Medicare's Advanced Beneficiary Notice 

Are you clear on the correct use of Medicare's Advance Beneficiary Notice (ABN)? If you are not sure, don't despair, you're not alone. In my travels, I have found that many physician staff members are confused about how and when the ABN is to be used.

Medicare has very specific rules when it comes to their beneficiaries being made aware of their financial responsibility. For example: Medicare has identified certain codes that have limited coverage. This means that the code is sometimes paid for by Medicare and sometimes not paid for by Medicare due to medical necessity. For codes with limited coverage, medical necessity may be shown with a diagnosis or a time factor. Some of these codes are only paid for if certain diagnoses are used. If the patient does not have one of the approved diagnoses then Medicare will not pay for that service. Other codes with limited coverage are only paid for periodically such as once every 12 or 24 months. If the appropriate time has not passed, Medicare will not pay for the service as it is too soon to have this service repeated as far as they are concerned. For example, Medicare will pay for a well woman once every 12 months if the patient is considered high risk by Medicare. If the patient is not considered high risk then Medicare will pay for this service once every 24 months. If you repeat this service, even one month too soon, Medicare will not pay.

Medicare has provided physicians with two Advanced Beneficiary Notices. One is the general ABN and the other is for laboratory services. These forms must be filled out by the physician's office and signed by the patient prior to the patient receiving the service. If this form is not filled and signed prior to the service the physician may not ask for payment from the Medicare beneficiary. Basically, the physician just performed the service at 'no charge' to anyone. The patient will not be responsible because they were not educated concerning their financial responsibility before the service was performed and Medicare will not pay if they do not consider the service medically necessary.

The physician can only ask the patient to sign the ABN if necessary. Your office cannot have every Medicare patient who walks through the door sign the ABN, "just in case." Medicare considers this abuse. Remember that the ABN must be filled out by your office before you ask the patient to sign. The form has a place for you to describe what the service is and why Medicare is not expected to pay for it. If these two areas are not filled out before you ask the patient to sign then you are not using the forms properly and can be sited for abuse.

If the patient signs the ABN and is made aware of their financial responsibility you may require the patient to pay for this service on the date the service is provided. You may also charge the patient 100 percent of your fee. You do not have to reduce your charge to the Medicare allowable.

When billing a service to Medicare that you have obtained an ABN for you should attach the -GA, -GY, or -GZ modifier to the charge. These modifiers let Medicare know that you have a waiver in place for this service. When the patient receives the MEOB it will show your fee for this service as the patient's responsibility to pay. If you fail to include one of these modifiers the MEOB will show that it is not the patient's responsibility to pay and the patient will want a refund if they have already paid you.

Keep in mind that physicians and Medicare very often have different thoughts about medical necessity. When it comes to the Medicare reimbursement a practice has to be concerned with what Medicare considers medically necessary so that the proper forms can be obtained to insure your right to collect from the patient.

The Practice Management Institute®
2007 Conference for Medical Office Professionals 

PMI is taking its 2007 National Conference for Medical Office Professionals on the road to a city near you! Check out the best sessions from this year's national conference, plus all-new topics and presenters. You won't want to miss the hottest issues in health care today, presented by PMI's trusted faculty and local experts.

Dallas area
Oct. 31 - Nov. 1

Las Vegas
Nov. 1-2

Memphis
Nov. 8-9

Baltimore area
Nov. 8-9

Interviewing Applicants for Office Staff 

An interview can help you screen applicants for a specific position in the practice. It can also be one of the most important determinants, beside orientation and training, for predicting the longevity of a staff member.

So what's the first step? Let's start with a well-written job description. This is the roadmap that will help you choose the right person for the job. Not only does a carefully-crafted job description help screen out non-qualified applicants, but it also serves a tool to define the official job responsibilities.

Now that you've placed the job solicitation in the local paper or perhaps an employment web site (incidentally, PMI has a brand new Job Bank where you can post your job description for free), you may have a number of responses to sift through to narrow down your candidates. Once you have chosen those who appear to closely match the experience and skills you are seeking, it's time to set up phone interviews.

Telephone interviews help you further screen applicants without committing a lot of time to formal and time consuming face-to-face interviews. It saves you and the candidate a lot of time. Have a set number of questions and record responses for review and comparison later. You can ask open ended questions such as: "tell me about your training," or "tell me about your previous work experiences." Answers to these and other questions on your list will allow you to earmark desirable candidates and eliminate those who don't match the skill set you are seeking.

Once you have narrowed your choices down to a few candidates worthy of a face-to-face interview, invite them to the office to complete an application for employment. You can access standardized forms at your state workforce commission or on the web. The job application is a standard form used for all applicants for comparison. Things to look for in evaluating the application should be: 1) is the application complete? 2) were directions followed correctly 3) is the spelling correct? 4) are the basic requirements present? 5) have they met the desired work history?

On to the interview phase. This is where you can best evaluate factors not covered in the phone interview. Here, you can review the application, give the candidate a rundown of the job description, and clear up any questions concerning the applicant's qualifications.

There are legal guidelines that you must follow when interviewing for a position. Keep in mind that you CAN NOT ask a candidate certain questions, like, 1) Are you finished with your child bearing years? [yes, this was asked] 2) What year did you graduate from high school? 3) What kind of car do you drive? 4) Do you have any health issues or concerns? Refer to your state's workforce commission for complete guidelines.

Take your time during the interview, have specific questions areas prepared, encourage the candidate to talk. Ask questions 20 percent of the time and listen 80 percent of the time. Remember, the candidate is interviewing you and your practice as well and the interview is only a conversation with a specific goal. The goal is to determine if the job candidate has the qualifications of education, experience, interests and temperament to fill the specific job available.

Ultimately, the decision for choosing the right candidate will be based on experience, salary, expectations, skills, and perhaps most importantly the proper "chemistry" to work will with the team.

Now, here are a couple of extra tips to help you non-verbally size up the candidate on the character of the person sitting on the other side of the table: 1) before the candidate arrives, place a pen clearly visible on the floor next the chair where they will be directed sit. If he/she picks up the pen, it shows initiative. This candidate will do what is necessary to get the job done. 2) This one comes from a CEO of a large company. He will take the candidate to lunch, if the person salts their food with out tasting it first, he will not grant a second interview. He figures that person will tend to make decisions without knowing all the facts. [Very interesting, don't you think?]

Well that's all for now folks…..Next month, I'll explain more about open ended questions, making the commitment, and the employee's first day on the job. Until then, try placing pens on the floor of your office and see which staff members pick them up.

Medicare's Smoking and Tobacco Use Cessation Benefit 

Over 400,000 smokers die each year from smoke related diseases. About 300,000 of those are Medicare patients age 65 and older. Research shows that about 10 percent of the total program costs for Medicare for 1997 were related to smoking. The U.S. Surgeon General has reported that quitting smoking leads to significant risk reduction and other health benefits even in older people who have smoked for years.

Medicare has a benefit that began on March 22, 2005, that can help beneficiaries kick the habit. This benefit is available to beneficiaries who have an illness caused by or complicated by tobacco use. These illnesses make up the bulk of the Medicare expenditures today, according to Medicare. Beneficiaries who take medication whose effectiveness is complicated by tobacco use are eligible for this benefit. Medications including insulin and some meds used to treat high blood pressure, blood clots and depression are examples. Illnesses such as heart disease, cerebrovascular disease, multiple cancers, lung disease, weak bones, blood clots and cataracts are examples of those that can get coverage for smoking and tobacco use cessation.

Medicare pays for two cessation attempts per year. Each attempt includes four intermediate (3-10 minutes each) or intensive sessions (longer than 10 minutes each) up to eight sessions in a twelve month period. Medicare recognizes HCPCS codes G0375 and G0376 for these visits. The diagnoses are carrier specific. The co-pay/co-insurance and deductible do apply for this benefit.

Your office may be losing out on some reimbursement if you are performing theses services and not charging Medicare for them. HCPCS code G0375 will reimburse from about $11.00 up to over $13.00, depending on the locality, for the 3-10 minute counseling session. G0376 reimburses between $21.00 and $28.00, depending on the locality, for a counseling session over 10 minutes. Physicians and other Medicare-recognized providers can provide these counseling services.

Will You Sign In, Please 

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 covers two major areas of focus: 1) Health Care Access, Privacy, Portability & Renewability and 2) Preventing Health Care Fraud & Abuse; Administrative Simplification; Medical Liability Reform.

Protected Healthcare Information (PHI) is considered to be any information about the health of a patient, individually identifiable information, information that is created or received by a covered entity or information that is maintained and or transmitted by any electronic means. Examples of PHI include: a patient's name, address, telephone number, social security number, ID number, date of birth, diagnosis, e-mailed laboratory results, a voicemail message about medication or a recent hospital bill or insurance claim. Individually identifiable health information contained in education records and employment records are excluded from the provisions of the Privacy Rule.

The Standards for Privacy of Individually Identifiable Health Information (the Privacy Rule) that took effect on April 14, 2003 established regulations for the use & disclosure of protected healthcare information (PHI). It required organizations to give new patients a Notice of Privacy Practices and that safeguards are put into place regarding the handling of PHI. The Privacy Rule applies to any healthcare entity that transmits any health information electronically. There is no exemption for offices with fewer than "X" employees. Unless your organization is 100 percent paper and pencil and uses only snail-mail, then your organization is considered to be a covered healthcare entity. Standards under the Privacy Rule require a covered entity to make reasonable efforts to limit PHI to the minimum necessary to accomplish the intended purpose. The covered entity must assess what PHI is reasonably necessary for a particular purpose without sacrificing the quality of health care and implement polices and procedures accordingly to limit unnecessary and inappropriate access to PHI. This brings us to the issue of sign-in sheets in the practice.

Can a covered entity still use patient sign-in sheets under HIPAA? Yes. Sign-in sheets are still permissible under HIPAA as long as the information disclosed is appropriately limited. The Privacy Rule permits the incidental disclosures that may occur as a by-product of another permissible or required use or disclosure, as long as the covered entity has applied reasonable safeguards and implemented the minimum necessary requirements.

The sign-in sheet should be limited to essential data like name and time of appointment. The sign-in sheet may not display medical information that is not necessary for the purpose of signing in (e.g., the medical problem for which the patient is being seen for, address, date of birth, or any unnecessary information). The covered entity's privacy notice should explain the use of the sign-in sheets. For example:

"The practice maintains sign-in sheets to acknowledge and document your arrival that are visible and accessible to patients, staff and others who may enter our office."