We held publication of The Link this month in order to bring you this anticipated Late Breaking News! Physicians and other non-physician providers will receive a reprieve from the 4.5% conversion factor reduction initially implemented as of January 1, 2006. The reduction was mandated by the sustainable growth rate formula (SGR). The SGR is the current method used to determine the annual Medicare conversion factor update.
Prior to the Deficit Reduction Act of 2005, Medicare fees had been scheduled for reduction by as much as 26% over the next 5 years. Interestingly, many Medicare watchdogs were surprised that the Act did not attach any type of Pay for Performance/P4P requirements. Especially since Medicare has instituted a voluntary reporting regarding the quality of care provided to Medicare beneficiaries. Services are to be reported utilizing level II HCPCS codes G8006-G8186.
It was touch and go for a while as the original legislation was voted on and passed by the Senate only in December 2005. Passing was actually down to the wire, as Vice President Cheney actually cut short a December trip in order to return to Washington and cast the tie-breaking vote in the Senate. The House of Representatives failed to pass the bill before the Christmas break and so had work to do when they returned after Christmas break.
The first week of February, The House of Representative finally (as expected) approved a bill, which will among other things; keep the physician fee schedule at the 2005 conversion factor.
The President actually signed the "Deficit Reduction Act of 2005" on Wednesday evening February 8, 2006. In addition to freezing the fee schedule at 2005 levels, the Act is an effort to control Medicare and Medicaid spending. There is an anticipated savings of over $40 billion in the next five years.
However, that does not necessarily mean there will not be any changes in your actual fee schedule. You must remember the Relative Value Scale changes also. (physician work, practice expense, and mal-practice expense) If any of those areas have changed for 2006 you will see it reflected in your fee schedule. You should be receiving the good news from your Medicare Carrier in the next week or so. They will be reprocessing your 2006 claims and sending the additional monies to you. Do not hold your claims unless the carrier instructs you to do so.
Mark my words: the year 2006 is going to be one of belt tightening in most medical practices. Cash flow is always critical but with more consumer driven health care upon us, patients will have larger balances and co-pays than ever before. Gone are the days of the five-dollar co-pay with insurance picking up the balance. Employers are under the gun to continue to provide group health care but the expense is becoming more than many can financially handle. Their only option is to shift much of the financial burden to the patient or guarantor through patient co-pay, deductibles, and patient percentage after insurance payment.
Even patients with a PPO may have large deductibles, perhaps no lab coverage, and the patient may still owe 20% or more after the insurance pays. What this means to the provider is they are stuck collecting after services are rendered as they are not even sure what the carrier will pay.
Whenever I begin a seminar on Accounts Receivable I always ask, jokingly of course, does anyone here work for a free clinic? No surprise to me that no one raises his or her hand to the affirmative. However, when I follow up with the question, does anyone have patients that think they are coming to a free clinic the hands fly up in the air.
So how do you collect those dollars? Every day that your accounts receivable remains uncollected the less it is worth. That of course is easy for me to say as I sit here at my desk writing this article. How do you collect without sounding heartless? Whether collecting a $20 co-pay or a $2000 balance, the practice must have the right person collecting.
The first step is confidence. Confidence that the care provided deserves payment. No matter what the circumstances are. The practice must have a clear financial policy that everyone is aware of and follows on a daily basis. Having a written policy gives the collection staff protocol to follow. Perhaps there is a written protocol for self-pay or a sliding fee schedule for low-income patients.
Not everyone coming into your office will be prepared to pay at the time service is rendered or even on receipt of the first bill. However, you must approach each patient confident that they are prepared to pay in full. Why do you assume they will pay? Simple, when they initially called to schedule the appointment they were asked about their insurance and were informed that they will have a patient portion of which they are expected to take care of at the time service is rendered. As a convenience to the patient your office should accept cash, check, credit cards, and debit cards. Many offices also have health care credit card options such as Care-Credit available for patients.
You may find it necessary to remind the patients that you are legally obligated, just as they are, under the insurance contract to collect their co-pay and any additional patient portion.
Can you have a discount policy for self-pay patients is a question frequently asked? Yes and I would tie in the discount to cash payment at the time of service. Never discount lower than your Medicare allowable. Do not discriminate; offer the same discount to all cash paying patients if asked.
The second step is consistency. It still never ceases to amaze me the numbers of practices that do not enforce collection of co-pays at the time services are rendered. When I go into a practice assessment one of the first things I do is to look at the end of day reports. If the providers saw 112 patients on a specific day I would expect to see 112 payments. Patients need consistency also in the billing process. Everyone knows when their electric bill and rent is due so you budget for it. The same holds true for your statements. Same time every month.
Your goal should be to get as much money in the door each month before statements go out. It costs a lot to send a statement. Let's say it's the 3rd of the month and statements go out on the 25th of the month. For the patient that is not prepared to pay today simple say something like; Ms. Ballard, I know you are aware of our payment at the time service is rendered policy, I can make an exception this one time. Here is a copy of your statement for today; I am going to ask you to send me a check in the next 5 days to clear this account. When can I expect you to do that? When the patient gives you the day, add a few days for mailing and put it on your calendar for follow-up. This is what is considered positive education of the patient.
The third step, look for the money. Collections or what I hear called "working the AR" is not something done just once a month. It is an on going process. Never run an AR report and start at the A's and go to the Z's. You will never get through the alphabet. Go for the money. Whether you are working patient collections or insurance, dig for the dollars, the big dollars. Don't get caught up spending a quarter to collect a nickel. You will spend the same 10 minutes on both calls. Make the call with the bigger return. It is not always wise to go after the oldest money either. The U.S. Department of Commerce reports that accounts over 90 days old depreciate at 0.5 percent per day. With that said: accounts lose 15 percent of their value every month after the first three months. Don't let those accounts get over 90 days old if at all possible.
The fourth step, follow up. When a patient says they will send a check next week. FOLLOW UP! Put it in as a reminder on your day planner or computer calendar for an automatic reminder. Microsoft Outlook works fantastic for this purpose. That way if a patient says they will send the check next Wednesday, call them the following Monday if you don't receive it. Let them know you are serious about collecting.
You may have some clean up to do in order to get the accounts receivable in good condition for 2006. It may mean one last shot at old accounts. Call the patient and let them know that your accountant is not going to allow you to continue to carry the delinquent account any longer. You felt that you should contact him and advise him that unfortunately the account will be turned over to collection if you do not receive "FULL" payment by cash, certified check or money order on the account within 10 days. The key here is to follow-up and turn the account over to collection bright and early on the 11th day. Alternatively, ask if they have a credit card they would like you to put the balance on and you can resolve the account right now. If the patient says they don't have that much money, this might be a time (if deemed appropriate by the practice) to negotiate a lesser payment. If the patient owes $200 and can pay $150 you would be able to write off the balance. Only write off the balance when you have received the payment. After all, if it goes to collection you will lose 50% or more of the value. For patients turned over to collection it would be appropriate to discharge the patient from your practice.
Join us this May for the National Conference for Certified Professionals, to be held on May 18 & 19, 2006 in San Antonio. PMI's veteran faculty team will present the program, along with guest presenters, to include Stan Luke, Deputy Chief, U.S. Attorney's Office, Civil Division, Department of Justice, and Michael Brown, Contributing Editor for Medical Economics Magazine
"This conference is jam-packed with information critical to the physician's office. Topics such as: 'EMRs -- Should you Implement a Paperless System?', 'Pay For Performance and Consumer Driven Healthcare' and 'Making Sense of the New Competitive Acquisition Plan' will be profiled at this year's conference," said Lynn Ballard, Conference Chair and VP of Professional Services for Practice Management Institute. "These sessions will be presented along with 20 other classes highlighting critical administrative issues that impact today's physicians and their practices."
Customized breakout sessions and round table luncheons are planned to promote group interaction with participants and faculty members. This conference has been limited to 300 participants. We expect the conference to be a sell-out. Please register early to ensure availability. For more information, visit: http://www.pmimd.com/conf2006.asp.
This year, PMI celebrates 25 years of coding, reimbursement and practice management training. The federal government recently recognized PMI's Certified Medical Coder (CMC) program. In 2004, the Centers for Medicare and Medicaid Services (CMS) named PMI's Certified Medical Coder program as an example coder certification programs that could be utilized to fulfill its coding certification requirement of Medicare Contractors. The requirement stems from implementation guidelines for the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). This recognition reinforces PMI's position as a top provider of certification for medical office staff.
PMI training and certification classes are currently presented to physicians and their staffs in 400 of the nation's leading hospitals, health care systems, colleges and medical societies. For a list of current classes in your area, visit: www.pmiMD.com.
As past due account balances become larger and more difficult to collect it should be evident there is no time like the present to evaluate your accounts receivable process. Train your new patients and re-train the established patients in regard to you collection policies.
Q. I have a general surgeon new to our hospital as an employee. I have told him he needs a "request" for consults documented in the chart. Does this need to be a document from the requesting physician? What if the requesting physician just calls over? Does the surgeon need to indicate that at the beginning of the consult?
I informed him after he documents his findings he needs to "reply" to the requesting physician. I am wondering if he cc's the document to the requesting physician if this is an appropriate "reply"? At the bottom of the consult he does thank the physician.
In past experience I have always had three documents... the request, the actual consult and the letter of reply.
I have the Medicare guidelines but I guess everyone interpretation of these are different. What is your opinion on this?
Thanks for any help you can give me!
J.C., CMC
A. The Medicare Claims Processing Manual has just been updated regarding coding for consultations. Transmittal 788, Change request 4215 dated December 20, 2005 and effective January 17, 2006. It clarifies and provides new examples of acceptable consultations. These changes were necessary because of the deletion of the Subsequent In-Patient, and Confirmatory Consultation Codes in CPT 2006.
It is very clear that there must be documentation in both of the provider's records that there was a consultation request for "advice and opinion". If the intent is "here take over the care of the patient for this problem" it will be billed as a new or established patient if it is in the office as it is or will be considered to be a "transfer of care".
Be sure and check out the entire change at: http://www.cms.hhs.gov/transmittals/downloads/R788CP.pdf. To answer your specific question I am providing the following:
Documentation for Consultation Services
Consultation Request
A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient's medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient's medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.
The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient's medical record and included in the requesting physician or qualified NPP's plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.
Consultation Report
A written report shall be furnished to the requesting physician or qualified NPP. In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician or qualified NPP and the consultant, the request may be documented as part of a plan written in the requesting physician or qualified NPP's progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record.
In an office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting physician or qualified NPP or if the consultant's records show a specific reference to the request. In this setting, the consultation report is a separate document communicated to the requesting physician or qualified NPP.
In a large group practice, e.g., an academic department or a large multi-specialty group, in which there is often a shared medical record, it is acceptable to include the consultant's report in the medical record documentation and not require a separate letter from the consulting physician or qualified NPP to the requesting physician or qualified NPP. The written request and the consultation evaluation, findings and recommendations shall be available in the consultation report.