Practice Management Articles

Distribution of Sample Medications in the Practice Setting
By Rose B. Moore, CPC, CCP 

Many physician offices accept sample medications from pharmaceutical drug representatives and dispense them to their patient population. The distribution of sample medication allows patients a "trial run" on a new medication without financial expense. Although the samples are free-of-charge, this does not lessen the physician's continuing responsibility to the patient. The physician's office should have a detailed policy and procedure that addresses the following areas in accepting and distributing sample medications.

Storage
1. All sample medications should be stored in a locked room in a location inaccessible to patients. Medications should not be stored in exam rooms where patients are left unattended.
2. The storage area should not be subject to extreme temperatures. All refrigerators containing medications should have daily temperature checks. Logs of these checks should be kept.
3. Lighting in the storage room should allow easy reading of medication names and dosages.
4. Samples should be well-organized by drug or drug group. Medications with similar names should be located in separate areas.
5. All medications in the practice should be checked monthly for outdates, deterioration and appropriate location. Include all areas in which medications are stored including refrigerators.
   A specific person should be assigned responsibility for the monthly inspection.
   A log should be kept indicating that the medications have been inspected.
   Expired sample medications should be discarded in accordance with federal, state and local laws. Contact your state or the federal Department of Environmental Services for advice on medication disposal.
6. It is recommended that an inventory of sample medications be maintained. A form should reflect the names of patients who received medications, including the lot number. It may be helpful to use an inventory sheet for each type of sample medication.

These sample logs are intended to provide your office practice with a methodology to track the sample medications that you dispense as well as aid you in identifying those that have expired and require disposal. The Inventory Inspection Log [PDF] allows you to check all expiration dates at a glance to streamline your review and discard process. The Patient Distribution Log [PDF] is a means to keep track of the lot numbers of the medications given to each patient. Use of this log will simplify the process of identifying your patients that have received a medication whose lot number has been recalled or has had other warnings or issues associated with it.

Access
1. Access to sample medications should be limited to specified medical personnel only.
2. Employees should not be allowed to access or request free samples. Self-medication can lead to adverse events of which the practice could be held liable.

Dispensing
1. Only pharmacists, physicians and mid-level providers with prescribing authority may actually dispense medications.
2. At times patients request refills of their sample medications. Sample medications can only be dispensed after a physician or mid-level provider with prescribing authority (physician assistant or nurse practitioner) has authorized the refill. This information should be noted in the patient's record.
3. When retrieving sample medications, the authorized medical professional should:
   review the provider's order/authorization
   double check the name of the medication on the package
   confirm the expiration date of the medication
   verify the patient's allergies to medications
4. All medications should be labeled with the following:
   Patient's Name
   Medication Name
   Dosage
   Frequency or Time
   Route
   Form, i.e., liquid, tablet, drops
   Date Dispensed
   Lot Number
5. The provider should discuss with the patient the administration, storage, and side effects of the medication. This discussion, as well as the patient's understanding, should be documented in the patient's record.
6. A double check of the patient's name and second identifier, i.e., date of birth, should occur when providing the patient with the medications.
7. Documentation of the provision of sample medications should be placed in the patient's medical record to include the name of the medication, date, dose, frequency, route, form, date dispensed, lot number and written authorization by the provider.

All physician practices that distribute sample medications should ensure mechanisms are in place for secure storage, patient distribution and education, appropriate record-keeping and regular monitoring. A detailed policy and procedure should support this process.

Reimbursement. Compliance. Overpayments. Auditing. 

Douglas O'Dell: Were you surprised by the recent Congressional block of the 5.1% decrease in Medicare fees? And that they ulti­mately wound up with a 1.5% increase?

Robert Liles: Yes, I was surprised. Despite their best efforts, most special interest groups, representing specialty providers, have failed in maintaining reimbursement levels. If Congress thinks margins are too generous they haven't hesitated to seek cuts. While there has been some progress, it's unusual for associations to walk out with a complete win. Overall, associa­tions and their lobbyists have only been marginally effective in convincing Congress that cuts are ill advised.

If you look back at reimbursement rate levels over the last 10 years, there's no question that Congress has consistently cut closer to the bone at every opportunity. When high mar­gins are perceived in certain areas, cuts often ensue. The fact is that the Medicare program is more costly than ever before. Moreover, most providers have adopted business models that rely on Medicare reimbursement in order for the business to survive. This fact isn't lost on Congress. They recognize that they have providers over a barrel. Not many providers these days can afford to forego participation. At the end of the day, Medicare is going to be a low margin, relatively high volume business for many providers.

In a 2004 study conducted by Taxpayers Against Fraud, a national non-profit organization focused on the enforcement of the False Claims Act, health economist Jack Meyer estimated that for every dollar spent by the government, $13 is returned. So why doesn't CMS put more emphasis on better policing the system?

Over the last decade, both the Department of Justice (DOJ) and the Department of Health and Human Services, Office of Inspector General (HHS-OIG) have substantially increased the amount of prosecutorial and investigative resources dedicated to health care fraud enforcement. When you think of HIPAA, most people think of the privacy provisions. But with HIPAA's passage came a special appropriation of funds to be used for additional law enforcement resources to finance anti-fraud health care enforcement activities. In 1997, the appropriation available was $104 million. That amount grew to more than $240 million in fiscal year 2003 to the present.

In the first six months of 2006, this program had already netted $1.02 billion from its efforts to reduce fraud.

This focus on accountability and enforcement will only continue to increase. I think that it's also important to remember that the days when compliance was optional are numbered. We're already seeing this trend. For example, Starting this month (January) companies that do at least $5 million a year in Medicaid business are required under the Deficit Reduction Act of 2005 to have a number of compliance mechanisms in place in order to participate in the program. They will have to teach their employees and officers how to detect fraud, waste and abuse. Health care providers also must tell employees that if they report fraud, they will be protected against retaliation and may be entitled to a share of money recovered by the government. I think that it's just a matter of time until Medicare participants will also be required to have a compliance plan in place.

In implementing a compliance plan, it is important that a provider recognize that the only thing worse than not having a compliance plan is having one and not following it. If a physician has knowledge of how claims are supposed to be processed, identifies erroneous claims, and continues down the wrong path, the government may view their conduct as indicative of fraud. Additionally, training is an essential element of all effective compliance programs. Providers who choose to rely on coders and billers who aren't properly trained are just asking for problems.

I understand one trade-off for the reduction block was the expansion of CMS' Recovery Audit Program (RAC) to all 50 states. For readers not familiar with RAC's, this is the pilot program launched in three states in early '05 as part of the Medicare Modernization Act to supplement CMS efforts in securing improper Medicare payments. CMS contracts with RAC's to uncover Medicare underpayments and overpayments and to collect the overpayments. The RAC gets a percentage. I've heard it described as a "bounty-hunter" system. Thoughts?

RAC efforts should be a concern of all Medicare participants. Please understand, no one is suggesting that overpayments shouldn't be returned. Everyone agrees that providers have an obligation to ensure that billings are proper. Nevertheless, there is a certain balance that is necessary to maintain both program integrity and a level of fairness in the system. While RAC's have successfully identified millions of dollars in overpayments, I'm concerned that in many cases the basis for these overpayments may be technical errors or mistakes rather than substantive in nature. Over the last few years, I have seen instances where Program Safeguard Contractors (PSC's) have sought to collect essentially all of the Medicare monies paid to a provider, in some cases covering a period of years, based on technical or administrative errors (e.g. lack of a PIN number), despite the fact that the services were properly ordered, medically necessary, the patients benefited and the provider was an authorized Medicare program participant.

The RAC system is likely subject to the same type of “overreaching,” especially since the RAC will reap financial benefit from the assessment of overpayments. It has been my experience that both CMS and HHS-OIG have exercised their enforcement authorities in a reasonable fashion with a degree of fairness. I am concerned that PSC's and RAC's may not have the experience or the discretion to recognize that all errors are not the same and should not all be automatically treated as overpayments. I believe it is shortsighted for Congress to permit PSC's and RAC's to take such unreasonable positions with providers. At some point, providers may take the position that Medicare / Medicaid participation isn't worth the headaches, especially if CMS' agents intend to seek repayments based on mere technical mistakes or administrative omissions.

What happens when a provider asks a certified coder or an independent consultant to assess coding and billing procedures to ensure that the practice is getting all reimbursement it is entitled to, and the auditor instead finds that the provider has in fact been upcoding and submitting improper claims? What obligation or protection does the auditor have by law?

It's important for a physician to understand that when they engage an outside certified coder or independent consultant to conduct a billing review, the findings (regardless of whether they are positive or negative) are unlikely to be privileged. Prior to conducting such a review, a better practice would be for the provider to have outside counsel engage and direct the work of the billing consultant so that any findings are least arguably privileged. If a physician is calling an auditor up about discreet questions about a practice, that's one thing - but if the auditor contracts with the physician, and they run across evidence of fraud, those findings would likely be discoverable and may be subpoenaed by the government.

Regardless of whether an outside certified coder is retained by counsel or directly by a physician, if problems are identified they must be addressed. If an overpayment has occurred, it typically isn't a matter of whether the overpayment should be repaid, but rather how to best handle the repayment.

With regard to the scenario you have raised, outside certified coders and consultants who identify an overpayment should advise the physician to repay the monies. However, upon completing a review, they often move on to their next project and don't know if follow-through has occurred. In some cases, a provider may seek a second review or a legal assessment before deciding how to respond to the findings. An outside certified coder has met their obligation in this regard. The provider is responsible for ensuring that proper remedial steps are taken.

Another scenario might include a situation where an outside third-party billing company is engaged to handle the billings and collections for a physician. Suppose they advise the provider “Dr. Smith, we have identified a problem. In many cases, your accompanying documentation doesn't support what you're billing.” While the third-party billing company has properly alerted the physician of their concerns, they are in a precarious position. First, the physician will need to repay any overpayments that have been identified. Second, remedial steps need to be taken to ensure that the documentation and coding fully supports the billings. If the third-party billing company merely advises the physician yet continues to improperly bill for services (based on the lack of documentation or faulty coding submitted by the provider), they may find themselves included in a subsequent government investigation.

While they don't want to lose the business, the billing company could be putting itself at risk. If the physician continues to submit erroneous claims, the billing company must fire the client to ensure it isn't implicated along with the physician. An outside coder/consultant has a better defense than the third-party billing company who is an integral component in the billing process. Nevertheless, this situation may still be problematic. Over time, the government may question the degree of an outside coder's involvement and perhaps argue that they somehow played a role in the submission of wrongful billings. Certified coders working for a physician should diligently work to ensure that coding is accomplished consistent with applicable rules and regulations. In some cases, a physician may disagree with a coder's assessment. Work through the issues; help educate the physicians regarding proper coding practices. If a coder identifies improper coding, they should go to the doctor and advise them of the problem. More often than not, a physician will appreciate knowing that a mistake has occurred and will readily correct any errors than have been identified.

A team approach, comprised of dedicated physicians, certified coders and trained billing personnel can go a long way towards better ensuring that claims are properly submitted for payment.

Biography

Robert Liles, Esq., is a health care fraud defense attorney based in Washington DC. His firm, Liles Parker, represents health care pro­viders in both civil and criminal proceedings around the country. Prior to entering private practice, Mr. Liles served as the first National Health Care Fraud Coordinator, responsible for coordinating the health care fraud enforce­ment efforts for all 94 U.S. Attorney's Offices. He was subsequently appointed to the posi­tion of Deputy Director for Legal Programs at the Department of Justice, Executive Office for United States Attorneys. He also worked as an Assistant United States Attorney in the South­ern District of Texas, Houston office, where he primarily handled False Claims Act cases. He currently serves on the faculty for the George­town University / National Institute of Trial Advocacy. He is a member of the American Health Lawyers Association. Mr. Liles may be reached at (202) 298-8750 or he may be e-mailed at rliles@lilesparker.com.

DID I HEAR YOU SAY WHAT I THINK YOU SAID? 

If any of you have ever attended a PMI seminar, you know that communication is the key?the key to performing your duties assigned, and a key topic in many performance reviews. In this article I will discuss the most important aspect of communicating: LISTENING:

Have you ever been in a conversation with a co-worker, be it your physician or manager or even a co-worker, and walked away wondering what was just said? You are not alone. A lot to times we listen but don't comprehend or we comprehend but don't understand. This could be for several reasons; one being that we zone out?meaning our minds run to other thoughts of the day in progress or re-playing last nights events. Another reason we fail to understand a conversation might be that the person we are trying to listen to just won't get to the point, so therefore we begin to jump ahead with our own thoughts with questions and provide our own answers. Or perhaps the person talking just won't come out and say what he/she is really trying to say, which leaves us scratching our heads and wondering and hoping we are doing correctly what was "talked about".

Listening takes practice and it's an art in itself. Listening is supposed to provide information so that we give can give feedback. When this doesn't happen, we walk away thinking "is it me or him/her". Well, it's both. It takes two to communicate, one talking and one listening.

If you find yourself with these thoughts, stop, drop and roll:

Listening is hard work but with a little practice, you will find that it is the key that unlocks the door to true communication.

Dude - Where's My Money? 

Many of us find ourselves asking the proverbial question, "Dude - where's my money?" at month's end, quarterly and then again at year-end. We sit and ponder all the reports that show exactly where it (the money) is hiding i.e., the AR 120+ bucket. There's even dollars tied up in outstanding insurance claims - like you haven't been trying to appeal and rework all those claims. Then there is our favorite, DISALLOWS, which really amounts to insurance discounts and write-offs. Expenses that sneak up - it's really as plain as day; it's all accounted for. But where is the money? It's all right there, just sitting on the bottom line.

So how do we convert these dollars from numbers on a report into tangible money that can be deposited in the practice account? First we have to understand exactly what our reports are telling us. If you are breaking down the reports, you are on the right track.. But now we have to reel in the money. It's like fishing. You buy the best rod and reel, line, hook, and bait. You purchase the best boat and hit the waters. You throw all your new equipment, knowledge, experience in the water then sit and wait, and wait and wait some more. Then you get a bite! Insurance pays! You post the payment and drop the balance to the patient. Easy, right? WRONG! There are always the denials, or worse yet, not paying the contracted rate, and of course the uncollectible debt.

Now, let's venture into this quagmire a little deeper and do some analysis:

Take a look at your outstanding claims report. This should be broken down by payer in an aging report. Then follow these steps:

1. Go after the biggest dollars that are 45 days old.
2. Go after your oldest dollar claims.
3. Go online and complete a claim status inquiry then start yelling - they say the squeaky wheel gets the grease.

Do you have a spreadsheet with all of your payer's contracted fees? Are they paying according to the contract? If not throw the fish back and get your reel (real) dollars.

Look through your aging AR. What percentage of your dollars are in each bucket? If more than 19% is in your 120+ bucket, then you've got a problem. Your collections are only as good as your collectors. Maybe you need to:

• Re-train your collectors
• Update your collection letters, and make collection calls
• Get payment by credit card over the phone, be sure to ask for the 3-4 digit security code from the back of the card
• Threaten to take their first born (just kidding).

Patients want payment options, so give them some. Total balance divided by three monthly installments sounds a whole lot better than one lump sum. Of course there are exceptions to this in every specialty. The idea is to be kind, but get some kind of payment commitment from the patient on a contracted payment plan (that means get their signature). Be sure the patient is given a copy of the promissory note so there is no misunderstanding or memory loss. Remember that if you get into a written formal payment arrangement of four payments or more you will need to be concerned with the Federal Fair Credit Billing Act. This Act gives the patient some specific rights when it comes to disputing a bill. If you don't follow the rules of the Act you may end up writing off part of or maybe even all of the patient's balance.

The patient needs to see the value in paying their doctor for continuation of their doctor's services. Good quality healthcare will help fill this bill. Good quality healthcare includes a staff with excellent customer service skills. Your staff should be able to educate the patient concerning their responsibilities of their insurance plan. An informed happy patient is more likely to pay their bill.

With all that said, the next time anyone asks you where the money is, just flash a big toothy smile and say "it's all right here," then put the 10 lb report in front of them and let the conversation flow from there.

ICD-10 Where is it? When is it? 

Did you know that we are the only country on the planet that has not converted to the ICD-10 system? ICD-10 has been trying to make its debut in the U.S. for more than ten years now. Currently, the implementation date is set for October 1, 2009.

ICD-10 has over 200,000 diagnosis and procedure codes; ICD-9 has a little over 16,000. ICD-10 codes are all alpha-numeric codes while ICD-9 codes are numerical codes with the exception of V-codes and E-codes. ICD-10 will allow us to code to a much higher specificity and after all, that is the name of the game when it comes to coding our patient's diagnoses for their insurance claims.

Why the big delay in rolling out ICD-10 in the U.S.? This is mainly because providers and payers will need to completely redesign their business processes and systems to be able to handle this massive coding system. Although other countries have switched to ICD-10, no other country uses a version as complex and the U.S. version.

There is a coalition of physicians, labs, and other providers and insurers that are urging Congress to push back the date. This group is urging for an implementation date of 2012 and here is why:

The industry is hoping to begin the implementation date in 2009 after providers and payers have implemented version 5010 and Medicare contracting changes are finished. The providers and payers would then need three years to implement ICD-10 making the full implementation date 2012. It will be interesting to see what happens!

Close "E"ncounters of the Third Kind 

Welcome to the land of the unknown…the land where few men have ever traveled…that is, until they came to a PMI coding class. Yes folks, I am talking about the infamous E codes. They can be found in the index in the back of your ICD-9, Vol. II, Section 3, that describes external causes of injury and poisoning. Now let's take a few minutes to get up close and personal with these foreign bodies.

Correct coding requires you to report added information so that you can code an encounter to the highest level of specificity as possible. These codes also support the work-related nature of certain injuries to differentiate worker's compensation care from non-worker's comp care. E codes should be used to describe the accident, circumstance, event, or specific agent which caused the injury or other adverse effect. That is, it will paint the full picture of what made your patient arrive at your doorstep. The Category I Code (CPT code) will describe what you did for your patient.

E codes do not change your payment amount because they are used for stats for informational purposes. These codes will never, ever, as long as you're alive, be a primary diagnosis! It says so in the directions in the index (make sure you turn to this index in your ICD-9 book and read through it before you embark on these codes). Ok, I know that few of you will read the entire thing, but I would like you to take note of the last sentence in the first paragraph: "…it is intended that the E code shall be used in addition to a code from the main body of the classification, Chapters 1 to 17." See I told you so.

Now, I don't know about you but I find E codes fascinating. It's amazing to me how many ways can a person injure themselves. They can have injury caused by: animal (ridden or not), bending (that's it, no aerobics for me – I can hurt myself), bite (human or animal, if you ask me they are sometimes one in the same), earthquake, fire, hurricane, rough landing (like my last job), sound waves (and consumers buy those sound machines to make them sleep - now we know), twisting (the twist is an outdated dance anyway, but now I know why I hurt the next day), in or on and don't forget stated as (that means I've got to rely on you-know-who for this bit of information to be documented in the patient's chart).

When you get your new ICD-9 book, you should always go immediately to the "Summary of Code Changes" to see what's new with all the codes. I have always taken special pleasure in reviewing the E codes. Now I have disappointed in the last two years that there haven't been any new E codes (I know – I need a life) but hey, here's to hoping and praying. Stay tuned for your new ICD-9 books for 2008 as early as August of this year. And don't forget that new codes should be implemented in October.

Tips on Selecting a Reputable Billing Company 

Recently, I had the privilege of speaking at a conference for medical billers in southern Florida. Over the course of two days, I spoke on topics ranging from compliance and leadership skills, to increasing collections while reducing denials.

I really think that this group was one of the most attentive, interactive and pleasant crowds I have ever lectured to. Their interests were genuine and their desire for doing things, the right way for their clients was very evident. I was, however, surprised to find that roughly 40-45% of the attendees at this conference were either brand new to the industry or have worked in their current capacity for less than 2 years. This caused me some concern because their inexperience can potentially cost physicians money if the billing services do not know how to code or verify what the doctors offices are providing them as information to bill to the insurance companies. Or they might try collecting for services or levels of services they are not entitled to causing doctors to have to make refunds.

Now, please understand I am not saying all billing companies are this way or even that the majority of them are this way because for me to say that, I would be a fool. There are many experienced and reputable companies out there that work hard to provide a valuable service for their clients.

In the interest of helping physicians find the right fit, I have compiled a list of suggestions for anyone considering outsourcing their billing.

1. Check to see if the company has been reported to the better business bureau.
2. Check to see if any of the officers or employees of the company are listed on the excluded or sanctioned provider lists.
3. Request references from other companies they bill for in the same specialty as yours.
4. Ask lots of questions about what software they are using, ask for sample reports they provide and how often they will be onsite at your office providing you with feedback on how your collection efforts are going.
5. Ask them to explain their appeals process to you and how it matches up to what the carriers use as an appeals process.
6. Do they provide as part of their service annual updates to your encounter forms?
7. Can they negotiate your fee schedule with insurance carriers?
8. Do they have certified coders on staff and if so who are they certified by (PMI, AAPC, or AHIMA)?
9. Have they adopted a third-party billing company compliance program and can they develop one for your group if you do not currently have one?
10. What and how are their fees structured and then compare this to other companies. The most expensive companies are not always the best and going with the cheapest may put you in a position that is not very comfortable.
11. Does the company carry Errors and Omissions Insurance? How much?
12. Are they bonded and insured? How much?

The bottom line here is to make sure to do your homework when choosing a billing company to ensure that you are not taken for a ride. There are great companies led by caring individuals who are happy, willing and able to assist you with your practice needs. Kathy Young, a billing company consultant out of Phoenix, Arizona, was a tremendous reference to me for this article. Also, I had the pleasure of spending time with Ken Engle, a billing company consultant and an educator for billing companies all across the country. Folks like these are the reason the industry has a bright future.

Sean M. Weiss is a Senior Partner and Principal with PMI Professional Resources/The CMC Group; a full-scale medical consultancy, education, products, and legal firm with offices in Atlanta, GA and San Antonio, TX. To contact Sean directly you can email him at sean.weiss@thecmcgroup.net.

Incorrect use of Modifer 25 & 59 

The Office of Inspector General recently released two reports, shown below, that bear repeating to all providers. It would serve all practices well to conduct a coding audit of all modifier use. Not just 25 & 59.

You can bet that the Medicare Carriers will be auditing, whether you do or not. Find and correct your coding mistakes now.

Use of Modifier 59 to Bypass Medicare's National Correct Coding Initiative Edits (OEI-03-02-00771) http://www.oig.hhs.gov/oei/reports/oei-03-02-00771.pdf

Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure or service. This modifier would allow the code pair to bypass the edit and both services would be paid. This inspection found that 40 percent of code pairs billed with modifier 59 in fiscal year 2003 did not meet program requirements, resulting in an estimated $59 million in improper payments. Specifically, modifier 59 was used inappropriately with 15 percent of code pairs because the services were not distinct from each other and with 25 percent of code pairs because the services were not adequately documented. This inspection also found that 11 percent of code pairs billed with modifier 59 in fiscal year 2003 were paid when modifier 59 was billed with the incorrect code. This billing error represented $27 million in Medicare paid claims. In addition, OIG found that most carriers did not conduct reviews of modifier 59 but those carriers that did found providers who were using modifier 59 inappropriately.

OIG recommended that CMS: (1) encourage carriers to conduct prepayment and postpayment reviews of the use of modifier 59 and (2) ensure that carriers' claims processing systems only pay claims with modifier 59 when the modifier is billed with the correct code. CMS concurred with these recommendations.

Use of Modifier 25 (OEI-07-03-00470) http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

OIG conducted this study to assess the extent to which use of modifier 25 meets program requirements. Modifier 25 is used to allow additional payment for evaluation and management (E/M) services performed by a provider on the same day as a procedure, as long as the E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. OIG found that 35 percent of claims for E/M services allowed by Medicare in 2002 did not meet program requirements, resulting in $538 million in improper payments. Modifier 25 was also used unnecessarily on a large number of claims, and while such use may not lead to improper payments, it fails to meet program requirements. OIG recommends that CMS work with carriers to reduce the number of claims submitted using modifier 25 that do not meet program requirements, emphasize that providers must maintain appropriate documentation of both the E/M services and procedures, and remind providers that modifier 25 should only be used on claims for E/M services. CMS concurred with OIG's recommendations.

Timely Tips for Collections 

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.

Customer Service: The Real Competitive Edge 

Customers are rightfully insisting on getting what they paid for, whether it is a clean glass, an impeccable hotel room, a decent meal in the hospital, an on-time appointment with the doctor, courteous treatment in the reception room or checking in for the appointment and discussing insurance details. The business organizations that will succeed are those that recognize today's customer revolution and are fully prepared to meet the challenge at the highest standards of service.

It is time for every practice to examine and reassess how well it manages its relationships with the two key groups:

• Internal customers (employees)
• External customers (patients and those who use the doctor's services)

  Both are essential and the two are inseparable.

  Trying to compete solely on the basis of product or price is insufficient. It is necessary for a practice to create a perceptible difference that separates them from competitive practices. The key is service…attention to the customer. Service is the competitive edge.

  Market research has shown that it is five times more expensive to obtain a new customer than it is to keep an old one. Another way to look at this concept is to consider that the cost of losing a repeat customer is approximately five times the value of that annual account. What drives most people away is rude, discourteous, inept, or incompetent service. It could be due to a matter of apathy or inattention. In either case, a practice will not survive if their patients view them in this negative light.

  What management policies and values produce the highest standards of service quality, timeliness and delivery? According to Robert L. Desatinick "Managing to Keep the Customer", the following characteristics can help a practice become a "superstar" in customer service:

• Recognize that employee relations mirror customer relations
• Create awareness of the importance of customer service in the minds of employees.
• Develop and implement support systems needed to teach and reinforce expected behaviors
• Recognize that everything that happens in the practice has an impact on customer service.
• Define and implement precise and demanding performance standards.
• Define the roles of managers and supervisors carefully to promote continuous service superiority.
• Use quantitative measures to monitor the effectiveness of service, personnel policies, practices, programs, and procedures.
• Build in strong, continuing reinforcement to sustain customer-oriented value systems

  Service superiority begins with dissatisfaction with the status quo. It is a matter of designing the practice value system to build these values into every aspect of the employment contract. It also begins with hiring the right people who share management's views. If the owner/manager of the practice is dedicated to establishing and reinforcing new standards of service superiority then the practice can achieve and maintain a true competitive edge.

How Your State Insurance Commissioner Can Help 

Q. We are struggling with one insurance carrier who never pays claims on time. What can we do to get them to speed up payments?

A. If an insurance company is continually a slow payer, a method to speed up payments is to include a note to the carrier stating they have 30 days to pay or deny the claim, or a formal written complaint will be filed with the state insurance commissioner. You state's insurance commissioner handles the following types of disputes:

1. Improper denial of a claim or a settlement less than indicated by the policy.
2. Delay in settlement of a claim
3. Illegal cancellation or termination of an insurance policy.
4. Misrepresentation of premiums paid to an agent or broker.
5. Misappropriation of premiums paid to an agent or broker.
6. Two companies cannot determine which is primary.

Requests to the insurance commissioner must be in writing. In some states, the insurance commissioner requires that the complaint come from the patient even if an assignment of benefits has been signed. You may want to prepare a form letter for the patient to sign and then submit. Depending on the situation, you may want to send copies to the state medical association and/or an attorney. Mail may be sent certified, return receipt requested. The request should contain the following information:

1. The inquiring person name, address and phone number
2. The policyholders name, address and phone number if they are not the inquiring person.
3. The name and address of the insurance company, broker or agent.
4. The policy effective date.
5. The policy or claim number.
6. The date of loss.
7. A statement of the complaint, if possible a copy of the policy, medical bills, unpaid insurance claim, cancelled checks and any correspondence from the insurance company pertaining to the claim.
8. The commissioner's responsibility is to the patient, not the physician, therefore the letter must include the patient's signature, address and phone number.

If an insurance company pays the patient directly, even though the physician has accepted assignment and signs such a statement, file a complaint with the insurance commissioner. The commissioner will write to the insurance company and request a review of the claim. If the insurance company admits they violated the assignment, the insurance company must pay the physician within 2-3 weeks. This will be done even if they have not recovered payment from the patient.

Good Luck!

Health Care Quality Standards 

Medical errors are one of the Nation's leading causes of death and injury. A recent report by the Institute of Medicine estimates that as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of medical errors. This means that more people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS.

Setting and maintaining proper standards for our patient (customer) services are important for many reasons. Since our patients come to us for health care, the quality standards we should follow are critical in not only providing friendly efficient health care, but also in eliminating errors. Knowing and keeping up with the Federal standards that are provided to patients will help us provide appropriate patient services as well as minimize our legal risks.

Government agencies, purchasers of group health care, and health care providers are working together to make the U.S. health care system safer for patients and the public. Resources are available online to help. The Agency for Healthcare Research and Quality (AHRQ) provides a fact sheet to help providers prevent medical errors. The following information appears on the AHRQ web site. A link to the site is provided at the end of this article.

What are Medical Errors?

Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place. Medical errors can occur anywhere in the health care system:

• Hospitals
• Clinics
• Outpatient Surgery Centers
• Doctors' Offices
• Nursing Homes
• Pharmacies
• Patients' Homes

Errors can involve:

• Medicines
• Surgery
• Diagnosis
• Equipment
• Lab reports

They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal.

Most errors result from problems created by today's complex health care system. But errors also happen when doctors and their patients have problems communicating. For example, a recent study supported by the Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not do enough to help their patients make informed decisions. Uninvolved and uninformed patients are less likely to accept the doctor's choice of treatment and less likely to do what they need to do to make the treatment work.

Patients are advised to be involved in their healthcare by taking part in healthcare decisions. Practice members should understand the following guidance given to patients by the AHRQ, as well as for their own healthcare needs.

1. The single most important way you can help to prevent errors is to be an active member of your health care team. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best, follow.

   Medicines

2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs. At least once a year, bring all of your medicines and supplements with you to your doctor. "Brown bagging" your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date, which can help you get better quality care.
3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. This can help you avoid getting a medicine that can harm you.
4. When your doctor writes you a prescription, make sure you can read it. If you can't read your doctor's handwriting, your pharmacist might not be able to either.
5. Ask for information about your medicines in terms you can understand - both when your medicines are prescribed and when you receive them.
   • What is the medicine for?
   • How am I supposed to take it, and for how long?
   • What side effects are likely? What do I do if they occur?
   • Is this medicine safe to take with other medicines or dietary supplements I am taking?
   • What food, drink, or activities should I avoid while taking this medicine?
6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose.
7. If you have any questions about the directions on your medicine labels, ask. Medicine labels can be hard to understand. For example, ask if "four doses daily" means taking a dose every 6 hours around the clock or just during regular waking hours.
8. Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you're not sure how to use it. Research shows that many people do not understand the right way to measure liquid medicines. For example, many use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people to measure the right dose. Being told how to use the devices helps even more.
9. Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared if it does - or, if something unexpected happens instead. That way, you can report the problem right away and get help before it gets worse. A study found that written information about medicines can help patients recognize problem side effects and then give that information to their doctor or pharmacist.

   Hospital Stays

10. If you have a choice, choose a hospital at which many patients have the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.
11. If you are in a hospital, consider asking all health care workers who have direct contact with you whether they have washed their hands. Handwashing is an important way to prevent the spread of infections in hospitals. Yet, it is not done regularly or thoroughly enough. A recent study found that when patients checked whether health care workers washed their hands, the workers washed their hands more often and used more soap.
12. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home. This includes learning about your medicines and finding out when you can get back to your regular activities. Research shows that at discharge time, doctors think their patients understand more than they really do about what they should or should not do when they return home.

    Surgery

13. If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. Doing surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. The American Academy of Orthopaedic Surgeons urges its members to sign their initials directly on the site to be operated on before the surgery.

    Other Steps You Can Take

14. Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care.
15. Make sure that someone, such as your personal doctor, is in charge of your care. This is especially important if you have many health problems or are in a hospital.
16. Make sure that all health professionals involved in your care have important health information about you. Do not assume that everyone knows everything they need to.
17. Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can't). Even if you think you don't need help now, you might need it later.
18. Know that "more" is not always better. It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it.
19. If you have a test, don't assume that no news is good news. Ask about the results.
20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. For example, treatment recommendations based on the latest scientific evidence are available from the National Guidelines Clearinghouse™ at http://www.guideline.gov. Ask your doctor if your treatment is based on the latest evidence.

Web Resources

• The United States Department of Health & Human Services provides a web site for patients called the Agency for Healthcare Research and Quality (AHRQ). Visit: www.ahcpr.gov/consumer/guidetoq/ to review the AHRQ "Guide to Health Care Quality – How to Know When You see It."

The tips presented here are provided to help patients be active in making decisions about their health care. One of the links at that site (www.ahcpr.gov/consumer/20tips.htm) is titled "20 Tips to Help Prevent Medical Errors"

Internet Citation:

• 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38, February 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/20tips.htm

Managed Care Audit Tips and Checklist 

Casting fear into the bravest of managers…"AUDIT NOTICE"!. With proper preparation, any audit can be faced with confidence. The secret is knowing what the auditors will be looking for in the office and your charts. The managed care audit does not focus only on the chart audit; they look into all aspects of the office operation. The auditor will review the physician's updated medical licenses, DEA, DPS and Malpractice Insurance coverage. A site check will include the following areas:

Staffing

Exam/Treatment Patient Care Areas

Appearance and Access

Appointment accessibility

Safety and Emergency Protocols

Medical Record Keeping

Each managed care auditor will have specific forms to follow in these areas. The forms will vary from company to company, but will generally follow OSHA and CMS guidelines. These audits will also vary in specialty; i.e., what is required for an OB will be more detailed than what would be required of an Ophthalmology office. This can be the proverbial "tow birds with one stone". OSHA and CMS office compliance will also cover most managed care audit areas. While the penalties are not in the CMS or OSHA range a general overview and quarterly review should be in your office management protocols.

Part-Time Work and Job Sharing 

Throughout the working life of any employee, different stages bring different responsibilities and demands at and outside of work. Child care or elder care arrangements may call for a more flexible schedule. Consider options such as part-time work and job sharing to create career flexibility and retain a trained, reliable staff.

For employees who have child care and/or elder care responsibilities, as well as those interested in phased retirement, job sharing and other part-time arrangements can be very attractive alternatives. They enable employees to continue their engagement with work, contribute to the family income, and progress in their careers. Your practice will benefit from retaining talented, experienced and loyal staff.

For more information on flexible career options, take a look at the "Part Time Employment and Job Sharing Guide" offered online by the U.S. Office of Personnel Management: Part-Time Employment and Job Sharing Guide

The Facts About Consultations
"What You Need To Know" 

With consultations continuing to be investigated by the Office of Inspector General (OIG), it's time once again to take a look at the process and understanding for what a consultation is, how to code for one, and receive proper reimbursement.

According to an OIG report released in March of 2006, Medicare allowed $3.3 billion for consultations in 2001. The Current Procedural Terminology (CPT) defines a consultation as "A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source."

A consultation differs from similar evaluation and management services in that a consultation involves a specific request for help with a particular diagnosis or course of treatment on a limited basis, while an office or inpatient visit lacks such a request and can involve ongoing care of a patient. The CPT defines four types of consultation: (1) office or other outpatient, (2) initial inpatient, (3) follow-up inpatient (removed for 2007), and (4) confirmatory (also called a second opinion, Please note these have been removed from the CPT manual for 2007).

Within each type, three or five levels of complexity exist, with a distinct billing code for each level. The level depends on three key components: (1) the extent of the patient history taken, (2) the thoroughness of the physical examination, and (3) the complexity of the consultant's medical decision making.

Pursuant to 42 CFR § 411.351 and section 15506 of the Medicare Carriers Manual, Medicare allows reimbursement for consultations if (1) a physician requests the consultation, (2) the request and need for the consultation are documented in the patient's medical record, and (3) the consultant furnishes a written report to the referring physician. Other provisions of Federal law require that physicians document all Medicare services and bill them with the correct code.

Medicare allowed approximately $1.1 billion more in 2001 than it should have for services that were billed as consultations. Approximately 75 percent of services billed as consultations and allowed by Medicare in 2001 did not meet all applicable program requirements, resulting in $1.1 billion in improper payments. Services billed as consultations often did not meet Medicare's definition of a consultation (19 percent - $191 million), were billed as the wrong type or level of consultation (47 percent-$613 million), or were not substantiated by documentation (9 percent-$260 million).

Consultations billed at the highest billing level (the most complex services, which generate the highest reimbursements under the physician fee schedule) and follow-up inpatient consultations were particularly problematic; approximately 95 percent of each was miscoded. Based on these findings it is highly likely the carriers are going to begin the performance of audits for more recent years. Do not be surprised if payments for consultations you are billing for start to be denied pending proper documentation to substantiate the services claimed.

Providers must take proactive steps in protecting themselves prior to an audit being performed by your carrier(s). I tell all of my clients as well as groups that I lecture for "The best defense is a strong offense." Solicit the assistance of an expert trained in Evaluation and Management Services as well as CMS audits and methodologies.

Knowing in advance can allow you to correct the problem(s) prior to a carrier audit. Don't think it won't or can't happen to your practice. No one is immune!

For more information on the OIG Audit Results and the CMS letter from Mr. Mark B. McClellan, MD, PhD. to Daniel R. Levinson/ Inspector General, or to find out how The CMC Group, LLC can provide your group with audit and consulting services please contact Sean M. Weiss at sean.weiss@thecmcgroup.net or (888) 262-8354 ext. 402.

Managing When the Stress Doesn't Go Away 

In recent years, Federal Government employees in several parts of the country have had to cope with rebuilding their homes and lives after a disaster while taking on new roles and responsibilities to help the community's recovery. Disasters are not the only source of long term stress that our employees may face. Threats of violence, whether from terrorism or street crime, can lead to severe stress situations which go on for weeks, and affect many people. Harassment campaigns directed against employees can be nerve wracking even when there is no apparent physical danger. The prospect of losing a group member to a slowly debilitating illness can produce a long period of stress for everyone involved. Organizational change can produce severe stress if employees feel uncertain and worried for long periods.

Getting the job done and taking care of employees under conditions of severe, long lasting stress can be one of the most difficult challenges a manager may face. It's not easy to take charge, develop innovative approaches, and be sensitive to the needs of others when you're at least as uncomfortable as your subordinates. There are, however, some management approaches that have proved helpful in these situations:

Take steps to reduce the sources of stress. If danger is a problem, call the right law enforcement authorities immediately, and get all the advice and concrete support you can for them. If employees are overwhelmed by competing demands in the aftermath of a large scale emergency, set clear priorities and make sure they are consistently followed. You probably cannot "fix" the entire situation, but you can improve it. Your employees will feel better if they know you are working on their behalf.

Communicate with your employees. This is always important, but even more so when everyone is under long term stress. In most stressful situations, one source of anxiety is a sense of being out of control. Your employees will feel better if they have up-to-date information and permission to approach you with their questions. Depending on circumstances, you may want to adopt new communications strategies, such as having frequent meetings, publishing an informal newsletter, and keeping an updated notice board in a central place.

Encourage teamwork and cooperation. Under long term stress, there is no substitute for a supportive, caring work group. Employees will find the situation, whatever it is, less painful if they are surrounded by co-workers who care about them, and will listen if they need to talk, or lend a hand if they need help. A group accustomed to teamwork rather than internal competition will usually be able to cover for members who are temporarily unable to function at 100% effectiveness.

Ideally, your group has always been strong and cohesive. If not, do what you can to help it pull together under stress. Encourage and validate teamwork and cooperation. Avoid any appearance of favoritism and make it clear that there is opportunity for everyone to achieve and receive recognition.

Set clear work standards. Doing good work is always essential, but even more so in times of high stress, since success can bolster self esteem and group morale. Keep your standards high, but allow as much flexibility as possible in how the work gets done. If you set clear standards, but give employees some freedom in working out ways to meet them, they will probably be able to develop approaches that fit the contingencies of the stress situation. Check on how much flexibility you have with regard to such conditions as work hours, administrative leave, alternate work sites, etc. It's natural to assume that the way we have always done things is the only way, but you and your employees may have options that you haven't considered.

Make it clear that this is a difficult period, and it's OK to share feelings of anxiety, fatigue, or frustration. If you set the example by letting people know you can do a good job even though you are not feeling your best, you can set a positive example. Define the situation in a way that emphasizes the strength of the group while acknowledging the challenges it faces. The tone should not be, "Poor us," but rather, "This is hard, but we're going to hang together and get through it."

Acknowledge the value of professional counseling, and encourage your employees to get whatever help they need. Long term stress can wear down the coping resources of the strongest person, and it makes sense to get extra support in order to preserve mental and physical health. One strategy is to bring in an Employee Assistance Program (EAP) counselor to talk to the group about stress management. Besides learning from the presentation, your employees will develop a personal contact which can make it easier to turn to the EAP if they need it.

Don't underestimate the impact of stress on you as an individual. Attend to your own stress management program, and use your resources for professional consultation and counseling. You will find it easier to take care of your work group if you also take care of yourself.

Going For the Gold  

In case you haven't noticed, we live in a twisted world.  What we always thought of as right has now become wrong.  Freedoms are being reasoned away under the guise of political correctness.  Insurance companies dictate your healthcare and doctors will not get paid unless we do our jobs correctly. 

A doctor goes to school for 8 or more years.  They spend a quarter of a million dollars on their education but they cannot get paid unless a clerk that they have hired does a good job with the billing.  How is it possible that a person can go to school for 8 years but he cannot make any money unless his employee who was schooled for maybe 6 months or so, does his/her job right?  I cannot answer that loaded question but I would like to discuss how that biller could do their job better.

When I went to medical billing school, they taught me how to code and the rules that went along with it.  I learned anatomy, insurance rules and I learned how to get the information onto the billing form.  It did not seem like brain surgery.  It's when I actually began to put all that theory into practice that I soon learned that there was much more to getting the claims paid then just putting information on a form.  Yes, it is of the utmost importance to put the correct information onto the form and send it out quickly; however, over 10% of the clean claims sent out of my office are not paid.  What can I do about it? 
This is where the training is incomplete.  If 10% of all claims are left unpaid, they can pile up into a very large sum of money.  Think about it.  An aging report generally only goes to 120 days.  That means that after a claim reaches that column, it will sit there and bask in the presence of all the other unpaid claims that are even older.  A good aging should have no more than 5% in the 120-day-old column.  Only 10% of all claims should make it past 60 days unless your doctor has a great many attorney liens or workers compensation claims.

When I'm marketing my billing company and speaking with a prospective client discussing what I can help them with, the first thing I look at is the aging report.  It is shocking what has become the norm for an aging report.  A doctor will look at his aging and see 12-50% of his aging sitting in the 120-day-old column.  He knows that he is starving for income but what is he to do?  He went to school to be a doctor.  There were no classes in accounts receivable. 
A good biller will not let this happen.  A proficient biller is a person who not only bills out a clean compliant claim but he also does that one thing that separates the bad from the good.  He follows up.  He calls on the claims.  He picks up the phone and calls the insurance companies to find out where the payment is.  It is interesting to note that over 50% of the claims that are called on have not been paid because the insurance companies state they have not received the claim.  I wish I had a dollar for every time this has been said to me.  I would be as rich as Donald Trump.   I have spent a good amount of my career arguing with the person on the phone that tells me they did not receive the claim that was sent to them in a packet that contained other claims that got paid.  Of course now that most claims are billed electronically, this makes even less sense but it has not decreased the use of that same excuse. 

I tried to reason with a Blue Cross executive regarding this issue.  That argument was on crossover claims sent to them by Medicare but "never received" by Blue Cross.  The typical response to me was to just re-bill it but I stated to this executive that it was easier to say that than to do it.  I educated this gentleman on the expense of sending out secondary claims more than once.  The fact is that time is money and then there is the paper, stamp and envelope.  And I argued on and on but in the end after all my diatribe, I simply re-billed it.  Why?  They did not have the claim and they would not have the claim until I re-sent it.  So whether I was right or wrong did not matter.  I just wanted the claim paid. 

This fight is ongoing with every insurance company and the war will continue to rage as we send in the claim and they find a way not to pay it.  It is my job to fight the fight.  I cannot fight every battle but I choose my battles and I win.  There are some insurance companies that have a very small window for billing before that claim is stale dated.  A sixty-day window of time is pitiful and it does not make allowance for errors that come in getting the correct information from the patient.  I have a standard letter of appeal for these claims.  I attach my proof of timely filing and I win almost every time. 

The purpose in this article is not to address every reason behind denials and how to win each battle.  The purpose is to incite you, the biller, to want to fight for the money that your doctor has earned.  It is my purpose to stir you with a passion to fight the battle for your doctor who has gone to school for so long and does his best for the patient.  All he wants is to make a living and grow his practice so that more patients can be seen.  The battle is yours to fight.  If you do not wish to battle the insurance companies then perhaps a different profession would be better suited for you.  Billing is more than putting information into a computer and onto a form.  Billing is a profession that assists the physician in making their dreams come true and in so doing your own dreams can become a reality.  A good biller is worth their weight in gold and if you bring in all the money, there is the gold.  And what is the Golden Rule?  He who has the gold, rules.  Go for the gold.

The Watchful Eye of the Government – Understanding The Office of Inspector General Work plan 

Each fiscal year, the Health and Human Services (HHS) Office of Inspector General publishes a work plan for the upcoming fiscal year.  This document highlights the projects assigned to various agencies under the umbrella of the OIG and describes the details of that project.  This document is of vital importance to healthcare providers as it can give you a head start on internal audit of your billing and coding compliance. 

The document can be accessed at:   http://oig.hhs.gov/publications/workplan.html

It is an Acrobat Reader file that can easily be downloaded through the internet.  The document is divided into various provider types and agencies with sub-topics on the various projects that have been assigned to that department.

Projects for FY2007 under the Medicare Physicians and Other Health Professionals category include:

• Billing Service Companies
• Physician Pathology Services
• Cardiography and Echocardiography Services
• Physical and Occupational Therapy Services
• Payment to Providers of Care for Initial Preventive Physical Examination
• Part B Mental Health Services
• Wound Care Services
• Evaluation of “Incident to” Services
• Potential Duplicate Physical Therapy Claims
• Eye Surgeries
• Place of Service Errors
• Review of Evaluation and Management Services During Global Surgery Periods
• Psychiatry Services Provided in an Inpatient Setting
• Medicare Reimbursement for Polysomnography
• Long Distance Physician Claims Associated with Home Health and Skilled Nursing Facility Services
• Violations of Assignment Rules by Medicare Providers
• Advanced Imaging Services in Physician Offices

You may be thinking to yourself, “none of these subjects affect me or my practice,” think again!  Here is the description of the Place of Service Errors – this particular project can affect many different provider types especially surgeons.

Place of Service Errors

This review will determine whether physicians properly coded the place of service on claims for services provided in ambulatory surgical centers and hospital outpatient departments.  Medicare regulations provide for different levels of payments to physicians depending on where the service is performed.  Medicare makes higher payments for physician office services.  (OAS; W-00-06-35113; various reviews; expected issue date: FY 2007; work in progress)

The OIG at the Federal and State level has very sophisticated data mining systems that review claims submitted for processing with Medicare and Medicaid.  Any provider is subject to review and audit by the Agency.    

Visit and review the OIG work plan at lease twice a year.  The initial plan is published in late summer and an update is published in the spring.  Keeping on top of these topics can keep you and your practice out of trouble by ensuring you meet the regulatory requirements of the Government.

Resources:  OIG 2007 Work plan

CUSTOMER SERVICE: The Other Medical Specialty 

Survey results printed in a national publication indicated that customers believe there to be a marked decrease in quality customer service over the last 5 years. Among the top 10 areas, the medical office ranked number four (4).

As healthcare professionals, we have the unique opportunity to impact every aspect of our patient's lives. We are involved throughout their growth and development, and in many cases, deal with intimate and confidential issues of which may lead to feelings of embarrassment, anger, withdrawal, denial and depression.

So why is customer service so important to a patient who goes to the doctor specifically for medical care? In order to understand the true meaning of customer service, let us first