Complimentary Kareo Webinar: Finish Strong – Make 2012 Your Most Profitable Year!

Kathy McCoy, MBA July 26th, 2012

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Thursday, August 30, 2012
1:00 PM EDT/10:00 AM PDT
Speaker: Karen Zupko

Expert Karen Zupko will show you dozens of ways you can improve efficiency, productivity and profitability in this complimentary Kareo webinar

Karen Zupko, an expert in practice and revenue management for medical practices, will coach you to sprint for operational improvements that result in year-end bonuses!

During this fast-paced, dynamic presentation, Karen will show you dozens of ways you can improve efficiency, productivity and profitability.   Her ideas on how to stop talking about it and getting things done are sure to please. You’ll learn how to:

  • Remove time-consuming redundant steps from your revenue cycle
  • Improve point of service collections
  • Use modern payment technologies optimally
  • Reduce no shows
  • And more

Peppered with real life specialty examples, this Kareo webinar features practical information and illustrates how small improvements can make a big difference.

Register now to learn how to make the most of 2012 in this complimentary Kareo webinar

You can download the handout for the webinar now.

Question-and-Answer Session

Ask your tough questions and get answers to your current concerns about how to finish 2012 with the highest possible revenue.

Who Should Attend
Private practice owners, office managers, billing managers, billers, billing service owners and others concerned about bringing more to the bottom line.

About Your Speaker: Karen Zupko

Expert Karen Zupko will coach you to sprint for operational improvements that result in year-end bonuses in this complimentary Kareo webinar

Karen Zupko is often described as “An entertaining educator.” With more than 25 years of experience in practice and revenue management for medical practices, Karen combines depth of experience with a practical approach to making change happen and stick in practices. Her TNGE thinking (“that’s never good enough”) will motivate you!

Karen is the president of Karen Zupko & Associates, Inc. a medical management consulting firm founded 27 years ago, based in Chicago with 24 team members who work exclusively with physician practices nationally. The firm has 20+ year relationships with numerous specialty societies.

Karen was the director of practice management at the AMA and serves on the editorial board of The Journal of Medical Practice Management.

Register now to learn how to make the most of 2012 in this complimentary Kareo webinar

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ACA Is Upheld: Will Medicaid Be Your Next Payer?

Laurie Morgan July 24th, 2012

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With ACA upheld, Medicaid is set to be the vehicle through which millions of currently uninsured patients will get coverage

Many of the practices we work with shy away from Medicaid, citing a mix of reasons that include poor reimbursement, more frequent no-shows, and potentially unpredictable administrative costs.  But with the Affordable Care Act (ACA) largely upheld by the Supreme Court, Medicaid is set to be the vehicle through which millions of currently uninsured patients will get coverage – a huge patient base that will be tough to ignore altogether.  What’s more, the mix of Medicaid patients will be substantially altered.  Higher income people (up to 133% of the federal poverty limit) will qualify, and adults without children (previously a small segment) will constitute a large proportion of the newly insured. 

States will have the option to decline to participate in the Medicaid expansion – but, the federal government’s commitment to absorbing all costs for three years, and 90% of costs from 2020 forward, is expected to make participation attractive.

Perhaps most promising for practices, the ACA also calls for Medicaid reimbursement rates for some primary care specialties in many states to increase sharply, for parity with Medicare – which in most markets is now competitive with private payer reimbursement.  For family practitioners, internists and pediatricians here in California, for example, that will mean that Medicaid reimbursement rates will more than double from their current level of 47% of Medicare.  There is one important caveat: the bump in pay is guaranteed for only two years.  New Medicaid patients who are profitable in the short term could become unprofitable in the long term, if the increases are rolled back.  However, because the goal of the pay bump is to forestall primary care shortages, many observers expect that the increases will eventually be locked in.

If your practice is considering adding – or expanding – participation in Medicaid, here are a few tips that can help put you on the path to trouble-free reimbursement:

Know what’s coveredAlthough Medicaid is technically a federal program, it’s implemented at the state level, and states have quite a bit of discretion in what is and is not covered.  Misunderstandings about coverage cut both ways.  Predictably, claims are sometimes denied due to lack of coverage, but many practices also end up under-billing Medicaid because they didn’t realize certain services qualified. More expensive screenings and oncological care, for example, are often covered.  Sometimes you may even be able to bill for no shows. Pediatric practices may be able to obtain vaccines at no charge for Medicaid patients through your state’s implementation of Vaccines for Children, CMS’s immunization program.  Be sure you understand your own state’s program thoroughly, so your practice doesn’t miss out on any reimbursement or covered cost.

Double-check credentialing and other requirements.  Just as coverage varies from state-to-state, there are also different credentialing requirements for physicians and NPPs.  Be sure you understand whether your NPPs must bill under a physician provider number or can bill under their own.

Verify addresses and eligibilityMany Medicaid claims are rejected because patient addresses don’t match Medicaid records.  Be sure to verify address information every time you see the patient.  Most state Medicaid systems also offer online eligibility checking – providing you with backup you can print off and retain in case a claim is questioned or denied.

Laurie Morgan is a management consultant with Capko & Company. She specializes in marketing, management and technology for medical practices and blogs about practice management issues at www.capko.com/blog. Laurie has a BA in Economics from Brown University and an MBA from Stanford. Laurie recently wrote for Getting Paid on Staying on Top of Business Trends to Protect and Build Your Medical Practice, My Receivables Are Growing: Time for a New Billing Service? and Hidden Ways Medical Billing Shortcomings Hurt Your Practice

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Your Nine-Step Plan to Better Practice Collections, Part II

Betsy Nicoletti, M.S., CPC July 19th, 2012

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Follow these nine steps to improve your practice collections

The first five steps to better (higher) collections were in the Getting Paid newsletter that went out on Monday.  The goal is to collect all of the revenue a practice is entitled to collect.  Here are four more steps towards achieving that goal, and a bonus step for primary care practices:

6.    Don’t take denials lying down

Some consultants estimate that as many as 30% of denied claims are never resubmitted or appealed.  The billed amount is simply adjusted away, as “Commercial insurance adjustment.”  Some staff members believe that if the payer denied it the first time, it is almost impossible to get the claim paid.  In some cases, the reason for the denial may have been practice error, such as a coding error or past filing limit and the claim balance is quietly written off.  Medical practices need to work denials quickly and with enthusiasm.  Kareo has published multiple articles on working and monitoring denied claims, and the links to these are below.  Track your denials by payer and reason code each quarter.  Of course, it is critical to fix each claim that is denied and resubmit the claim, but use this tracking report to improve future claims submissions.  Fix problems in registration, or eligibility verification or coding so that future denials are eliminated.

7.    Correct coding errors

The best outcome for a coding error: payment delay.  The worse outcome: no payment at all.  Avoid both outcomes by monitoring and correcting coding errors.  Use a claims scrubber to identify these errors before claims are submitted to the payer.  Fix individual claims, and educate clinicians and staff to prevent future mistakes on claims.   Incorrect use of modifiers and failure to follow bundling rules are two common coding errors that result in claims denials.  Failure to understand medical necessity and coverage policies are a close second.  There are many services that are covered with only a certain frequency and for specific indications.  Check Medicare and private payers’ policies about frequently performed procedures and diagnostic services.  Be sure that staff and clinicians are up-to-date on coding for all services performed.

8.    Use technology, early and often

Manual processes cost more and take longer than automated processes.  Calling an insurance company to verify coverage for each patient, one by one, takes longer than an automated batch query.  Setting up a recurrent payment of six installments takes less time than billing a patient monthly and posting the monthly payment manually.  Practices are rightly concerned with the cost of add-on programs and additional features, but using outdated technology costs revenue in the long run.

9.    Track key indicators

Key revenue and collection indicators include days in receivables, gross and net collection rates, aging of accounts over 90 days, and percentage of claims denied on first submission.  The Medical Group Management Association publishes specialty specific norms in each of these categories.  Some specialty societies collect survey data from their members and make that available.  First, calculate your group’s baseline for these key indicators.  Then, monitor it over time.  Compare your group’s data to norms for your specialty and measure your performance each quarter.  Groups that consistently monitor their performance perform better.  Review this helpful article by Elizabeth Woodcock on using key performance indicators to make sure you’re using them effectively

Bonus step for primary care practices serving adult patients: Provide Medicare Wellness Visits!

It is true: Medicare does not pay for the typical preventive medicine services described by CPT codes 99381-99397.  Medicare does pay for a Welcome to Medicare visit and Annual Wellness Visits (initial and subsequent).  Many practices disdained these visits initially because they did not correspond to the CPT definitions of an annual physical, and indeed, have very sparse physical exam requirements.  Some groups, however, have embraced them because patients expect the service and it gives the clinician an opportunity to talk to the patient about preventive issues and get paid to do it!  Before you turn your back on these visits, review the CMS requirement and take a look at the payment for each.  It is a way of increasing revenue while providing a valuable service. for more information, watch this video on making the most of wellness visits for your practice.

Take these steps to collect at a higher rate for the services your medical practice is already providing.

Betsy Nicoletti, M.S., CPC, is the founder of Codapedia.com, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at www.mpconsulting.org.

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Strategies to File Effective Medical Billing Appeals – and Get Paid

Elizabeth W. Woodcock, MBA, FACMPE, CPC July 16th, 2012

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If it seems like you’re bleeding money in the billing office, then it’s time to get your medical billing appeals strategy in gear.

Nothing seems to make a billing manager’s blood pressure rise like the topic of filing appeals to reverse denied claims. If it seems like you’re bleeding money in the billing office, then it’s time to get your medical billing appeals program in gear. This process doesn’t require special software to buy; rather, it’s a systematic approach to identifying denials, filing appeals and – just as important – tracking the resolution of each appeal.

The most recent report on health insurance billing and payments by the American Medical Association (AMA) found that while error rates by private insurers have dropped steeply (from 19.3 percent of medical claims in 2011 to just 9.5 percent in 2012), claim denials are on the rise. Nearly every major private health insurer included in the AMA’s fifth annual National Health Insurer Report Card, released June 18, 2012, increased its rate of denials. The rates among the private insurers ranged from a high of 5.07 percent (Anthem Blue Cross Blue Shield) to 1.38 percent (Regence). Even a one percent denial rate represents a substantial amount of money to a physician – assuming a practice bills $300,000 in gross charges, the denial rate typically results in a loss of more than $3,000. Many physicians experience denial rates approaching 10 percent and, even worse, they do not appeal the denials. Thus, that $30,000 ends up as write-offs.

The options to improve your claims appeals process start, of course, with a related protocol of systematically reviewing and working on each denied claim until it is corrected and resubmitted successfully. If it is denied again (or was correct in the first place, but the insurer denied it anyway), the next step is to file an appeal. Although this process requires work, the payoff is significant.

Strategies for filing effective appeals

Use these strategies to file effective appeals – and improve the odds that your physicians get the money they deserve when their claims are denied.

Identify. For each denied claim, ask, “why?” Remark and reason codes help explain the insurer’s reasons for the denial. If you discover that the problem is your error, correct and resubmit the claim. (This may require a review of the documentation to determine if another diagnosis, for example, was substantiated but wasn’t included on the claim.) Just resubmitting the original claim without any alterations will not only cost you time, but it may also even raise a red flag for fraudulent billing.

Act. Set a goal of creating and submitting appeals within seven days of receiving the denial. Delaying your investigation and response just keeps that unpaid claim on your accounts receivable and raises your risks of missing the insurer’s timely filing deadline.

Investigate. An effective appeal is more than a letter demanding payment; it is an argument backed by evidence. Examine the insurance company’s rationale for denial. Make a list of the reason (or reasons) that you disagree with the insurer’s decision. This may require detective work: reading the medical record; reviewing the insurer’s provider manual; and seeking a clarification about why the physician selected and submitted the codes involved. If the denial was due to medical necessity, you need to expand your investigation by talking to the physician who performed the service.

Respond. Although some denials may be reversed based on a telephone conversation, appeals often have to be put in writing. Review the basics of creating a professional letter. After a proper salutation, begin your appeal letter by referencing the patient, date of service and the claim number. Following this introduction, briefly describe the service for which payment was denied. Keep the focus on recording your side of the story and making the case for payment, instead of demeaning the insurer for its actions. Be sure to request a review of your appeal by someone familiar with your specialty, also known as a “peer-to-peer review.” (If your appeal is denied, this request allows you grounds to re-file the appeal if the reviewer was not an expert in your specialty, which is most often the case.)

Don’t let your appeal go into bureaucratic limbo by submitting it to the wrong place or otherwise incorrectly. Some insurers demand that you use their forms for appeals. Most have a designated address (physical and mail) for sending appeals. Some of this information may be included on the patient’s insurance card, but be prepared to communicate with the insurer to obtain the details.

Most insurers have multi-level appeals processes, all of which should be explained in writing in their provider manual. Understand the insurer’s processes and do not hesitate to take your case to a higher level if you are turned down.

Incorporate evidence. An effective appeal goes beyond opinion; it is accompanied by supportive references to objective sources, such as descriptions or guidance issued in the CPT® Manual or other related AMA publications; relevant, peer-reviewed medical literature; your contract with the insurer; the insurer’s published reimbursement policies – and perhaps even the insurer’s own marketing materials. Your practice’s internal quality guidelines may be useful, too. To refute a denial based on the necessity of a service or the need to have provided it as a distinct service, ask the physician to write a short description of the specific benefit of the service to the patient. Class action settlements between physician organizations and large insurance companies also may provide ammunition for your appeal, so check the Physician Advocacy Institute’s website. Keep a copy of your letter, as well as the accompanying documentation, in the event that you need to create an appeal for a similar situation in the future.

Don’t forget. Once you submit an appeal, it’s important to determine whether it had any effect. Set a reminder in your calendar to follow up in 30 days by calling the insurer. If they claim not to have received your appeal, ask to speak to a supervisor and get his or her fax number so you can resubmit your appeal that day (and call later to confirm that the fax was received). Document the details of all of your conversations.

Log it. Closely related to setting a reminder for follow-up is keeping a log of all denials you receive and the appeals you file for each insurer. For each denial, capture the amount in question (the charge), the reason for the denial, and the important dates associated with each situation (date of service, date of denial, etc.). Add a column for the result – did your efforts pay off in the form of payment? At six-month intervals, review this log and the results. You may find trends, such as one insurer consistently denying certain types of claims. Alternately, you may find many insurers denying certain services, which may indicate a problem with your internal systems or coding practices. Of course, you also want to review how many denials you were able to get reversed – and the value of them. All of this data is important to review, periodically, with your physicians who may provide insight into denials that plague the billing office – as well as ideas for effective appeals. If possible, rely on your practice management system to track and report this important data, instead of creating and maintaining a manual log.

Appeals are time-consuming, but up to 75 percent of appeals are eventually paid, experts have concluded. Unfortunately, most claims denials are never appealed. As the saying goes:  if you don’t ask, you won’t receive. In the billing office, if you don’t appeal a denial, you definitely won’t get paid!

Elizabeth Woodcock explains how to to get your medical billing appeals program in gearElizabeth Woodcock, MBA, FACMPE, CPC, is an expert, author, speaker and trainer in practice management operations and revenue cycle management whose clients include Kareo medical billing software. She is a co-author of “The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid.” She recently wrote for Getting Paid on Government Incentive Programs for Healthcare Providers: 2012 a Turning Point in our March newsletter.

You can hear Elizabeth speak on Effective Appeals in Medical Billing: Breaking Through the Barricade to Get Paid in our complimentary webinar. Register now!

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Your Nine-Step Plan to Better Practice Collections, Part I

Betsy Nicoletti, M.S., CPC July 16th, 2012

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All practices want to collect every dollar they can, legally and within their contracts.  Some medical practices believe they are doing just that, and some groups wonder if they could be doing better, and by better, they mean, “Collecting more cash, a higher percentage of what was billed.”

This two-part series identifies nine steps to take to increase practice collections.  Some of these steps focus on patient due collections, some on insurances and some on improving systems and work processes.  But several themes emerge in all of these strategies: invest in technological solutions and constantly assess progress.

1.    Start at the beginning

Do any of you remember fondly the days of the handwritten appointment book, with the patient’s name, phone number and brief description of the reason for the visit “penciled” into the book?  And then not so fondly, sharing the book with other front desk staff or the nurse?  All patient appointments require full registration in today’s world.  Although time consuming, register the patient completely, with full demographic and insurance information when scheduling the appointment.  This allows for electronic demand or batch verification of eligibility and benefits before the patient arrives and will save chasing the patient later.  When the patient presents at the front desk, scan their insurance card into the system with a small scanner made for the purpose.  No more walking to the copier and copying the front and back of the card.  Investing in this technology will pay off.

2.    Take your time when hiring

Start at the beginning, take your time: that’s advice our mothers gave us.  In this instance it means making sure your clinicians are credentialed and enrolled before the first patient is scheduled.  Some groups now say they execute a contract with a clinician and expect the first patient day to be in 90 days.  Medicare and third party payers have strict rules about enrollment.  It is not correct to bill for a new provider under an established provider’s number.  Allowing a clinician to start seeing patients before this process is complete will result in uncollectible revenue.  Medicare has increased penalties for false statements on enrollment applications and strictly limited a group’s ability to bill retroactively for services.

3.    Collect patient due amounts before and during the service

Patient due balances account for 30% of receivables in many physician offices, and the proportion of patient due balances is growing as patients have higher deductible plans. Besides collecting co-pays at the time of service, collect past due patient amounts.  Have a script and a policy that makes it easy for the front desk to ask for patient balances at the time of service.  Many insurance companies allow medical practices to check on-line to see if the patient has met their deductible, before the service is performed.  Surgical practices should use claims estimators before elective surgery. Claims estimators are a function on a payer’s website that allow the practice to enter in the expected procedures to be performed for that individual patient, and then receive an estimate of the patient due amount for that procedure. Although not 100% accurate in all cases, this gives the practice the opportunity to discuss the cost of the procedure, the amount the insurance is expected to pay, the patient due portion and how it will be paid before the service is performed.  Many surgical groups require a deposit before the surgery and an agreement that the balance will be paid during the global period.  Set up recurring payments (discussed below) for the balance.

4.    Collect patient due amounts after the service

Despite a group’s best efforts, there will be patient due balances.  Consider using recurring credit or debit card payments to save the cost of sending a statement.  Gyms, religious institutions, car finance companies all do it: agree on an amount and deduct it from a bank account or charge a credit card.  This can be more effective than budget payments.  Hey, we work in health care.  Are our gyms more sophisticated than we are?

Recently, my twenty-five year old daughter had to pay a bill and she told me, “I don’t have checks for my checking account and they don’t accept on-line payments.”  Most of us have checks for our accounts, but younger patients are using on-line payments with greater frequency.  Make it easy for patients to pay your bill on-line, with debit or credit cards.

5.    Compare your insurance paid amounts with your contract

It sounds like as much fun as having a root canal, but every practice needs to know if its major payers are paying the allowed amount as described in their contracts.  The first step in this process is to find your contracts with your two or three biggest commercial payers.  Take a look at the contract to see how your group’s fees are determined.  Is it by a fee schedule that is sent to you annually?  Is it a percentage of local or national Medicare?  Does it vary by the type of contract?  If so, your job is much more difficult.  Is it a conversion factor times Relative Value Units (RVUs)?  If a percentage of Medicare, are fees based on the current year or a previous year?  Next, print out a frequency distribution of your procedure codes.  For some specialties, 80% of revenue is generated by 20 codes.  If so, look only at those 20 codes.  Some specialties will need to look at 30 or 50 codes.  Start with the most frequently billed codes, and load the payer’s allowed amount into your practice management system.   Then, when payment is received, compare the paid/allowed amount with the expected fee from the payer.  If there is variance, a call to your provider rep is needed.

These are the first five steps in your nine-step program to better (higher) collections.  The final steps will be published on Thursday, July 19, on this blog.  Remember as you take these steps to automate procedures whenever possible and track your progress!

Betsy Nicoletti writes on how to develop a nine-step plan to better practice collectionsBetsy Nicoletti, M.S., CPC, is the founder of Codapedia.com, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at www.mpconsulting.org.

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Staying on Top of Business Trends to Protect and Build Your Medical Practice

Laurie Morgan July 16th, 2012

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A few years ago, we had the opportunity to work with a wonderful gastroenterology practice in a rural Southern community.  This little town had but one significant employer (and one main payer), a large regional manufacturing plant – and the plant was rumored to be on the chopping block, as the company began off-shoring many of its manufacturing operations.  Employees were already being offered opportunities to train up workers in China (presumably their own replacements).  Things were not looking good for these employees or their hometown. 

You would think this would have also spelled doom for the practice.  But, as it turns out, the future still looked very bright for our clients.  The practice team had already planned ahead for the possibility of the plant closing.  They understood that, even if the plant closed, the town’s population was aging and unlikely to relocate – and they’d need services.  So, they developed a strong Medicare patient base, and positioned themselves to be the Medicare practice-of-choice for locals as they reached 65.  They also established a satellite office in an underserved nearby town, opened a much-needed ambulatory surgery center, and explored a variety of new marketing approaches.  As a result, the practice was actually booming – and well-positioned to keep thriving – despite the looming threat.

Handling these sorts of environmental changes – which can seem like they come from out of the blue – is critical to the long-term profitability of your practice.  In the current economy, medical practices can be “collateral damage” when big employers struggle or close up shop. 

Planning for ways to reach new patients – like our clients in the South did – is one way to protect and build your medical practice.  Another important step is to be extra vigilant about verifying insurance – and confirming patient payment responsibilities – when a major local employer begins laying off employees or closes a facility.  Remember that, because of typical processing delays and the impact of COBRA, terminated employees can appear to be covered by their previous policies for several months past their termination date.  If you’re not updating and verifying patient employment information at every visit, your exposure to payment retractions for terminated plans is growing.

Stay informed about business activity in your local area

Above all, it’s important to stay informed about business activity in your local area that can impact your practice indirectly.  Most US cities offer a business publication such as the Business Journal (which offers scannable email newsletters with local business news for 40+ metro areas), or a local newspaper with business coverage.  To stay current on-the-go, Google Alerts are a handy resource – just enter keywords about your local market (e.g., local businesses, business leaders or key lawmakers), and Google will send you tailored news-links at the interval that works best for you. 

Keep in mind, also, that staying current on local business news won’t just help you avoid problems – it can also help you spot opportunities.  A few years ago here in San Francisco, an initiative by the mayor to reduce the tax burden on start-up companies made big headlines because it encouraged Twitter, one of the hottest Internet companies, to remain here – and to expand in an area of town that is desperate for redevelopment.  The expansion of a company known for attracting hard-working young professionals should have caught the attention of family practitioners, OB/GYNs and pediatricians – because those Twitter employees represent practice growth now and several years down the road.  What’s more, the Twitter decision kicked off an influx of fast-growing Internet companies to Twitter’s neighborhood and surrounding areas – a trend that’s expected to continue.  A savvy practice could find lots of ways to capitalize on this type of information – by considering opening an office in Twitter’s previously undesirable neighborhood, for example, or by creating marketing programs targeted towards the new employees coming into town.

Laurie Morgan is a management consultant with Capko & Company. She specializes in marketing, management and technology for medical practices and blogs about practice management issues at www.capko.com/blog. Laurie has a BA in Economics from Brown University and an MBA from Stanford. Laurie recently wrote for Getting Paid on My Receivables Are Growing: Time for a New Billing Service?, Hidden Ways Medical Billing Shortcomings Hurt Your Practice and Fine Tune Your Hiring Process to Reduce Turnover and Build a Better Medical Billing Team, Parts I & II.

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Medical Billing Tip of the Month – July

Kareo July 16th, 2012

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Wow, it was a hard-fought battle this month for Medical Billing Tip of the Month, with more votes than we’ve ever received. It was close, but one tip pulled ahead in the voting. Thank you to everyone who voted on our blog and Facebook. The winner of our Medical Billing Tip of the Month contest this month is…

AR Categorizing Using Batch Number

I make use of the customized reports option in Kareo to pull outstanding claims by category.

The Application:

We use the Batch # field in Kareo to pick a specific category of outstanding claims.

When outstanding claims are analyzed, if the reason is identified to be one of the following:

  • Insurance f/u required
  • Already appealed claims
  • Awaiting EOB
  • Requires client assistance
  • Denial

Then the following trick can be used to pull outstanding claims by category.

The Trick:

Below-mentioned category names can be entered in the Batch # field of the analyzed claim [replacing the Charge file name]:

For example,

  • Insurance f/u required – INS F/U
  • Already appealed claims – APPEALED CLAIMS
  • Awaiting EOB – AwEOB
  • Requires client assistance – CLT ASST
  • Denial – DNL

Note: The original Charge file name can be copied in the business notes field for future reference of such claims.

The Result:

To pick outstanding claims for a specific category:

Run the Insurance Collection Summary report in Kareo: Reports -> Accounts Receivable -> Insurance Collections Summary

Then click the “Customize” button and enter specific “Category name” on Batch # field & generate the report:

This medical billing tip of the month explains how to use the customized reports option in Kareo to pull outstanding claims by category

Then Click OK . Outstanding Claims by category will be reflected on the report. Please refer to output screenshot below:

This medical billing tip of the month explains how to use the customized reports option in Kareo to pull outstanding claims by category

This method has helped me a lot while categorizing outstanding claims and I hope it will be useful for every user.

David Beckett
EccoHealth LLC

Thank you to all who entered; please be sure to submit your Medical Billing Tip of the Month to Marketing@Kareo.com by Wednesday, July 25, for inclusion in the next round of judging. We’ll post the top three tips on our Facebook page and on the Kareo blog for your vote! You will win a $250 American Express gift card if your tip is chosen. Good luck!

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Patient Files Disappear: Could This HIPAA Violation Happen To You?

Laurie Morgan July 11th, 2012

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Avoid HIPAA violations with these tips from expert consultant Laurie Morgan of Capko & Company

An amazing headline from the local news here in Northern California today: “’Overwhelmed’ Clerk Brings 1500 Patient Files Home.”  The clerk apparently started bringing files home because she was falling behind in her duties – which included organizing and copying the files and creating reports for the physicians at her hospital. All of the files apparently contained test results and other medical information, and some included financial information and social security numbers. 

Are you thinking what I’m thinking? Holy HIPAA violation!  Even more alarming: this kind of thing may not even be that rare: commenters are mentioning examples of similar things happening in other medical offices across the country.  Worst of all, while the clerk in this case appears to have removed the files because she was overworked, the fact that she was able to do it suggests that someone looking to steal medical identities could have easily done the same.

Management controls and policies should have prevented something like this from happening.  What’s more, appropriate controls would have flagged the situation for attention – potentially leading to a restructuring of roles or more staff to alleviate the clerk’s disproportionate load.

How can this be avoided?

What procedures could have made a difference?  Here are a few:

Chart-handling policies:  Charts should only be removed from a medical office for very specific, HIPAA-compliant reasons (for example, when a provider will need the chart for treating the patient at the hospital).  And, it should always be clear who has control of the chart and where it is when it is removed from the office – a sign-out/sign-in system can be used for this purpose.  

Billing processes: When an external billing service is used, only needed information should be provided to the service, and the method for delivering should ensure that confidentiality is protected (and, of course, it’s essential that the service itself be HIPAA-compliant). 

Audits:  Several types of audits might have spotlighted that a clerk was removing patient information.  For example, chart audits performed to monitor billing and coding processes – a good idea to ensure your practice’s coding is ship-shape in case a payer wants an audit – would have revealed missing files. Even a weekly co-pay audit – which is a great tool to encourage staff to collect co-pays up-front – could have illuminated this issue before it got out of hand.

Staff/management communication: Weekly meetings – and some open door hours for practice managers each week – can help bring workload issues to light more productively.  If one person is consistently unable to fulfill their job duties, it’s likely the job is too big for one person, or the wrong person is doing the job.

Cross-training: If the job really was too large for one person to complete during the workday, a policy of cross-training employees could have revealed that.  Cross-training also would have prepped other staff to help out the buried employee – and is always a good idea to ensure an employee departure (or even vacation) won’t lead to backlogs and errors.

Laurie Morgan is a management consultant with Capko & Company. She specializes in marketing, management and technology for medical practices and blogs about practice management issues at www.capko.com/blog. Laurie has a BA in Economics from Brown University and an MBA from Stanford. Laurie recently wrote for Getting Paid on My Receivables Are Growing: Time for a New Billing Service?, Hidden Ways Medical Billing Shortcomings Hurt Your Practice and Fine Tune Your Hiring Process to Reduce Turnover and Build a Better Medical Billing Team, Part I and Part II.

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Using RVUs to Improve Your Bottom Line, Part 2

Kathy McCoy, MBA July 9th, 2012

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RVUs can be an important tool for helping to assess--and improve--the productivity and profitability of a medical practice.

RVUs can be an important tool for helping to assess—and improve—the productivity and profitability of a medical practice. That was the message during Using RVUs to Improve Your Bottom Line, a webinar presented recently by practice management expert and author Sara M. Larch, MSHA, FACMPE. Our first blog on Sara’s presentation explained what RVUs are and how they are calculated. Our second blog here will show how you can use RVUs to price services correctly, evaluate payer and physician productivity, and analyze your own practice trends on profitability.

Sara recommends that practices use Medicare rates as the benchmark to use in setting their fees. Even though not all practices accept Medicare, RVUs are the methodology upon which CMS sets its payment schedule. She has seen some practices that have set fees less than 100% of what Medicare will pay—leaving money on the table. She also notes that many commercial plans pay more than the Medicare allowable fee. Sara has seen some practices with fees that are 200-300 percent of the Medicare rate, yet are in line with contracted rates with commercial payors. She recommends that you always set your fees above the highest reimbursement you receive for each service–otherwise, you are walking away from dollars you could otherwise have. Using the same percentage above Medicare rates for all your fees makes for a more precise analysis when you start evaluating reimbursement trends.

Sara recommends that practices use Medicare rates as the benchmark to use in setting their fees. Even though not all practices accept Medicare, RVUs are the methodology upon which CMS sets its payment schedule.

RVUs can also be used to evaluate the overall value of individual payers to your practice. Sara recommends that you calculate total collections by payer divided by total RVUs reflected in claims submitted to that same payer. The result will be a dollar figure that you can use to compare the per-RVU reimbursement of various payers. Comparing that dollar figure to the Medicare rate will help you understand if a particular payer’s rates are more–or less–favorable for your practice.

In her presentation, Sara also showed ways to benchmark physician productivity using RVUs. The Medical Group Management Association’s 2011 Cost Survey publishes worked RVUs by specialty that practice managers can use to gauge their own physicians’ productivity. Or, practices can create their own RVU targets for their doctors and then evaluate their performance accordingly. This methodology can be used to calculate compensation or bonuses.

RVUs can also be used to calculate your costs per CPT. Remember, every CPT code has an assigned RVU. Divide your annual operating expenses by total RVUs billed for your practice that same year. By multiplying the resulting dollar figure by the assigned RVUs per CPT code, you can see your actual cost to provide the service associated with that code. In the example Sara gave, one practice was making $2.06 on every new office visit–and losing $5.04 on established patient office visits! Drilling down to this level of detail will help you understand where your practice is making—and losing—money.

According to Sara, questions that RVUs can help you answer include:

  • Are services priced correctly?
  • Are payers reimbursing services according to contractual agreements?
  • Do payments from payers cover the practice’s costs?
  • Are physicians working as hard as they think they are?
  • Are some physicians or specialties performing at higher levels than others?
  • Is physician compensation appropriate?
  • Is the practice overhead appropriate?

While RVUs aren’t perfect, they can serve as a useful tool for evaluating many variables that affect profitability. Be sure to view the entire webinar for actual formulas from Sara that will help you evaluate your own practice’s performance.

Kareo often features educational webinars on practice management issues that can impact your bottom line. Join our notification list to learn about upcoming informative webinars such as this one. You can also view our archived webinars to find more topics of interest to you. If you would like to learn more about Kareo’s innovative tools for streamlining your medical billing and collections, watch the demo.

You can also register now for our next informational webinar, Effective Appeals in Medical Billing: Breaking Through the Barricade to Get Paid, on July 26 featuring Elizabeth W. Woodcock, MBA, FACMPE, CPC. Don’t miss it!

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Hidden in Plain Sight: Five Medical Coding Gems from Your CPT Book

Betsy Nicoletti, M.S., CPC July 5th, 2012

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A spy in a novel I was reading said the best place to hide was in plain sight. I’ve never traveled incognito, so I don’t know if that’s true.  But, I do know that the answers to many of my medical coding questions are an arms’ length away from me, hidden in plain sight in my CPT book.  Here are five of my discoveries.

1.      Lesion destruction in sensitive areas have their own codes

Medical practices that perform minor surgical procedures are very familiar with lesion destruction codes in the skin section of the CPT book (17000—17250).  Two commonly used sets of codes are destruction by any method of pre-malignant lesions, (17000—17004) and wart destruction (17110—17111).  For skin tags, see 11200 and 11201.

But what about lesion destruction in sensitive areas, such as the mouth, eyelid, conjunctiva, anus, penis, vulva or vagina?  The editorial comments at the start of the Destruction codes refers us this way: “For destruction of lesion (s) in specific anatomic sites, see 40820, 46900—46917, 46924, 54050—54057, 54065, 56501, 56515, 57061, 57065, 67850. 68135).  The AMA doesn’t use the word “sensitive,” but having listed the body areas above, I’ll say it.  If your medical practice destroys lesions in any of the sensitive areas I’ve listed, get out the CPT book and find the more specific code.

2.      Modifiers don’t switch sides

Modifiers are faithful to their partners.  If a modifier is meant to be on an Evaluation and Management code, it won’t pair well with a procedure or diagnostic test.  If a modifier is defined as a service used with a procedure, it won’t be accepted on an E/M code.  Appendix A in the CPT book defines each modifier clearly.

3.      Sometimes, we don’t like what we see

Clinicians frequently want to know how they can be paid for all of the time and work they spend caring for patients, particularly hospitalized patients.  Often, the answer is that the extra time and work is not separately payable.  For example, all of the inpatient codes are defined as the care of the patient “per day,” so second visits by that physician or a covering partner are not separately paid.

The editorial comments at the start of inpatient hospital care remind us that if the patient is admitted in the course of an encounter in locations such as the office or Emergency Department, bill only for the admission.  I wish I could tell physicians that they could bill for both the office visit and the hospital service, but in plain English, the CPT book says to report only the admission.

4.      To add or not to add

Do you add together the length of the repair of two arm lacerations?  What about two excisions on the trunk?  Are they added and billed as one?  A medical group that performs these services every week knows that answer by heart.  But for the rest of us, look at the editorial comments at the start of excision of benign lesions, and find, “Report separately each benign lesion excised.”  At the start of the section on Repairs, the CPT book states, “When multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor.”  Excisions: report each.  Repairs: add together in the same classification and location, as defined by CPT.

5.      Head, shoulders, knees and toes

Take a break from your computer and remember the old song/exercise, “Head, shoulders, knees and toes, knees and toes.”  The surgical sections of the CPT book are organized anatomically, which makes it easier to find the code you’re looking for in many sections.

Take the musculoskeletal section:  It literally starts with the head and goes to the toes.  Within each body area, as relevant, are sections  describing procedures: incision, excision, manipulation, introduction, repair, revision and/or reconstruction, other procedures, fracture and/or dislocation, arthrodesis, amputation.  Similarly, the digestive system, 40490—49999 starts with lips and ends with abdomen, peritoneum and omentum.  Each of these sections describes procedures in the same order, as relevant: incision, excision, endoscosy, laparoscopy, repair, manipulation, other.  The first pages of each section in the CPT book are like the table of contents and show the organization of the codes.

Let me end with a reminder that you can and should take CPT literally.  When the CPT book says “do not use” or “do not report,” that means, do not add that code to the claim form, do not bill the patient for the service.  If the CPT book states “see also” or “use also,” that means, “go to the referenced code.”  If the service was provided, use it on your claim form as well.  The important notes and comments in the CPT book make it necessary to continue to buy a paper version of the book, even with electronic search.  Use this information: don’t let it be hidden in plain sight on your desk.

Betsy Nicoletti, M.S., CPC, is the founder of Codapedia.com, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at www.mpconsulting.org.

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