Should You Charge a No-Show Fee?

Lea Chatham May 29th, 2013

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Rochelle Glassman discusses strategies to increase medical billing revenue for Kareo

Patients who cancel appointments or surgeries at the last minute can be a huge drain on your practice’s cash flow. This is a practice management and medical billing issue that all practices face. The average physician has about a 7% cancellation/no-show rate. This means that for many doctors, one to two patients a day don’t show up or cancel at the last minute. You could be losing hundreds of dollars a day as a result of patients who don’t show up.

There are a lof of things you can do to reduce this rate. Some studies suggest doing email and/or phone reminders one to three days in advance can reduce no-shows by as much as 50%. Another strategy recommended by practice management expert Rochelle Glassman is to analyze your highest no-show patients and appointments and consider double-booking some of those. For example, Medicaid estimates 30% of their patients don’t show so look at double-booking those appointments.

Another recommendation Rochelle has is to set a cancellation policy, and be sure it’s communicated to every patient. Ideally, this takes the form of a document that new patients sign when they first come to the practice. Afterward, make it a point to discuss your policy at the time of booking subsequent appointments or surgery and when reminder calls or emails go out to patients.

In the cancellation policy, many practices require patients to cancel their appointment at least 24 hours before their scheduled appointment time. For surgeries, the required notice time can be even longer. For those patients who do not comply, consider charging a late cancellation/no show fee. Rochelle is often asked if this is really ok, and her response is always the same: Always check your payer contracts to be sure you are complaint with those agreements as well as any other legal or regulatory requirements, but otherwise, yes, it is not only ok, it’s just good business sense. And it is easier than you think.

Collecting cancellation fees can be achieved easily when your office is set up to bill for cancellations and accept credit card payments. By creating a cancellation code, you can bill the patient using electronic statements. The day of the cancellation or no-show, process a patient statement and direct the patient to pay online by credit card. Enabling patients to pay online can increase patient payments and speed the turnaround on those payments whether it is for the cancellation fee or for standard co-pays and deductible payments.

Setting up a cancellation and no-show policy and following through with charging patients a fee is one of Rochelle’s recommendations for increasing revenue at your practice. In her recent guide, 3 Easy Ways to Increase Medical Practice Revenue by 25%, she discusses this as well two other simple strategies. To find out more download the guide now.

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Answers to Your Top Medical Billing Audit Questions

Lea Chatham May 28th, 2013

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5 Activities

In the free webinar, Five Critical Activites to Prevent a Government Audit, medical billing and coding expert Betsy Nicoletti reviewed her five suggestions for preventing an audit. She covered a lot of information, and attendees had many good questions. We’ve selected a few of the most common questions to share with everyone.

Q: Are there private audit companies and how can we find one that is right for us?
A: Yes, there are thousands of private companies that can do an audit for you. I suggest starting with your specialty organization to see if they have recommendations.

Q: My physician sees a lot of patients with chronic and complicated conditions so most of his coding is at the highest levels. Should I lower the levels to prevent an audit?
A: The goal is to be complete and accurate in your coding and to be able to justify your coding in the event of an audit. If the documentation, diagnosis, etc. supports higher levels of coding, then code for the services you are providing. I would not recommend changing your coding to prevent an audit if the changes are not reflecting the documentation. But, there are many patients with chronic illnesses and not all physicians use the highest level of codes.

Q: Is there an app or online version of the CPT book?
A: There is an online option for the CPT code book. And there are many apps. If you do a search for CPT apps you’ll find options for android and apple. The AMA offers bound books, eBooks and apps for CPT at

Q: If we do an internal review and we find a mistake, how do we notify Medicare without raising a red flag that triggers an audit?
A: If there are just a few claims, correct the claim. If there are multiple problems or systemic issues, contact a healthcare attorney.

Q: As a billing service, are we liable if one of our clients gets audited? Should we be keeping track of their coding activity?
A: It is the provider who does the coding and it is the practice that is responsible for ensuring that their coding is accurate. If the practice is audited for coding practices, they are liable not the billing service they use. This is a question to address to your lawyer.

For more details on Betsy’s recommended strategies to prevent an audit, check out the recording of the full webinar.

About Your Speaker:

Betsy Nicoletti discusses strategies to prevent a government audit

Betsy Nicoletti is the author of The Field Guide to Physician Coding and the 2007 Physician Auditing Workbook, as well as founder of She developed The Accurate Coding System to help doctors get paid for the work they do. She simplifies complex coding rules for practitioners and engages physicians in a positive and respectful way, which encourages attention and accuracy in their coding. Besides doing auditing and compliance work, she is a speaker, writer and consultant in coding education, billing and accounts receivable.

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Use the OIG Work Plan to Help Audit-Proof Medical Coding

Lea Chatham May 23rd, 2013

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Betsy Nicoletti discusses strategies to prevent an audit for Kareo

Earlier this month, Betsy Nicoletti, a medical coding and billing expert, discussed strategies to prevent an audit in her webinar, 5 Critical Activities to Prevent a Government Audit. Her number one recommendation was to be a copycat. In other words, find out what the government will look at in an audit and look at it yourself. A simple way to do this is to use the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan.

Every October, the OIG publishes a work plan that gives healthcare providers fair warning of their areas of interest. These areas, which are all related to coding accuracy, are the key things the OIG would look at in the event of an audit. In addition, if you would like more information, you can get information about current and ongoing investigations at the OIG website along with reports of finding from previous years.

In 2013 the plan includes 33 items related to Part B Medicare services, and there is something for everyone. For physicians practices, some of the items listed include Place-of-Service coding errors, potentially inappropriate payments for E/M services, the use of modifiers during the global surgery period, and Incident-to Services performed by non-physicians.

Betsy laid out three simple steps to her copycat approach:

  1. Download the work plan and review it
  2. Make a list of services you provide that are on the plan and review the coding requirements for each one
  3. Then audit the coding for those services for accuracy

The important thing to remember is that this review is not something you do just once. It is an activity that you need to perform each year when the new plan is released.

For more information about Betsy’ recommendations to avoid an audit, view her entire presentation or download the slides.

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Work Smarter, Not Harder, Part 2

Lea Chatham May 21st, 2013

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By Thom Schildmeyer

In my last blog post, I introduced a practice that wanted to address its decreased income (lower reimbursement, higher costs) simply by seeing more patients.  The thought was that, by increasing its volume of service, the practice would automatically increase its revenue. To that end, they were exploring different marketing initiatives and staffing needs to meet this “strategic” goal of seeing more patients instead of looking at their medical billing processes.

While this works for some practices, it is often better to look within your practice and try to work smarter not harder. Ultimately, I encouraged the practice’s management team to focus on its current claims and collections (working smarter), rather than serving more patients (working harder—while at the same time adding strain on themselves and their staff).

The practice heeded my advice, focusing on its current accounts receivable (A/R), while also implementing a couple other strategies that immediately yielded better financial results.

In addressing its current A/R, the practice employed a straightforward approach. The management reviewed reports that identified the practice’s highest balances (money owed) by payer, then further analyzed the A/R to see what patients owed the most money (reviewing the list from largest balances to smallest).

This led to a “quick hit” or “low-hanging fruit” list of highest dollar amounts owed. At the same time, the practice targeted the oldest dates of services to help identify and avoid any timely filing issues that would result in loss of claim re-submission—and thus, payment collection.

These two activities—sorting A/R by amount and date of service—enabled the management team to focus its medical billing staff on the highest-priority claims that would yield the fastest results.

Over a 90-day period, the practice remained focused on this activity, leading to an average increase each month of 19% in collections, while at the same time significantly reducing overall A/R balances.

A secondary, yet important, benefit derived from this activity was the staff’s awareness of high-dollar balances and timely filing issues. Frankly, it was an “eye opener” as to the amount of money sitting out there and the risk of losing that revenue when claims are not worked properly.

The billing staff’s increased sense of urgency—and knowing that management is looking more closely at the claims and A/R balances—has created a new billing environment that is focused on maximizing the practice’s bottom line by more diligently and aggressively working outstanding claims. Not only has this resulted in a more motivating culture, it has enabled the billing staff to share in the practice’s rewards.

Beyond collecting on unpaid claims, with a targeted focused as described above, there are several other areas the practice chose to focus on, including:

  • Collecting co-payments at time of service
  • Collecting past due balances at time of service
  • Reviewing and adjusting its fee schedule
  • Transferring balances and sending statements
  • Checking eligibility

Want to learn more? Be sure to read my next blog post, where I will provide more explanation on the above areas.

 About the Author

Thom Schildmeyer shares tips to solve real world medical billing problems for Kareo

Thom Schildmeyer is President of Aesyntix Health, Inc, a leading provider of billing and purchasing solutions for dermatologists and cosmetic surgeons. He has more than 20 years experience consulting with practices in the areas of financial analysis, practice valuation, human resources, training and development, sales management, marketing, and patient relations.

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Top 6 Meaningful Use Stage 2 Questions Answered

Lea Chatham May 20th, 2013

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In the free webinar, Listen. Learn Implement. The Ins and Outs of Meaningful Use Stage 2, medical practice expert Elizabeth Woodcock guided us through the requirements for Meaningful Use Stage Two—and recent announcements that will affect Stage One. She reviewed what the government will require in Stage Two—and what it will take for your providers to successfully qualify. She reviewed a lot of information, and attendees had many good questions. We’ve selected a few of the best questions to share with everyone.

Q: I reported Stage 1 in 2012. Do I report for Stage 2 now for the full year or 90 days or do Stage 1 again?
A: If you attested for Stage 1 in 2012 for 90 days then you would attest for Stage 1 again in 2013 but for a full 365 days. Stage 2 attestation doesn’t begin until 2014.

Q: Will there be more eReporting procedures in the future? Will it include CQMs and Menu/Core requirements?
A: Yes, for Stage 2, EPs will be able to send the reporting data electronically. For more details on this, see the Stage 2 tip sheet.

Q: If no CQMs are required but they recommended does that mean that 2014 CCHIT certification will require all EMRs to have ALL 64 CQMs available?
A: There are still requirements for reporting CQMs; in fact, Stage Two requires nine of 64 approved clinical quality measures (CQMs) to incorporate at least three reporting domains. Vendors are not currently required to have all 64 CQMs.

Q: Related to the program ending—will the penalties continue after 2016?
A: The penalties are scheduled to begin in 2015, and will be one percent per year for three years applied to Medicare payments. After that time, the Secretary of Health and Human Services has the option to increase the penalties an additional two percent, for a total of five percent. The additional increases of two percent are only applicable if an insufficient number of eligible professionals have implemented an EHR.

Q: For the 5% of patients using a patient portal and transmitting questions to the practice—is this 5 % of the 50% OR is this 5% of the patient base?
A: There are a couple of different criteria here. To clarify, 50 percent or more of all unique patients must be provided with timely online access (within 4 business days) to their health information. Also, 5 percent or more of all unique patients must view, download, or transmit to a third party their health information. So, it is 5 percent of all unique patients, not 5 percent of the 50 percent. In addition, there is a separate criterion for electronic messaging, which requires 5 percent of the unique patients seen during that reporting period to send your practice a secure electronic message.

Q: Can you please talk a little about Transfer of Care. What constitutes a transfer of care? Specifically, as it relates to Medication Reconciliation and providing a summary of care record?
A: CMS reveals the definition of “transfer of care” to be “the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory, specialty care practice, long-term care, home health, rehabilitation facility) to another. At a minimum this includes all transitions of care and referrals that are ordered by the EP [eligible professional].” The summary of care record, which is the focus of this measure, does require the inclusion of an active/current medication list, which is defined as “a list of medications that a given patient is currently taking.” For more information, please see the tip sheet that CMS prepared for the measure entitled “Summary of Care.” For more information, download the tip sheet.

Check out the recorded webinar to get all of the great information provided there. If you find this information useful, then you may want to register for our next event, Key Strategies for EHR Success with Ron Sterling.

Note: This Meaningful Use information is subject to change. For the latest updates, visit

About the Speaker

Expert Elizabeth_Woodcock reviews meaningful use stage two for Kareo

Elizabeth Woodcock, MBA, FACMPE, CPC is a professional speaker, trainer and author specializing in medical practice management. She has focused on medical practice operations and revenue cycle management for more than 20 years.

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3 Reasons to Check Out CMS eHealth

Lea Chatham May 17th, 2013

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You are probably getting inundated with emails, webinars, postcards, etc. about implementing an EHR and attesting for Meaningful Use and other incentive programs. Even though you find some time to review these materials or attend an event, your resources are probably stretched pretty thin. So if you are looking for a quick, easy go to resource for information on incentive programs, consider adding CMS eHealth to your favorites. Here are three great reasons why:

  1. The whole point of this website is to align health information technology (Health IT) and electronic standards programs and simplify adoption for you.
  2. It provides a central location to look for information about all CMS programs, including EHR Incentive Program, PQRS, eRx, Administrative Simplification, and ICD-10.
  3. And, it offers tools to stay up to date via email alerts or social media.

Kareo provides resources for EHR

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New Survey Shows Optimism about EHR Adoption

Lea Chatham May 15th, 2013

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Deloitte 2013 Physician Survey Overview from Kareo

Recently, Deloitte released a report about health information technology (HIT) based on its 2013 Survey of U.S. Physicians. The report looks at the rate at which physicians are adopting, what they think is working with electronic health records (EHR), and what the barriers are to increasing adoption. Deloitte uses the data collected to make some predictions about the future of health information technology.

The view of Deloitte is that “U.S. physicians who use HIT are optimistic about its prospects for better care and lower administrative costs once fully integrated.” In fact the survey showed that 73% of all physicians believe that HIT will improve the quality of care provided in the longer term.

The survey also showed how providers who are currently using a certified EHR feel about the benefits to their practices now:

  • 74% agree or strongly agree that it is faster and more accurate billing for services
  • 67% agree or strongly agree that it provides time savings through e-prescribing
  • 67% agree or strongly agree that it improves communication and care coordination capabilities due to interoperability
  • 59% agree or strongly agree that it offers Clinical benefit due to immediately available data
  • And just over half (56%) believe that there is patient care improvement through clinical guideline prompts and faster lab results

Despite increasing optimism, there are still many physicians who are hesitant to adopt an EHR. Only 31% of solo practitioners have a certified EHR. Another 55% of solo practitioners say they will adopt in a year or more. The numbers are higher for larger practices, but the reasons for delaying or not implementing are the same. Most cite up front cost, complexity and ongoing maintenance as the reasons they are not making the leap to automation.

Despite the barriers, Deloitte states in the report that they believe skepticism is likely to change because, “Powerful market forces exerted by health plans and consumers are accelerating HIT adoption.” And they add that, “Those physicians who are early adopters of HIT, especially the full capabilities of certified EHRs, will potentially gain market advantages over time.”

To find out more, read the full report.

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Don’t Let EHR Tempt You into Non-compliant Medical Billing

Lea Chatham May 14th, 2013

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By Lisa A. Eramo

With just a few simple clicks of a mouse, physicians using an electronic health record (EHR) can create quite impressive notes filled with clinical information. The technology certainly saves time, but what effect, if any, does it have on compliant medical billing?

In its FY 2013 Work Plan, the Office of Inspector General (OIG) says that EHRs may have the potential to foster fraudulent practices that can yield inappropriate payments for evaluation and management (E/M) services.

Overly-templated documentation and/or the ability to quickly copy and paste information make it far too easy for physicians to unknowingly upcode (i.e., report higher-level evaluation and management [E/M] codes than what’s clinically justified), says Betsy Nicoletti, co-founder of, a wiki devoted to physician reimbursement.

Data suggests that physicians have certainly been billing higher levels of evaluation and management (E/M) services over the last decade. In its May 2012 report, Coding Trends of Medicare Evaluation and Management Services, the OIG states that physicians increased their billing of higher level, more complex, and expensive E/M codes in all 15 visit types from 2001 to 2010. Approximately 1,700 physicians billed higher level, more complex and expensive E/M codes in 2010 at least 95% of the time.

However, are physicians intentionally coding higher levels of E/M services to obtain higher payments, or do these billing patterns simply reflect sicker patients or improved physician documentation?

The Department of Health and Human Services and the Department of Justice suggest that physicians may be using EHRs to intentionally engage in fraudulent practices. Both departments sent a letter dated September 24, 2012 to the American Hospital Association, three other hospital groups, and the Association of American Medical Colleges stating that there is evidence of providers who are “using this technology to game the system, possibly to obtain payments to which they are not entitled.”

Nicoletti says most physicians don’t knowingly engage in fraud. However, how can a physician be sure that his or her medical billing patterns don’t suggest such a trend?

Tip #1: Monitor your E/M codes. On a quarterly basis, compare your own data with that of CMS. Your specialty society may publish this information, or you may be able to obtain it from one of several publishers. Two examples include:

Your profile doesn’t need to match CMS norms exactly, but it also shouldn’t be a complete outlier, says Nicoletti. “A small variation is to be expected. Also, some specialists only bill level fours and fives,” she adds.

Tip #2: Work with your EMR vendor. Some EHRs suggest an E/M level, but physicians should only use this as a guide, says Nicoletti. Some practices may want to turn this functionality off entirely. “If you’re going to use it at all, someone needs to check the accuracy. An auditor needs to audit a percentage of notes before you turn it on and starting using it,” she says.

Tip #3: Use common sense. “If a patient comes in with a sore throat, and you document a comprehensive history or comprehensive exam, you don’t need to bill a higher-level code for that,” says Nicoletti. Take a few moments to review Appendix C in the CPT Manual, which includes specialty-specific clinical examples for E/M levels.

For more tips from Betsy Nicoletti, check out her upcoming webinar, Five Critical Activities to Prevent a Government Audit, which is coming up on May 16.

About the Author

Lisa Eramo Freelance

Lisa A. Eramo ( is a freelance writer and editor based in Cranston, RI who specializes in healthcare regulatory topics, health information management, and medical coding.

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CMS Incentive Updates and Deadlines

Lea Chatham May 13th, 2013

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Over the past few months, CMS has hosted several updated calls on the three CMS incentive programs that are going on now.  The calls reviewed the current eligibility requirements, exemptions, and upcoming deadline for eRx, Meaningful Use, and PQRS. The recording for the call includes the recorded event along with several supporting documents, the presentation slides and links for more information and assistance. You can listen to the entire presentation here.

One of the most useful aspects of the call is the decision tree provided for each CMS incentive program. The trees review all the questions you should ask yourself to help determine whether or not to participate in the incentive programs and what the results will be if you opt to participate or not. The discussion also addresses exemption opportunities.

CMS Incentive updates from Kareo

2013 is a big year for all three programs. Here are a few key highlights from the call:

  • EHR
    • Payment adjustments in 2015 are based on participation in 2013. The last day to start reporting for a 90-day period and avoid the adjustment is October 3, 2013.
    • December 31, 2013 is end of participation for the year.
    • Doctors with the designation of radiology, anesthesiology, and pathology are automatically exempt from adjustments.
    • Remember: You can’t do Medicare and Medicaid at the same time. You are allowed to make a one-time switch. This needs to happen before the end of 2014.
  • PQRS
    • Payment adjustments in 2015 are based on participation in 2013. October 15, 2013 is the last day to elect the administrative claims option to avoid the 2015 adjustment. More information will be available soon about this. The other way to avoid the adjustment is to submit one valid measure or measures group.
    • The adjustment in 2015 will be 1.5%.
    • There are cases where you may be eligible but not able to participate. These situations and other exemptions are reviewed in the call in detail.
    • You can earn incentives for both Meaningful Use and PQRS at the same time.
  • e-Prescribing
    • June 30 is end of the 6-month reporting period for 2013 to avoid the 2014 adjustment. The adjustment will be 2% of the Medicare physician fee schedule allowed charges. The claims must be processed into the National Claims History by July 26. So don’t wait until the last minute. If claims aren’t clean and bounce back you could end up without enough claims filed by the deadline and be assessed an adjustment.
    • There are hardship exemptions, which include: being located in rural area with limited Internet; having limited access to pharmacies with e-prescribing; being unable to do e-prescribing due to local, state or federal law or regulation; and having limited prescribing activity (this is defined in more detail on the call).
    • You can also get automatic exemption if you achieved Meaningful Use (either first year for 90 days or second year for 365 days) between January 1, 2012 and June 30, 2013.

To get the full details on each program’s current requirements, upcoming deadlines, and exemptions, along with the current incentive amounts and adjustments, watch the entire presentation, which is about 60 minutes.

For other great resources, check out Kareo’s recent webinars on Meaningful Use: Everything Small Practices Need to Know about Meaning Use Now and Listen. Learn. Implement. The Ins and Outs of Stage 2 Meaningful Use.

Note: This Meaningful Use information is subject to change. For the latest updates, visit

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Complimentary Webinar: 5 Critical Activities to Prevent an Audit

Lea Chatham May 9th, 2013

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Thursday, May 16, 2013
1:00 PM EDT/10:00 AM PDT

Speaker: Betsy Nicoletti

Physician practices can and must decrease their audit risk from both government and private payers. How can they do that? This one-hour webinar will review five preventive strategies that will decrease medical coding risk in your practice. At the end of the session, you will be able to:

  • List three sources of coding risk in your own practice
  • Describe the OIG Work Plan, it’s importance, and where to find it
  • Implement two key strategies to decrease coding risk

The five strategies you’ll learn about include:

  1. Be a copycat: audit what the government is auditing
  2. Compare and contrast your data with the government’s data
  3. Audit high risk activities
  4. Don’t fall victim to “WNL” We Never Looked in your EMR notes
  5. Ignorance is never bliss: educate, educate, educate

Register today!  You don’t want to miss this.

Who Should Attend Private practice owners, billing managers, practice managers, office managers, billers and any others concerned about compliant medical billing.

Register now to learn strategies to prevent a government audit

About Your Speaker:

Betsy Nicoletti discusses strategies to prevent a government audit

Betsy Nicoletti is the author of The Field Guide to Physician Coding and the 2007 Physician Auditing Workbook, as well as founder of She developed The Accurate Coding System to help doctors get paid for the work they do. She simplifies complex coding rules for practitioners and engages physicians in a positive and respectful way, which encourages attention and accuracy in their coding. Besides doing auditing and compliance work, she is a speaker, writer and consultant in coding education, billing and accounts receivable.

Register now to learn strategies to prevent a government audit

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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.

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