Presentation on theme: "Maximizing Practice Revenues in the Face of Reform &Transition"— Presentation transcript:
1 Maximizing Practice Revenues in the Face of Reform &Transition Get Paid Now!Maximizing Practice Revenues in the Face of Reform &Transition
2 Agenda Healthcare Trends & Impacts Collect from Insurer’s ICD-10 & ACATech ToolsCollect from Insurer’sDenial ManagementEffective AppealsCollect from PatientsEasy Pay PolicyScripting
3 Major ChangesThe healthcare industry is undergoing extraordinary transformation in the face of the Affordable Care Act and the transition to ICD-10.Healthcare providers, practice managers and billing-collections staff should expect to see, and prepare for, dramatic impacts to revenue and collection.
4 ICD-10 Do an assessment of your current clinical documentation Identify and assess ICD-10 transition impacts on other areas of the practiceMake a list of your vendorsPost implementation
5 Narrow NetworksThe insurance companies created "narrow networks" within their full network of providers; only a subset of physicians within any given insurance company's network "qualify" for participation in the exchange plans.A physician could be participating with an HMO and a PPO-type product, but be excluded from the exchange product.
6 Narrow NetworksKnow whether you are participating with an exchange plan.Determine your fee schedule.Communicate clearly with patients that are not in the exchange plansDon’t put all your eggs in one basket!
7 The ‘90 Day Grace Period’Patients with exchange plans can actually use the plan for 90 days without paying any premium – this is the grace period.Practices are at risk financially for the cost of any services provided to patients with exchange plans during the first 90 days of the plan. Convert to an electronic Credit Card on File (CCOF) program, in order to have the ability to control the timing of the payment of patient-responsible balances, and can protect themselves financially.
8 Preventative vs. Diagnostic Under the Affordable Care Act, insurance plans now cover preventative care without patient cost sharing, i.e., without co-pays, co-insurance, or deductibles.Services that are not classified as preventative care are still subject to cost sharing. It is important for physicians and their staff to be able to differentiate between the two in order to avoid blindsiding patients and avoid experiencing a revenue loss.
9 Preventative vs. Diagnostic Preventative services:If an abnormal finding on a preventative mammography screening is later found to be normal, then the future mammography screening is considered preventative.Diagnostic services:If an abnormal finding on a preventative mammography screening is later confirmed to be abnormal, then the future mammography screening is considered diagnostic, and any deductible, co-pay, or co-insurance is applied.
10 Preventative vs. Diagnostic Services If coders know the difference between the two, and can code correctly with supporting documents as a backup, they can effectively maximize physician reimbursement.Provide a disclaimer to your patients making them aware of the different types of care and what their potential out of pocket costs might be: “I do (or do not) want to receive diagnostic services not covered under my preventative benefits.”
11 Technology Tools EZ PayDR. patients pay their bills online OAISYS. Provides secure, reliable and affordable call recording and quality monitoring solutionsWellero. allows your patients to connect with your practice, make payments and verify insurance coverage using their smart phoneKiosks. Let your patients check-in and make their copayment at a kiosk in your reception area.CareCredit. Doctors offer CareCredit payment options as an alternative to consumer credit cards, cash or checks
12 Collect from Insurance Companies Insurance companies are trying to spread risk and keep as much money in their organization for as long as possible as they “adjudicate a claim.” They use auditing software, often called “claim review programs” (Denial Engines) to sift through millions of submitted claims.
13 Claim Denial RateAccording to the American Medical Association claims denied by insurers on the first submission ranges between 1.38 percent and 5.07 percent.The Medical Group Management Association reports (2012 Performance and Practices of Successful Medical Groups) that the best-performing medical practices experience a denial rate of 5%. In worst cases, practices are seeing claims being denied at a rate of 10% to 30%!
14 Remember, your goal should be 5% or less! Claim Denial RatePayerTotal Value of ClaimsValue of Denied ClaimsDenial RateAetna$379,000$36,0009.5%United$256,000$17,0006.6%Total$635,000$53,000*8.0 %The Average Claim Denial Rate for this practice is 8%.Remember, your goal should be 5% or less!
15 Appeals Solutions “THE SQUEAKY WHEEL GETS THE GREASE!” United Healthcare Ordered to Pay Civil FinesInsurance Director, Christina Urias, orders United HealthCare of Arizona to pay a civil penalty of $243,250 and United HealthCare Insurance Company to pay a civil penalty of $121,250, for violations of Arizona’s insurance laws.The combined fine of $364,750 is the largest the Insurance Department has ever assessed for such unlawful practices and both companies have agreed to take corrective action to prevent future violations.In particular, the Department found that both companies had violated state laws governing: (a) member appeals of denied services and claims; (b) timely payments to providers; (c) provider grievances; and, (d) record keeping and documentation requirements.
16 State & Federal LawEach state has very specific rules regarding timely payment of claims (30-90 days). Claims must be paid or denied within a reasonable amount of time and comply with the states unfair claims settlement practices.ERISA/Self Insured’s & Union Plans: Title 29 of the United States Code of Federal Regulations.(B) Post-service claims.Medicare: Current law also mandates a minimum of 14 days to pay claims that have been submitted electronicallyMedicaid (pray)
17 These claims are typically sorted for priority adjudication! Claims DepartmentClaims with written formal complaints get routed to the claims manager, the lead or customer service supervisor.These claims are typically sorted for priority adjudication!AdjusterSupervisorLeadClaims ManageCS ManagerUnit Manager
18 Actions Steps Get the Patient Involved! To: The Insurance Commissioner or Regulatory Board From: The patient Dear Insurance Commissioner, On (date) a claim was submitted on my behalf by (name of provider) to (name of insurer). As of (date), my claim has not been responded to. According to (statutory code) this claim must either be paid or denied in (number of) days. My provider has informed me, that all necessary claim information was filed in an appropriate and timely manner. In addition, my provider has supplied me with all other documentation I might need to pursue a formal complaint against (name of insurer). My doctor and I have operated in good faith with (name of insurer). This letter shall serve as a written formal complaint with your office. Thank you for your time and attention. Sincerely, (Name of patient) CC. Claims Manager
19 Action Steps Effective Scripting ‘Attention! Unless this claim is paid or denied in ____days, I will file a written formal complaint to the insurance commissioner.’Attention, this claim is being audited for legal action!”“Attention this claim is in violation of State Law”“Attention, we know where you live, so don’t mess with us!”
20 Actions Steps Monitor Payers- Record Calls! Verification and Preauthorization of Benefits‘For your protection and ours we record all calls for prompt payment’ Archive your calls for easy retrieval. You can use the same process for managing patient conversations.
21 Action Steps Aging Reports Check aging reports and trial balances. Make a plan to audit, follow up and file written formal complaints with your worst payers.Payer306090120AetnaMet. LifeUnited HCCignaBlue Cross
22 Appeal ActionsDepending on the number of bills you submit each week you should expect to spend time filing appeals letters on a regular basis.Address your letters to the Claims Manager or Claims Supervisor.Make sure you send a copy to the regulatory agency, i.e., the insurance commissioner, department of labor, or Attorney General in your state.Maintain and be ready to send a second appeals letter restating your position with factual information and documentation.Maintain fax numbers and collect address for the payers’ that you routinely bill.
23 File Your Appeals Letter for Stalls Medical Necessity “I use your appeal letter templates on a regular basis. I have a new practice that I just started managing and used three of the appeal letters and was able to recover $7,000 in less than one month!”Sami Spencer, Past President, Akron Chapter“I use your appeal letter templates on a regular basis. I have a new practice that I just started managing and used three of the appeal letters and was able to recover $7,000 in less than one month!”Sami Spencer, Past President, Akron Chapter“I use your appeal letter templates on a regular basis. I have a new practice that I just started managing and used three of the appeal letters and was able to recover $7,000 in less than one month!”Sami Spencer, Past President, Akron ChapterFile Your AppealsLetter for StallsMedical NecessityBenefit ReductionsTimely FilingRefund RequestVerification of BenefitsWorkers CompensationERISA“I use your appeal letter templates on a regular basis. I have a new practice that I just started managing and used three of the appeal letters and was able to recover $7,000 in less than one month!”Sami Spencer, Past President, Akron Chapter
24 Oregon Timely PaymentPlease be advised ORS , "Payment or denial of health benefit plan claims; rules," requires insurers to pay or deny benefits on properly filed claims as follows:Except as provided in this subsection, when a claim under a health benefit plan is submitted to an insurer by a provider on behalf of an enrollee, the insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the claim
25 Timely FilingRefusing to process a claim due solely to lack of timely filing may be a violation of many states court’s rulings on the matter.“Most recently, I got a very large claim paid that was denied for timely filing by Railroad Medicare. This claim that was already two years aged when I resubmitted the claim with the timely filing letter the day we got back from the seminar and received payment one week later!”Michelle Gipson, Insurance Department, Purchase Orthopedics, Paducah KY
26 Verification of Benefits Liability for false representations made during verification of benefits may be the responsibility of the insurer according to many state courts. We believe that your obligation is to provide accurate information throughout the benefit verification process. Knowingly misstating facts and policy benefits may be a violation of state courts rulings as well as a breach of the Unfair Claims Settlement Practices Acts.
27 Scripting “We Never Received Your Claim” We know for a fact that you did receive this claim because I’m holding a receipt from the United States Postal Service (I can document an electronic transmission or a faxed copy)…” “It’s nothing personal, but my boss tells me that my job is to audit, track, and trace each and every claim form that leaves our office…” By the way, I’m the chief executive responsible for all insurance reimbursements in the northwestern region (that’s your office!) Shall I hold the phone while you research and process this claim, or shall I have to name you and your supervisor personally, in my written, formal complaint, signed by your premium paying subscriber, to the insurance commissioner and the attorney general in this state? What would like me to do?
28 Collect from PatientsIt is predicted that providers will face up to a 25 percent decline in revenue over the next five to ten years due to reductions in reimbursement in an ever changing healthcare marketplace.Taking a proactive approach to collecting payments ‘up front’ will be necessary in order mitigate both bad debt and the decreases in cash flow that will invariably occur in the transition to ICD-10.
29 Financial PolicyThe medical practice financial policy is the most critical component for managing revenue, cash flow and collections. Your policy sets the table for how your staff will interact with patients about insurance, past due balances, and co-payments.Is your financial policy in writing? A financial policy that is not written down doesn’t exist!Is your policy up to date? Do you offer several payment options or on-line payment portals?Does your staff understand how to communicate with patients and what the protocols are for implementing policy; when to make exceptions or ‘hold the line’?
30 Financial Policy Introducing to new patients Convert Existing Patients Review all existing patient files for missing or outdated information.Enclose updated forms to be completed and returned (see sample cover letter below)Forms that should be reviewed prior to mailing the new financial policies to patients include; The Patient Information Form, The Insurance Benefits Verification Form, The Easy-Pay Form with Credit, Debit or Check information. Optional: Care Credit, Wellero, on-line payment authorization options.
31 Financial PolicyRegarding Your Insurance, Balances & Payments We accept all major credit cards, checks and cash. We are also pleased to offer several on line, secure, easy pay options to help manage copayments, deductibles, or balances that may not covered by your insurance. Our Patient Finance Counselors are dedicated to making sure your insurance paperwork is filed accurately and promptly. Your partnership in this process is certainly appreciated. If you will please initial beside your type of insurance coverage listed below, this will help us to expedite your claim payment and minimize your out of pocket expenses. Thank you.
32 Financial PolicyIndemnity (non-contracted) Insurance Plan: We may bill your insurance as a courtesy. Our office, as a convenience and a service to you, will absorb all costs incurred for billing. In the event that your insurance does not reimburse us within 45 days, we will simply transfer the balance of your account to your credit, debit, or check card. Please indicate your preference. Plans in which are a participating providers: HMO Plans; all co-pays must be satisfied each and every visit. There can be no exceptions due to contracting and uniform compliance rules. You are responsible for getting proper referral information in advance of your appointment. PPO Plans; we have agreed to accept the discounted rate from your plan, however all co-insurance is your responsibility. We will estimate balances to the best of our ability. Since the balances are estimates only, we may require one of our ‘easy pay’ options to guarantee any balance due after service. Once your insurance has cleared, you may leave the balance on your card, or you can send a check.
33 Easy PayI authorize [~Name of Doctor~] to maintain my credit account on file and I assign my insurance benefits to the [~Name of practice~].Account Information:Credit Card: ______________________________________________Care Credit: ______________________________________________Check Acct: ______________________________________________Other: _________________________________________________ Transfer my balance to my preauthorized account on file___ Please contact me before processing my card on file; I may want to use another option.I have read the Financial Policy. I understand and agree with this Financial Policy.Signature of responsible party X _________________________________________Signature of co-responsible party X _______________________________________Date _____/_______/_______
34 Collecting Co-Payments AMA Opinion Forgiveness or Waiver of Copayments It is vitally important for healthcare providers to collect or make an attempt to collect copayments, deductibles, and coinsurance. Physicians should be aware that forgiveness or waiver of copayments may violate the policies of some insurers, both public and private; other insurers may permit forgiveness or waiver if they are aware of the reasons for the forgiveness or waiver. Routine forgiveness or waiver of copayments may constitute fraud under state and federal law. Physicians should ensure that their policies on copayments are consistent with applicable law and with the requirements of their agreements with insurers
35 Co Pay LetterDear Patient: We are required to collect co-payments each and every visit. It may be considered fraud for us to collect from some patients and not from others. Please be advised that should you choose not to pay your co-payments for any reason we may notify your insurance insurer, and in turn, they may drop you as a subscriber. We refer to AMA Opinion Forgiveness or Waiver of Insurance Copayments which states; “Routine forgiveness or waiver of copayments may constitute fraud under state and federal law.” Our intention is to support you by providing the highest quality of care and assist you you’re your insurance plan. We would never want to jeopardize your insurance by not collecting your co- payment. As a convenience to all of our patients, we offer many easy payment options. Please ask [~Financial Counselor Name~] our Patient Finance Counselor about those options. Of course, you may prefer to use check or cash. Please understand that if you come unprepared to make your co-payment, we must reschedule your appointment. Thank you for cooperation,
36 Easy Pay Scripting“We offer easy-pay. It’s a program by which we simply maintain your credit or debit card on file to capture any co-pays, deductibles or balances not covered by insurance. We offer this as a convenience to all our patients. Which card works best for you?”“Our Easy Pay payment options are very similar to many of the other on-line services you are probably already using. They are secure and simple, saving you time and the hassle of receiving paper bills in the mail and writing checks!”“As of [date] we will no longer be able to bill for co-pays, deductibles, and out pocket expenses. We have done that in the past but times have really changed, haven’t they! What I can do is set up one of our easy options for you.”“As of [date] we will no longer be mailing paper bills. Our practice is upgrading to a secure, on line payment portal. We are doing this to improve efficiencies in billing, reduce administrative costs and increase focus on your healthcare!”
37 Telephone Scripting“The minimum you can expect to pay on the first visit is $____. How will you take care of that?” New or established patients with minimum payments due at time of service; “Can you please confirm your co-payment? How do you think you will take care of that when you come in, cash, check or charge?” Patient asks “why do you need this information now?” “For legal reasons, we are required to collect co-payments each and every visit. We want to make sure you are prepared. This will avoid rescheduling if you forget!” -or- “Our system doesn’t even allow me to block time into the schedule until I enter how much and by what method you will be paying…it’s this dumb computer…”
38 Office ScriptingAsk for the co-payment prior to service! “The co-payment today is $____. Are you still planning to (use a credit card or write a check) as you indicated when you called in?” If yes, say; “Just go ahead and make that check out now paid to _____and we can get you going as quickly as possible.” “As you can see we are very busy today. By getting your payment information now I can process your paperwork faster…I’d hate to keep you waiting. If you’re like me when you’re ready to go- you’re ready to go!”
39 Office ScriptingIf the patient says “no”, or says something like, “no one told me” or “can you just bill me?” “I see that when you called to make your appointment you told Sally that you would be paying by check. We could not have put you into the schedule unless you told us how you would be paying. You may have forgotten. Did you forget?” If yes, then say; “That’s not a problem; you can pay check or if you like with credit or debit card…which one works best for you today?” If you’ve now determined the patient has come unprepared to pay, you say; “I really wish we could do it that way, but as we told you over the phone, we are legally required to collect your portion. We can’t collect from some customers and not others. Not only could we get in serious trouble, but also you could lose your insurance! If you don’t make your co- payment, we may be obligated to notify your insurer and they could drop you as a subscriber. We certainly don't want that, do we?"
40 Collections CallsWhen working with patients on financial matters it’s best to think of your role as a ‘patient finance counselor’. Most patients do want to pay what they owe, they may have questions or they may not know how to take care of the bill. Your job is to help them.Category 1The good payExisting patient with a good pay history and generally co-operative. Not much to do to get them to pay. Keep them happy!Category 2The slow paySlow paying patient who are willing to work with you. They probably need more time to pay.Category 3The no payUncooperative, unwilling to work with you no matter what you do.
41 Call Matrix Bills Calls Payment History Dialogues Outcomes 30 days 40 Cat. 1(good pay )“We can take care of the whole bill right now. I’ll ‘hold’ while you get your card or checkbook.Credit, debit, check card, check by phone6070Cat. 2(slow pay )“How much more time will you need to take of your balance?”Payment Plan- Patient needs more time.90100Cat. 3( no pay)“Then you will not be paying your bill?Not paying; Verify personal information. SS#, Bank Info.
42 Collection Letters Patient to Provide Information Dear Patient,We have received correspondence from [name of carrier] stating that they have requested additional information from you on the matter of your insurance. As of this notice they have not received that important documentation necessary to process your claim.Until they receive it, they will not remit payment for services rendered to you by [name of provider or facility] on [date]. Therefore, the responsibilities of the charges incurred are due by you.Thank you for your prompt attention to this matter. Our Patient finance counselor(s) will be more than happy to assist you in taking care of your balance.Sincerely,Practice Manager for Dr. Jones
43 Collection Letters Patient Receives Insurance Check Dear Patient, We have received notification from your insurer that you are in possession of a check in the amount of [ ]. In light of the fact that you have authorized this office to receive assignment from your insurer, we ask that you forward that payment to us immediately. If we do not receive a response within 7 days, we will be forced to report that amount to the Internal Revenue Service. IRS code states that such payments are considered income and must be reported on federal returns. We provided service in good faith and ask that you respond in kind. [~Closing Text~] Sincerely, Dr Jones Enclose verification of social security number and IRS form 1099
44 Questions? Need More information? Jerry Bridge Office 760.918.6701 Love the Appeal Letters? Want More?