Transcript Maximizing Reimbursment

Maximizing Income & Staying out of Trouble
Robert E Goff
University Physicians Network
Top 10 rules of claim payment
1.
Just because it has a code, does not mean it’s covered
2.
Just because it’s covered, does not mean you can bill for it
3.
Just because you can bill for it, does not mean you will be paid for it
4.
Just because you have been paid for it, does not mean you get to keep the money
5.
Just because one health plan paid you, does not mean you will get paid by another
6.
Just because you have been paid for it once, does not mean you will be paid for it
again
7.
Just because you got paid for it in one state, does not mean you will get paid in this
one
8.
You will never know all the rules
9.
Not knowing the rules can cost you big
10.
The rules are subject to change without notice
Robert E. Goff
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Maximizing Income Is About Maximizing Receiving
What You Have Earned
5-15% lost
5-10% Lost
5-7% Lost
• Uncollected patient responsibilities
• Under coding caused by the chilling effect of coding challenges
• Services provided and not billed
6-15% Lost
• Timely filing denials
5-15% Lost
• 50% of rejections not resubmitted
3-7% Lost
6% Lost
2%+ Lost
• 50% of denials not appealed (70% of appealed successful)
• Payments less than fee schedule not identified or challenged
• Post payment recoveries not challenged
Lost opportunities in being busy • Analyze your payer mix
By 2015 30% Of Medical Costs Are Expected To
Become The Responsibility Of The Patient
• 60% of commercial
plans nationally carry a
high deductible ($1,000
- $3000)
• The most popular
products of the HIX are
expected to carry large
deductibles
Increasing Patient Responsibility Cost You
• 80% of self-pay accounts are
never paid in full
• 50% of patient financial
responsibilities become bad
debts
• 31% of physicians say they lose
revenue due to uncollected
patient responsibilities
• The ability to collect the full
amount of patient financial
responsibility drops to less than
20 percent after the patient has
left the physician’s office.
Robert E. Goff
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Require Contingent Credit
Card Authorizations
Require Credit Cards as a guarantee
Well, not a perfect guarantee, but the increased likelihood of being
compensated
But as near perfect as you can get, other
than requiring a cash deposit
Contingent Credit Cards Also Protect Against
• Inaccurate eligibility verification
Inaccurate benefits verification
• Promised payments under HSA
that never materialize
• Copays higher than represented
• Deductibles higher, or not fully
satisfied prior to your services
• Plans always use weasel
words
• If you look at any eligibility
confirmations, you will find that
eligibility and benefit
confirmations are not guarantees
of coverage or benefits
• If the payer won’t guarantee, why
should you be at risk?
Services Provided and Not billed
Per AMA 7% of all services provided – documented - are not billed
• Lost between the
completion of the
medical record and the
super bill
• Lost between the super
bill and the insurance
bill
• Get a fully integrated
EHR/PMS that “scans”
the medical record and
sweeps all services to
the bill
Don’t Lose To The Lag
• AMA up to 17% of all
claims are denied for
timely filing
• All commercial payers
have timely filing limits
• Medicare has a
tightened timely filing
limit
• Bill within 24 hours
(surgery may need 72 hours)
• If not paid by day 35
check payer website to
very claim received by
them
• If not paid by day 45,
file a NYS Prompt Pay
Complaint
Once Received a Claim is…
•
•
•
•
•
Paid
Challenged – more information requested
Lost in space – see prior slide
Rejected
Denied
I’ve got claims that
have been rejected
more than those
guys on “The
Bachelorette”
• Do you know what denials/rejections can
be recovered using which approach?
• Resubmission
• Appeal
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No 1 Reason for rejection
An error in the patient name
and/or address
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Top 10 Reasons
Rejections or Denials
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Incorrect or missing patient demographics
Incorrect or missing ICD-9 diagnoses
Incorrect of missing CPT-4 modifiers
Incorrect or missing CPT-4 procedure code
Physician Identification missing
Incorrect or missing place of service code
Missing or incorrect number of units of service
Claim submitted to the wrong address
Duplicate claim
Additional information needed to process the claim
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Denials
• Another opportunity to get
paid
• 70-80% recoverable
• Never accept a denial
without a challenge
• A lost appeal is learning
opportunity
• Most denials are
recoverable by simply
correcting errors and
resubmitting
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The Chilling Effect Of Coding Challenges
• 5%-10% Lost
• Audit by AAPC (AM Academy of Professional
Coders) – 37% of records were
under coded, extrapolated to
loss of $64,000 per physician.
• The average physician is under
coding to the loss of $25,000
to $45,000 a year.
• Severity of illness is under
reported by a factor of 20%
• Learn how to document
and code
• Understand and fully use
all applicable ICD codes
• Code checker technology
is an aide not a
replacement for physician
decision making
• Compare your coding
pattern with your
specialty
Knowing Coding Can Increase Your Income
No knowing it can get you into trouble
When it comes to
coding &
documentation
“Like frogs in
boiling water,
physicians don’t
feel the heat
until they are
cooked”
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How Can You Recognize Improper Coding?
Physician Practice
70%
60%
50%
40%
30%
20%
10%
0%
99211
99212
99213
National Average*
99214
99215
Undercoder
*Source: Ingenix, 2001
Established Patient Visits
E&M Codes
99211
99212
99213
99214
99215
National Average*
% of Total
2.7%
20.6%
63.5%
11.3%
2.0%
Undercoder Health Center
# Visits
% of Total
2,300
23.0%
3,500
35.0%
3,800
38.0%
400
4.0%
0.0%
How Can You Recognize Improper Coding?
When we add payer-based coding information, the differences
may become even clearer:
60%
Medicaid
50%
Medicare
40%
30%
Commercial
Insurance
20%
Self Pay
10%
0%
99211
99212
99213
99214
99215
National
Average
2
1
Missing Revenue
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Variation from Peers of Dx
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Mis-coding can mean more than restitution to a plan
 A federal judge sentenced a corporation headed by
prominent dermatologist N G to five years' probation
yesterday for overbilling Plan more than $178,000 for acne
procedures.
 U.S. District Judge J. M Seabright also ordered NG, M.D. to
pay a $316,642 fine and $39,720 in restitution. In a plea
agreement with federal prosecutors last year, G pleaded
guilty on behalf of the corporation to billing Plan for about
20,000 acne surgeries when Plan members received less
expensive cryotherapy procedures.
 His lawyer B H said the overbilling was the result of G's
office staff using the wrong billing code. G pleaded guilty
because he did not properly supervise the staff to use the
proper code
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Wrong coding can cost you even more
A sad but true tale - Patients with Oxford were complaining to the billing company about being
billed for a copay for well-woman visits, when the benefit plan requires no such copay.
The billing company response, “you own the co-pay, $15, we checked with Oxford, and you
are responsible”
Ignoring this patient’s complaint, besides being bad for customer relationships, can cost the
practice big.
Why was there a copy to begin with?
The practice was billing the well-woman visits as 99214, rather than 99396.
The difference – being paid $69 vs. $109
Leaving $40 on the table for each visit.
Moral of the story– learn from patient complaints, don’t be quick to dismiss them, and find a
billing company that will help you , not hurt you.
For this group of 5 OB/GYN – the estimated hit was in excess of $40,000 annually
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Coding & Profiling
 Coding patterns create the profile
 Coding patterns will determine the “pay-for-performance” measures
 Coding patterns will determine the inclusion or exclusion form
“preferred” networks:
 Aetna – Aexcel
 United/Oxford Premium Designations
 Cigna Care Network
These networks are being created within the existing participation
provider networks
▪ Patient is incentives to use – lower co-pays & recognition with “stars” in
directories
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ICD-9 Codes
 Specificity
 Use the 4th and 5th Digits where applicable
 Additional disease – Is there an underlying cause that must be used with this
diagnosis?
 Always code left to right, underlining associated code with description.
 DO NOT USE unspecified codes unless nothing else more appropriate exists
Don’t let your office superbill dictate what diagnosis you use, consider writing out
the diagnosis in full AND legibly so that your billing person will know which
diagnosis to use.
Keep medical necessity in mind. The diagnosis used should support the service(s)
provided There is a huge difference in 250.00 and 250.02 in terms of medical
necessity.
GET READY FOR ICD-10
Modifiers
Modifiers provide additional information about the services provided. There are many
but these are most common to family practice.
• 24, -25, and -57 are all used to show that the CPT code they modify was a separate
procedure and should not be bundled with other procedure codes or should not
be limited because of a defined global fee period.
**The complete list of modifiers is located in Appendix A of the CPT Code book.
•
24 Unrelated Evaluation and Management Service by the Same Physician During a
Postoperative Period (make certain that you DO NOT show the diagnosis that is
under the global period)
•
25 Significant, Separately Identifiable Evaluation and Management Service by the
Same Physician on the Same Day of the Procedure or Other Service.
•
57 Decision for Surgery
Now You Have Been Paid Your Done – Right?
Wrong
• 6% of claim dollars
are lost to payments
less than the
allowable
• Audit your payments
• Build a comparison
chart
• Use an automated
tool - RightRemit™
Money on the margin
• If you get paid 100% of
billed – you may be
leaving money on the
table
• Plans pay the LOWER of
the amount billed or the
allowable fee
• If you don’t fill in the
dollar amount on the
claim, you will be paid -0Robert E. Goff
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Recovery Demands - Dispute
“Just because we don’t have
the right to offset a claim
does not mean that we
can’t ask for the money
back. Physicians are
expected to know their
contract and the
regulations”
Just because you have been
paid for a claim does not
mean that you get to
keep the money
Payers are mining paid claims to see
what they can find. Often by an
outside commission based
company.
Loran Furbush, Oxford
NYS Now requires that plans
provide 30 days notice before a
negative remit
– Ignore at your own peril
– Silence means consent
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Analyze Your Revenue Mix To Understand Where
To Grow And Where To Shrink
1.
Bench Marking Model
2.
Extrapolation Model
3.
Percent of Revenue vs.
• Strategic thinking
– Who to grow with
– Who to shrink from
Percent of Patient Visits
4.
Percent of Revenue vs.
Percent of Patient Model
5.
Conversion Factor Model
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Bench Marketing Model
This is a review using the plan reimbursements for key and frequent CPT codes in comparison with your
private schedule. As an alternative, you might use instead of your usual and customary fee schedule a
comparison with current year Medicare.
You can do this for the CPT codes on your super bill, for they should be your most frequent, or you can take
a months worth of claims and use the volume from those to set your most frequent
Type
Code
Private
Oxford
As % of private
Aetna
Aetna as a % of
private
Hosp Proc
67038
$4500
$2414
54%
2508
65%
Cryopexy
67105
1500
912
61%
1015
68%
Lasers
67105
1500
912
61%
1015
68%
Laser
87110
1500
1030
69%
133
89%
Est pat
99212
75
44
59%
42
56%
Est Pat
99213
75
54
72%
42
56%
Consultation
99242
200
68
34%
63
32%
Consultation
99243
200
123
62%
63
32%
This review will provide a sense of how the payers are paying you in comparisons with your private fee schedule, or if you use Medicare instead of
private, in comparisons with current year Medicare. The problem with this analysis is that there is no consideration as to your own volume. And
without your actual volume, you maybe are putting too much emphasis on procedures or office visits.
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Conversion Factor Model
This is among the most sophisticated of the models, it brings the “value”, or the effort the physician puts into a payer
down to the individual average payment per RVU, relative value units. However it is dependent upon the availability
of information. You can build this chart using a conversion of each CPTs in the top 20% of codes into RVU units, then
using the volume numbers for each CPT , divide by the total payments to identify the revenue that you receive from
each payer on a RVU basis.
Carrier
Total RVUs
Total Units/volume
Total Payments
Medicare
7181305
4496
$209227
Average Payment
Per RVU
$29.14
United
2734.61
2035
76193
27.86
Vytra
1075.17
801
24573
22.86
Health Net
664.52
494
19510
29.36
1075
801
24573
22.86
Oxford
This then shows you clearly to what level you are being compensated for each element of effort using RVUs. Under
this analysis the practice would do best to seek to grow Medicare and Health Net, and diminish Vytra and Oxford.
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Official Disclaimer
The information presented is for general information only and are not
meant to substitute for legal advice. Always seek the advice of an
attorney on legal matters.
The presenter makes any recommendation 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.
Legal Guidance
Misuse of the handouts, copy righted © material is subject to fine of
$5000 per occurrence
Thank you - Robert E Goff