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Practice Intolerance Add 5%, 10%, 15% or more to your income Presented by: Robert E. Goff & Kamal Hashmat Official Disclaimers The information presented today is for general information only and not meant to substitute for legal advice. Always seek the advice of an attorney on legal matters. No recommendation is made as to an individual physician’s participation or non-participation with any specific health plans, insurance company or payer. Each physician is urged to give due and proper consideration to their own individual practice needs and act independently regardless of the actions or non-action of other physicians. Top 10 rules of claim payment Just Because… 1) 2) 3) 4) …it has a code, does not mean it’s covered …it’s covered, does not mean you can bill for it …you can bill for it, does not mean you will be paid for it …you have been paid for it, does not mean you get to keep the money 5) …one health plan paid you, does not mean you will get paid by another 6) …you have been paid for it once, does not mean you will be paid for it again. 7) …you got paid for it in one state, does not mean you will get paid in this one Also… You will never know all the rules Not knowing the rules can cost you big The rules are subject to change without notice What you’re up against Contract Law Extremely powerful Impossible to overcome, except for Contrary to federal, or state law Impossibility REALITY FIGHTING CONTRACTS LAW IS A LOSING PROPISITION 2 Critical Factors In Dealing With Payers A corporation is a legal entity – an artificial person Never expect justice from a person without a soul The Parole Evidence Rule The written evidence always trumps the oral Tolerance is for people, not for corporations Reality Check The majority of claim dollars are lost due to selfinflicted injury Failure to submit a claim in a timely manner Failure to monitor EOB’s to identify denials or payment errors Failure to resubmit initially denied claims in a timely manner with correct information Failure to appeal errors in denials in timely fashion Failure to hold plans to the provisions of the NYS PPR Failure to monitor your own coding The Physicians Not So Secret Weapon Part 332-4 NYS regulations must become YOUR rules in dealing with payers Claims must be paid in 45 days from the date received The plan has 30 days from the date received to challenge you for more information or to question their obligation to pay If they don’t - 12% interest per year Potential fines and penalties by NYS DOI – up to $500 per day per claim Rejections/Denials Rejections – resubmit Errors in the claim submitted Denials - appeal Lack of documentation of permission No referral No preauthorization Lack of eligibility Ineligibility for coverage/Policy not in effect An other insurer is primary Do you know what denials/rejections can be recovered using which approach? Denial Tracking Work Sheet Date Denial Received Pat. Acct. No. Ins. Co. Payer 7/15 123 United 7/23 124 Oxford 7/30 125 Aetna 8/1 126 Oxford Where Error likely occurred Coding Front Desk Referral/ authorization Billing Ins. Co. $200 $300 $2000 $100 Action Taken Including date of appeal Reason Explanation 7/30 charred pat credit card Ineligible at time of svc 9/30 appealed Denied for no referral – ref on file 8/15 Resubmitted Coded as global delivery – patient started 2nd trimester Saw patient without referral – no recovery possible Documentation & Coding When it comes to coding & documentation physicians are…. “Like frogs in boiling water, they don’t feel the heat until they are cooked” When charts are requested it is too late Where did the $12.1 Billion in improper Medicare payments go in 2001? 43.2% Medically unnecessary services 42.9% Documentation deficiencies 17% Coding errors 4 Acts of Intolerance that will add income to your practice Insist on patients accepting responsibility Just say no to post-treatment attempts to renegotiate your rates If you get paid 100% of billed, bill higher Dispute demands for past paid recoveries Practice Intolerance is a guide to improving the income of your medical practice CureMD Practice Resource System (PRS) implements many of the tools and techniques of Practice Intolerance, automatically bringing the benefits of technology to your practice. Resources www.CureMD.com www.ins.state.ny Abridged version “Practice Intolerance” by Robert E. Goff is available at: www.CureMD.com Contact Information CureMD Corp. 1181 Broadway, 6th Fl New York, NY 10001 (P) (212) 213-6230 (F) (212) 684-7034 Please visit www.CureMD.com Email [email protected]