn’t even have time to look for oddities in the Exhibit Hall.

The day started with Washington Update, an overview of regulation changes and proposed regulation affecting practices that was so fast-moving I got a cramp in my thumb from taking notes. First Allison Brennan, senior advocacy advisor for MGMA, reviewed the federal debt issues driving pending Medicare cuts, and the select committee that’s attempting to solve the problem. She mentioned that there is “not a lot of transparency in the process—a lot is happening behind closed doors.” This is a surprise in Washington? But I agree with her position that there should be more transparency in the process.

Allison mentioned that the MGMA has recommended that the SGR be repealed as part of the debt resolution, and I think we can all agree that would be a good thing. She mentioned that MGMA is asking for your support on this, and you can find sample letters and other ways to get involved on the MGMA website. MGMA is also conducting research into the effect of the proposed SGR cut, and they will be releasing the results soon.

For the future, Allison said that Medpac is recommending cuts of 5.9% for certain services each year going forward, excluding primary care practices. As Medscape pointed out in a recent article, “The proposed fix, which would ultimately require Congressional approval, translates into a 10-year freeze of Medicare pay for primary care physicians. Specialists would experience a 5.9% pay cut for 3 straight years, followed by 7 years of no change.”

Progressing to Accountable Care Organizations (ACOs), Allison reminded the audience that the program is voluntary and then covered the changes announced last Thursday. The key changes include:

  • How patients will be assigned to a particular ACO
  • Quality reporting requirements were reduced to 33 measures from 65.
  • Shared savings—CMS is considering two different types of models, one-sided and two-sided, with the two-sided model involving risk for the practice
  • Fraud and abuse waivers

Allison also reminded the audience that this is just one of multiple longer-term payment reforms, so we have more to look forward to.

Revenue Enhancement Tactics - Halley

On a more positive note, Marc Halley presented a packed session (many of us were sitting on the floor) entitled “The Game Has Changed: Adapting for Maximum Performance.” This session was packed with ideas for improving practice profitability, from increasing revenue to containing costs. Among his points:

  •          He’s hearing from clients that after a year of launching an EMR, they’re at 60% of previous productivity. “An EMR is like a baby: it requires care and feeding.” Thus the need for increasing productivity wherever possible.
  •          Be sure to get sponsorship for change, particularly from physicians. Only so many changes can be implemented at once.
  •          Patients want:
                  • Access
                  • Communication
                  • Nice Staff
  •          To increase referrals, script answers to calls from referring physicians to reinforce their value to the practice: “The doctor’s in an exam room, but I know he’d want to talk to you. Would you like me to interrupt him?” Since the answer will almost always be no, the following answer should be: “Where can he reach you in the next 20 minutes, because he will want to talk to you.” (Then make sure the call back is made.)

Expense Reduction Strategies - Halley

  •          Adjust your fee schedule. Often he’ll find fees that are below Medicare rates. Why would you want to leave money on the table?
  •          One of his clients scheduled 35 appointments to get 25 slots filled, since no-shows were high in the area. Test different scheduling levels to fill your appointment slots, and consider adding physicians with staggered hours.
  • Twelve Critical Revenue and Expense Factors - Halley
  •          Make sure you have the right staff performing the right tasks, which he calls Highest and Best Use Staffing. It doesn’t make sense to have a doctor standing at the fax machine for two reasons: 1) He’s too highly paid to do that and 2) He’ll break it. (The audience loved this one.)

Finally, I ended the day at the Women Business Leaders reception, at the invitation of Sara Larch, one of the group’s founders. This terrific group was celebrating their tenth year, and I was very pleased to be part of it. Now, on to Day 3!


Read More

Observations from MGMA 2011: ICD-10, RVUs, Elvis and More

Kathy McCoy, MBA October 24th, 2011

Leave a Comment Latest by COMMENTOR NAME

Cirque du Soleil performers entertained on the first day of MGMA 2011

Very lively and engaged audience at MGMA 2011—sessions I have been in have been very well-attended and information-packed. Here are some brief observations, with more indepth info to follow:

On Sunday, the exhibit hall was well-filled as participants visited the many booths, enjoyed food and entertainment at receptions and learned in vendor-sponsored educational sessions in the Healthcare Innovations Pavilion (HIP) in the exhibit hall.

Heard in a session on 5010/ICD-10 in the HIP, Sherry Thomas, CCP, CCP-AS, of the Professional Healthcare Institute of America (PHIA), said that every third party payer she has talked to has said that after ICD-10 rolls out on Oct. 1, 2012, unspecified codes will come back to you. In Twitter conversation with Steve Shimko (@ShimCode), Steve said that unspecified codes will work for transition period, “yet beware to those who ignore specificity. Just saying.” Sherry gave a number of good examples of the specificity required, including where injury occurred, degree, etc. She described ICD-10 as “a huge transformation for your office.”

Also in the HIP, Cass Schaedig of Trellis Healthcare gave an excellent brief presentation on “Data-Driven Business Decisions Yield Improved Tracking Results” that featured tips for utilizing RVUs in analyzing your practice productivity. Her recommendations included:

  • Develop standard calculations—look to professional organizations for definitions
  • Identify key measures and stay consistent
  • Accommodate changes to CPT codes
  • RVUs can be used as a standardized unit of measure

Ms. Schaedig also presented some useful tips on Using RVUs to Compare Payers and using RVUs for Productivity Analysis, as seen in the slides below.

Using RVUs to Compare Payers - SchaedigRVUs for Productivity Analysis - Schaedig

Finally, I know Inga at HISTalk posted last night that she thought the Cirque du Soleil performer was a little creepy—but frankly, I find the Elvis impersonators more so. Although the Young Elvis did a fairly decent voice impersonation…but that hair! You be the judge.

Elvis at MGMA 2011

More to come. And if you’re here at MGMA, be sure to stop by the Kareo booth–#1716. We have free gifts, but they’re running out fast! And you could win our drawing for a free customized iPad2. Look forward to seeing you!

Read More

Complimentary Webinar – Guarding Your Revenue: How to Prevent and Uncover Embezzlement

Kathy McCoy, MBA October 20th, 2011

2 Comments Latest by COMMENTOR NAME

Thursday, November 10, 2011
10:00 AM – 11:00 AM PDT
Speakers: Judy Capko & Joe Capko

Learn how to protect your practice or medical billing business from embezzlement

Embezzlement can part you from your hard-earned money illegally and without your knowledge.  The embezzler can be brilliant at deception – they often flourish at your expense by creating a relationship of blind trust.  There are many schemes the thief can use to steal away your money.  This course will cover how embezzlers think and how they work their way into taking your money. You will be provided with some tools to protect your practice.

You will be able to:

  • Apply techniques that influence staff’s attitude toward respecting finances
  • Examine ways to deter the potential thief
  • Identify red flags that indicate someone may be taking money
  • Understand how to  communicate your expectation with guarding practice finances
  • Strengthen processes to reduce temptation and eliminate opportunities for theft
  • And more

Many, if not most practices and businesses are subject to theft, but you work too hard for your income to risk a preventable problem. Knowledge, attention to detail and effective communication can thwart the intended embezzler; you’ll learn how to use these tools from experts in the field.

Register now for this informative look at how to prevent embezzlement in your practice or medical billing service

You can download the Guarding Your Revenue–How to Prevent and Uncover Embezzlement Webinar Handout for this session now.

Question-and-Answer Session — Ask your tough questions and get answers to your current concerns about how to prevent and detect embezzlement.

Who Should Attend
Private practice owners, office managers, staff accountants, billing managers, billing service owners and others concerned about avoiding embezzlement.

About Your Speakers
Judy Capko

Judy Capko will discuss how to protect your practice or medical billing business from embezzlement

Judy Capko is the founder of Capko & Company and author of the popular book “Secrets of the Best-Run Practices,” Greenbranch Publishing, September 2005. Judy has specialized in medical practice operations and marketing for more than 20 years, and is a certified risk management specialist. Her emphasis is on building patient-centered strategies and valuing staff’s contribution. Beyond this, she focuses on maximizing resources, resulting in improved operational and financial performance.

Judy is a popular speaker for major healthcare conferences such as MGMA, national specialty associations, healthcare systems, regional medical societies and healthcare executive summits. She has been interviewed by and published in over 30 prestigious national medical journals including American Medical News, Dermatology Times, Family Practice Management, Group Practice Journal, Medical Economics, Physicians Advisory, Physicians Practice, Private Practice Success, and The Journal of Medical Practice Management.

Joe Capko

Joe Capko will teach you how to identify the signs of embezzlement and protect your practice or medical billing company

Joe Capko is a senior consultant with Capko & Company. Joe has substantial business experience in applying qualitative/quantitative studies and statistical analysis for healthcare and high technology sectors. As a support engineer at CCH Computax, he specialized in the design and implementation of database systems for the Big Six accounting firms. He is a member of the American Statistical Association.

Joe has guided medical groups in adapting to a changing environment by applying solid business strategies. This results in improved productivity and profits without compromising patient service.

Register now for this informative look at how to prevent embezzlement in your practice or medical billing service

Read More

Medical Billing Alert from AMBA: Regulatory Update on RACs, CERT and Compliance

Kathy McCoy, MBA October 18th, 2011

Leave a Comment Latest by COMMENTOR NAME

Cyndee Weston shared an overview of RAC Underpayments & Overpayments for 2010 & 2011 at the AMBA Fall Conference

One of the excellent sessions I attended at the American Medical Billing Association (AMBA) meeting last week was a talk by Cyndee Weston, founder of AMBA: “Regulatory Update: RAC, CERT, Compliance and 5010.” Cyndee has been in this business a long time, and she makes a point of knowing what’s going on in terms of regulatory changes. Among the interesting points she shared:

Recovery Audit Contractors (RAC)

With increased overpayments found this year and the blessings of Congress, RACs are stepping up their efforts for 2012 (see chart above):

  • RACs collected $233.4 million in overpayments from March through June of this year – total of recouped overpayments since October 2009 $575.2 million
  • Returned $55.9 million in underpayments to providers for the third quarter – more than double the $23.7 million in underpayments it returned in the previous quarter.
  • Since October 2009, RAC has returned about $109.6 million in underpayments.
  • Top overpayment issues during the third quarter included medical necessity, incorrect coding, and billing for bundled services separately.

Common CERT Errors

CERT Statistics have increased significantly over the last five yearsCyndee mentioned that Comprehensive Error Rate Testing (CERT) is done with claims selected randomly from all claims submitted. If a provider fails to submit a requested record, it counts as an error, and the OIG has defined “error-prone providers” as providers that had at least one CERT error in the last four years. She provided an example of the envelopes that will be sent by CERT Documentation Contractors (see below) and advised that billers and providers be on the lookout for these envelopes, since failure to respond counts as an error, as stated above. Other common errors include:

  • Medical record documentation did not contain a valid physician’s signature
  • Radiology report/diagnostic test performed did not contain a valid physician order or an identification of the provider who rendered the service
  • Documentation did not adequately describe the service defined by CPT or HCPCS Coding or HCPCS modifier billed
  • Documentation that did not support the ICD-9 Code billed
  • Lack of physician signature on the medical record for the physician certification or plan of care
  • Insufficient documentation to support the service billed

Be on the lookout for envelopes like these bearing record requests for CERT

2012 OIG Work Plan – Medicare

For 2012, the OIG has indicated they will focus on these areas (those with an asterisk are new for 2012):

  • Ambulance Questionable Billing – transports ALS potentially not medically necessary
  • Compliance w/Assignment Laws – if beneficiaries are inappropriately billed in excess of MDCR allowed amounts
  • *High cumulative Part B payments over a specified time
  • POS errors for ASCs & OP departments
  • *Incident to – unqualified non-physicians performed 21% of services that physicians didn’t personally perform
  • *Opt Out physicians – review of extent to which physicians opt out and whether they are submitting claims. Also determine whether specific areas of the country have seen higher numbers opting out
  • *Chiropractic claims to see if billing for maintenance therapy
  • E&M claims to identify trends 2000-2009 and identify providers that exhibited questionable billing for E&M services in 2009. $32 billion paid for E&M in 2009 – 19% of all Medicare Part B payments.
  • E&M services provided during global surgery periods
  • *E&M – use of modifiers during the global surgery period
  • E&M services documented through use of EHR (increased frequency of Medical records w/identical documentation
  • Independent Therapists – OP, PT services overutilization
  • Claims with G Modifiers where a denial was expected and providers with unusually high number of claims with G modifiers
  • Services ordered or referred by excluded providers
  • Claims submitted by error-prone providers (providers submitting claims with errors over 4 year period (CERT)
  • Overpayments currently not collectable (CNC) (over 210 days) to see if debtors are closely associated with other businesses that receive Medicare payments
  • EHR Incentive Payments
  • Data Security Breaches and medical identity theft of Medicare services
  • Oversight review of OCR and privacy, breach notification
  • Oversight review of CERT
  • First level of appeals timeliness

2012 OIG Work Plan – Medicaid

Cyndee also shared the work plan for Medicaid, which will begin audits in January:

  • PT, OT & ST – check to ensure compliance w/state standards and limits on coverage
  • Transportation Services appropriateness of payments
  • Payments to Federally excluded providers
  • Overpayments with credit balances
  • Medicaid incentive payments for EHR

OIG Resources

Finally, Cyndee provided some resources for medical billers and providers to use in keeping up with regulatory issues:

Provider Compliance Training

16 modules

Self Disclosure

Open Letters

Many thanks to Cyndee for her informative session, and for permission to share this information with you. Watch for more posts on the sessions at the AMBA, and read an overview of the first day of the meeting.

Read More

Reporting from AMBA 2011: Advisories for Medical Billers

Kathy McCoy, MBA October 13th, 2011

2 Comments Latest by COMMENTOR NAME

We’re in Las Vegas this week for the American Medical Billing Association 2011 Conference, and the first day was very informative. It featured sessions by:

  • Timothy Kaja, United Healthcare Group
  • Tammy Banks, AMA
  • Cyndee Weston, AMBA
  • Robert W. Liles, Liles & Parker
  • And other experts

We’ll be posting more indepth articles on their presentations after the conference, but in the meantime, here are some highlights:

Timothy Kaja reported that for United Healthcare, 5010  has been “the most expensive technology project UH has ever done” and reported that
ICD will cost 3x as much. In response to a question about a period a few years ago when UHG received a low rating on the AMA’s National Health Insurer Report Card (NHIRC), Mr. Kaja said that there are no penalties levied by any government entities, but that they received calls from “Boeing, AT&T…every large customer. UHG received a rating of 92.26% on the most recent NHIRC. Interesting to know the report card provides that kind of leverage. Mr. Kaja also encouraged AMBA members to “Get Involved – Change the Game for our Constituents,” saying that those in healthcare “need to stick together and say No to more complexity in this business.”

Tammy Banks of the AMA discussed the costs of adminstrative waste in the claims process during the 2011 AMBA meeting

Tammy Banks from the AMA discussed the impact of denials and rejections on medical practices, saying that administrative waste costs $21 to $210 billion annually and causes providers to spend 5 phys work weeks per year on admin tasks; the avg. cost to physicians is 10 to 14% of gross revenue. Ms. Banks also mentioned that she believes 5010 is going to improve eligibility because insurers are required to provide more information, not just yes/no. She mentioned that the AMA is focusing on 7 key areas in order to reduce administrative waste, as described on the slide at right.

The AMA is focusing on 7 key areas in order to reduce adminstrative waste in the claims process

We’re looking forward to more informative sessions tomorrow, and to meeting more medical billers. If you’re at the AMBA meeting, be sure to stop by our booth and say hello.


Read More

Preparing For 2012: What Needs to Happen When? Create Your Calendar Now

Sara M. Larch, MSHA, FACMPE October 10th, 2011

Leave a Comment Latest by COMMENTOR NAME

Preparing for 2012 now can help your practice or billing service have a more profitable year

The Patient Protection and Affordable Care Act (PPACA) became law on March 23, 2010, with elements of it taking effect through 2018.  Conversion to the 5010 electronic claim transaction standard is effective January 1, 2012.  The Department of Health and Human Services announced that the US would move from ICD-9 to ICD-10 as of October 1, 2013.  As you know, those are not the only changes going on right now. As a leader in your medical group, it is essential that you take time to strategize and plan for these big changes!

My recommendation is to utilize a calendar approach to change management.  Most of these changes have an ultimate deadline but some of these can be implemented earlier so everything doesn’t fall on the medical group at one time.  Still, there is only so much change anyone can pull off in a three or six month period, thus a calendar approach will help you look forward for the next 12-18 months. As an example, I have identified the possible major changes on our horizon and made some assumptions on when to implement them.  Not every medical practice will implement these changes along the same timeline.  Some practices may wait to implement voluntary programs until they become required.

Read through the following calendar example.  Determine which of these projects your medical group is going to take on in the next 12-18 months and then determine when you want to start each project and when it must be finished.  Timing decisions will likely be affected by resource sequencing (e.g., we have to finish 5010 format conversion before we start the ICD-10 transition project).  As you walk through the calendar, you will see additional information and resources available to assist you.

Project Calendar:

October, 2011:

  • Final testing of your practice management system upgrade for 5010 – you need to be on the latest software version by the end of 2011 in order to submit 5010 claims. If you haven’t started working on this yet, contact your software or billing vendor. (Note: Kareo customers will not need to conduct testing; see Will Kareo Customers Be Ready for 5010? Of Course!)
  • Submit your e-Prescribing exemption form before November 1, 2011 by going to CMS’s website and filling out an attestation.
  • Has your medical group decided to become an Accountable Care Organization (ACO) or joined one?  The PPACA requires CMS to establish a voluntary Medicare ACO program by January 1, 2012 using a shared savings model to reward integrated or coordinated groups of providers that organize to deliver quality care at a reduced cost while continuing to be paid by Medicare on a fee-for-service basis.
    • It is already too late in 2011 to consider trying to make this happen by the January 1, 2012 timeline.  Some medical groups have already made this decision, know which model to pursue, and have made the medical practice changes necessary to operate in this new structure.
    • Based on your medical group’s approach to ACO’s, move this project on/off the calendar and in the right month.
    • Additional reading: and
  • Order CPT, HCPCS, and ICD-9 books for 2012

November, 2011:

  • Test your electronic claims submission in the new HIPAA compliant 5010 format with your payers and clearinghouses.
  • Participate in government affairs advocacy through your professional association or medical society to help prevent 2012 Medicare payment decrease (example at:

December, 2011:

  • Focus on cash collections in the door before the calendar year closes.
  • Does your medical group include primary care physicians?  Are you up to date on submitting claims to Medicare?  Find out more information about the new Primary Care Incentive Program (PCIP) which started January 1, 2011 at:
    • Primary care providers will receive bonus payments from Medicare based on submitted claims data up to 10% and will also be eligible for an additional bonus if they practice in an HPSA (Health Professional Shortage Area).

January, 2012:

  • Send electronic claims in the new HIPAA compliant 5010 format as of January 1, 2012.  Claims submitted in version 4010 will be rejected.
  • Register and attest to meaningful use for Medicare and Medicaid EHR incentive program. The last day is February 29, 2012 if your medical group wants incentive payments for CY11.
    • What is “Meaningful Use”?:  The American Recovery and Reinvestment Act of 2009 specifies three main components of Meaningful Use:
      • The use of a certified Electronic Health Record (EHR) in a meaningful manner, such as e-prescribing.
      • The use of certified EHR technology for electronic exchange of health information to improve quality of health care.
      • The use of certified EHR technology to submit clinical quality and other measures.
      • Simply put, “meaningful use” means providers need to show they’re using certified EHR technology in ways that can be measured significantly in quality and in quantity.
      • More information is available at:

February, 2012:

  • Revalidation of Provider Enrollment Information for Medicare providers: Review your providers’ enrollment status with Medicare.  How many providers have revalidated their enrollment via PECOS (Provider Enrollment, Chain and Ownership System)?  Have you budgeted for the application fee? (The 2011 fee is $505/provider.)
    • Per CMS, “All providers and suppliers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notification from their MAC (Medicare Administrative Contractor). Between now and March 23, 2013, MAC’s will send out notices on a regular basis to begin the revalidation process.  Providers must wait to submit revalidation only after being asked by their MAC to do so.”  For more information, go to:
    • Your MAC will be contacting your providers.  If they don’t take care of this, then their Medicare credentialed status may be deactivated in 2013.

March, 2012:

  • Outline action plan for ICD-10 implementation project, identify key milestone dates and identify the resources needed. Note: ICD-10 mandatory effective date is October 1, 2013.

April, 2012:

  • Sit down and re-review the 12-18 month change implementation plan. Evaluate how the 5010 format conversion has gone.  Re-validate ICD-10 project plan.

May, 2012:

  • Obtain critical ICD-10 Transition answers from practice management vendor regarding upgrades, costs, and timing.

June, 2012:

  • Reach agreement with practice management vendor regarding ICD-10 implementation plan.

July, 2012:

  • Have you implemented the voluntary program, PQRS (Physician Quality Reporting System)? In 2012-14, providers are eligible for up to .5% incentive payment for participating.  In 2015, providers will have payments reduced for non-participation.  Each medical group needs to decide when it is time to work on their PQRS project. If your medical group includes primary care, start building the infrastructure to help your primary care providers earn PWRS bonuses.  For additional information, go to:

August, 2012:

  • Go on vacation!

September, 2012:

  • Contact your major payers and clearinghouse(s) about their ICD-10 implementation plans to determine their readiness and timing, identify any new costs, or changes in claims processing (e.g., new claim edits.)

October, 2012:

  • Complete staffing and internal process redesign plan as needed for ICD-10

November, 2012:

  • Install any practice management system upgrades for ICD-10.

December, 2012:

  • Design ICD-10 staff and physician training curriculum


  • Complete any pending 2012 projects
  • Implement staffing and internal process changes for ICD-10
  • Conduct ICD-10 testing with payers and clearinghouse
  • Deliver ICD-10 staff and physician training
  • ICD-10 Go live October 1, 2013


  • Additional health reform regulations will be finalized in the coming years and will be your medical group’s focus in 2014.


  • PQRS non-participation will result in a 1.5% decrease in Medicare payments.  Implement this before 2015 wherever it seems to fit and when your physicians and clinical nursing team are ready.

I hope you found this collection of projects helpful and that you will use it to create a unique calendar for your medical group.

Next Actions:

  • Cross off any projects your medical group has already completed.
  • Customize the calendar to fit your medical group’s project milestones.
  • Review this on a regular basis because it will impact your bottom line.

Sara Larch advises on steps to take for preparing your practice for 2012 and beyond

Sara Larch, MSHA, FACMPE, is a speaker and consultant in practice operations and revenue cycle management and co-author of “The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid.” She contributed an article on “Strategies for Successful Denial Follow-up in Medical Billing” in our June Getting Paid newsletter, and an article on Denial Management 101: Remember the Basics” in our March Getting Paid newsletter. You can hear her speak on a recent webinar on Managing Your Medical Billing Team: Get the Performance You Expect.

Read More

Five Essential To-Dos to Prepare for 2012

Betsy Nicoletti, M.S., CPC October 10th, 2011

Leave a Comment Latest by COMMENTOR NAME

October is too early for New Year’s resolutions, even if they are the same as last year’s: “Eat more fruit,” and “Renew my gym membership.”  But October is the right time to plan for 2012 to insure your practice’s continued success.

  1. Stop me if you’ve heard this one:  Test your electronic claims submission format this month to be sure that your software and clearinghouse can send the new HIPAA compliant 5010 format.  Many private practices bonus their physicians in December, leaving little money in the practice.  If your claims aren’t successfully transmitted in January, in the new electronic format, will there be money for payroll and rent in February and March?  Establish a line of credit if you don’t already have one.
  2. If you aren’t using an e-Prescribing program:  Find out if you can claim an exemption, and do so before November 1, 2011.  Two exemptions already existed for practices that had limited high speed internet access or whose area pharmacies had limited internet access.  These two exemptions were made on a claims basis, prior to June 30, 2011 to avoid a 1% reduction in 2012.

Four additional exemptions were given by Medicare, and are claimed by filling out an attestation on CMS’s website before November 1, 2011.  Physicians are eligible if:

  • They have registered in a Medicare or Medicaid electronic health record incentive program or have a certified EHR
  • Were unable to prescribe electronically because of a local, state or federal law or regulation (mostly prescribe narcotics, for example)
  • Had limited prescribing activity
  • Had insufficient opportunities to report e-prescribing for eligible patient visits

You can read more about this on CMS’s website at

  1. Watch for coding changes later this year:  If you haven’t ordered your 2012 CPT, HCPCS and ICD-9 books, do so now.  Watch for articles that describe the changes for your specialty.  If you order the CPT Professional Edition, changes to the editorial comments are in green, which can be helpful.  Some groups order the specialty specific version of their book sold by commercial vendors, which also includes RVUs, covered diagnoses and indications, global days and NCCI edits. If your practice is large and you typically order more than one CPT book, order one of each to see which is most helpful for your practice.
  2. Review the CMS clarification on observation and consults:   In late August, CMS released to transmittals described as E/M Clarifications. (You can search for this in a search engine by putting in CMS Transmittal 2282 CR 7405 and CMS Transmittal  147, CR7405.)  They did not break any new ground in these transmittals, but definitively answered some leftover questions.   CMS wants only the admitting observation physician to use subsequent observation visit codes 99224—99226.   All other physicians who see patients in observation status should use new and established patient office/outpatient visit codes, with the correct place of service.  Most of our contractors paid claims this way, but CMS has made it official, and amended the Medicare Claims Processing Manual to state that.  There is no similar CPT rule, making it a question what category of code to use (subsequent observation or office/outpatient visits).

CMS also re-stated its policy on paying for consultations, the policy change they made in January 2010.  Some physicians questioned what to bill in 2010 and 2011 when the service would have been a low level inpatient consult, billed as a 99251 or a 99252.   There was not an official CMS crosswalk, but 99253 (level three consult) and 99221 (level one initial hospital service) had exactly the same documentation requirements.  But what if a physician performed a lower level of consult?  CMS instructs us not to use the unlisted code 99499 in these instances but reminds us that their policy is to allow the physician to bill a subsequent hospital visit, 99231-99232 in these instances.

  1. Be on the latest version of your software in 2012:  It goes without saying that you’ll be on the latest version of your software at the end of 2011.  If you’re not, you won’t be able to submit 5010 claims.   In order to submit ICD-10 codes in 2013, you will also need to be on the latest version of your software.  Don’t wait until the last minute to make these upgrades.  Stay up to date in the next two years. (Editor’s Note: Kareo customers are always using the latest version of the software, since it is web-based and updated automatically.)

As always, physician practices are dealing with the uncertainty of Medicare payments starting in January, and the threat of a large reduction.  Our medical societies and professional organizations are working hard to avert this reduction, as they do every year.

Betsy Nicoletti describes the steps your practice should take to prepare for CMS and other medical billing changes in 2012Betsy Nicoletti, M.S., CPC, is the founder of, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at You can watch an informational video by Betsy Nicoletti on Better Collections Through Improved Medical Coding now. Or, view her archived webinar on What You Can Do to Prepare for Medicare Payment Reductions.

Read More

Best Practices: Managing Your Patients for Better Business Results

Judy Capko October 10th, 2011

Leave a Comment Latest by COMMENTOR NAME

Busy administrators often get swept up in managing the day-to-day operations of their practices.  Stepping back and looking at things from a different perspective can sometimes result in making changes that can increase the efficiency in the practice – often with accompanying improvements in staff and patient morale.  Everybody wins!

Various trends, such as rising co-pays and higher deductibles, are shifting more of the burden onto patients – who are themselves dealing with a reduced capacity to pay.  Sometimes it seems that busy or cash-strapped patients are also more likely than ever to cancel their appointments, or, even worse, fail to show up without a cancellation call.  Your staff may be put into increasingly awkward positions as a result, e.g. dealing with a patient asking to mail in a check later instead of paying at time of service, or confronting repeat offenders who routinely skip their appointments.  Staff may feel their job satisfaction waning as more of their time is spent being “bad cop.” Worst of all, these unhappy interactions often don’t even have the intended effect of improving patient compliance!

The powerful economic trends behind some of this behavior are inescapable, and, to a certain degree, medical practices are going to face the same challenges all businesses face in this environment.  But, too many practices just accept that all their collection and scheduling problems are unsolvable – when the fact is, it is possible to do much better by being willing to look at your procedures with an eye toward improving and taking control.  Leaving it all to chance will cost your practice plenty!

Manage your patients’ behavior

The key is to adopt a mindset of managing your patients – your physicians manage their health, you need to manage their business behavior with your practice.  There are many ways you can do it without being offensive or bossy or straining the relationship.  In fact, managing your patients better is in many ways a form of clearer and more effective customer service.

Consider two big areas where patients let you down: keeping appointments and prompt payment.  How you communicate with patients makes a big difference in whether they do what you want.

Whether or not your patient keeps his appointment (and arrives on time) is influenced at several touch-points:

  • When they register as a new patient, are you asking for several forms of contact information – home phone, work phone, cell phone, email – and, most importantly, learning what the best ways to contact are, and the best times?  Are you getting permission to contact via multiple means?
  • Are you reconfirming that information each time the patient schedules or comes in for a new appointment?
  • Are you contacting the patient 2-3 days prior to the appointment for a reminder?
  • Are you contacting patients who no-show after the scheduled appointment to find out what happened, get better contact information, and reschedule?  Do you remind them how important it is to keep scheduled appointments?
  • Do you have a clear policy for late and no-show appointments – i.e., a “three strikes and you’re out” policy for dismissing chronic offenders?
  • When patients come to the practice for their appointments, are they seen promptly – within 15 minutes of their scheduled appointment –and, if not, are delays adequately explained?

Contacting patients in the way they prefer, reminding them far enough out that they have time to reschedule if necessary (but not so far out that they forget!), and being on time for patients who arrive on time are all important ways to show patients that you value their time – and that you run a tight ship. And having a clear policy for terminating patient relationships when the patient simply won’t respect the need to keep appointments sets the foundation for patient compliance.

Payment compliance requires clear and direct communication

With payment compliance, the need to be clear and direct is similar.  Is your practice:

Confirming insurance coverage and determining co-pay and co-insurance amounts payable at the appointment, and letting the patient know what their financial obligation will be as part of the appointment reminder call?

- Asking patients for payment in a presumptive way, e.g., “How will you be paying your co-payment today, Ms. Evans?”

- Establishing clear payment terms for larger expenses like surgery before the costs are incurred?

- Billing promptly and handling all inquiries about bills promptly as well – so there’s less chance of the patient not recognizing the amount due?

- Sending past due accounts to collections if no payment is received after two statements – and making clear to patients that this is the standard process?

Staff members need to be trained to ask for payment in a way that’s not timid or open to discussion (i.e., not “will you pay your co-pay today?” but “how will you be paying your $120 balance today?”).  Most patients will simply present a credit card when payment is not posed as optional. 

Of course, even the most organized practices will have some patients who accumulate bills they don’t intend to pay.  For those patients who will be slow-payers or non-payers, it’s always best to learn that faster – to avoid wasting more money and staff time on fruitless, discouraging collection attempts.  These patients can be ethically dismissed – much like the unrepentant no-show problem cases – and physicians and staff can use the time freed up for more profitable and positive activities.

Judy Capko advises how to manage your patients to improve your practice profitabilityJudy Capko is a healthcare management and marketing consultant, speaker and author or the best-selling book: Secrets of the Best-Run Practices. She is based in Thousand Oaks, CA, and can be contacted at In September, Judy wrote on How Do Your Payers Stack Up?

Read More

Welcome to Getting Paid, a weblog by Kareo offering ideas, news and opinions about medical billing and practice management with the goal of making medical billing easier and yes, getting you paid. Visit the Product Blog for more information on our products.

Subscribe to the Newsletter

Enter your email address to receive "Getting Paid" as a monthly email newsletter. Privacy Policy

Subscribe to RSS Feed

CDW 2015 TOP 50 Health IT Blog

Follow Kareo

Find Kareo on LinkedIn Find Kareo on Facebook Find Kareo on Twitter Find Kareo on YouTube Find Kareo on Flickr

Search the Blog


Monthly Archives

Web–Based Software by Kareo

Practice Management

Simplify the daily essential tasks of your medical office from patient records, to scheduling and more.

Electronic Medical Records

Improve patient care with electronic charting, electronic prescribing and medical labs interfaces.

Medical Billing & Collections

Streamline your entire medical billing and collections process from charge entry to reporting.

Clearinghouse Services

Integrated electronic claims, electronic remittance advice and insurance eligibility services.

Analytics & Data

Store and access data with insightful reports, document management and faxing, and an integration