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Maximizing Income & Staying out of Trouble Robert E Goff University Physicians Network.

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Presentation on theme: "Maximizing Income & Staying out of Trouble Robert E Goff University Physicians Network."— Presentation transcript:

1 Maximizing Income & Staying out of Trouble Robert E Goff University Physicians Network

2 Top 10 rules of claim payment 1.Just because it has a code, does not mean it’s covered 2.Just because it’s covered, does not mean you can bill for it 3.Just because you can bill for it, does not mean you will be paid for it 4.Just because you have been paid for it, does not mean you get to keep the money 5.Just because one health plan paid you, does not mean you will get paid by another 6.Just because you have been paid for it once, does not mean you will be paid for it again 7.Just because you got paid for it in one state, does not mean you will get paid in this one 8.You will never know all the rules 9.Not knowing the rules can cost you big 10.The rules are subject to change without notice Robert E. Goff 2

3 Maximizing Income Is About Maximizing Receiving What You Have Earned Uncollected patient responsibilities 5-15% lost Under coding caused by the chilling effect of coding challenges 5-10% Lost Services provided and not billed 5-7% Lost Timely filing denials 6-15% Lost 50% of rejections not resubmitted 5-15% Lost 50% of denials not appealed (70% of appealed successful) 3-7% Lost Payments less than fee schedule not identified or challenged 6% Lost Post payment recoveries not challenged 2%+ Lost Analyze your payer mix Lost opportunities in being busy

4 By % Of Medical Costs Are Expected To Become The Responsibility Of The Patient 60% of commercial plans nationally carry a high deductible ($1,000 - $3000) The most popular products of the HIX are expected to carry large deductibles

5 Increasing Patient Responsibility Cost You 80% of self-pay accounts are never paid in full 50% of patient financial responsibilities become bad debts 31% of physicians say they lose revenue due to uncollected patient responsibilities The ability to collect the full amount of patient financial responsibility drops to less than 20 percent after the patient has left the physician’s office. Robert E. Goff 5

6 Require Contingent Credit Card Authorizations Require Credit Cards as a guarantee Well, not a perfect guarantee, but the increased likelihood of being compensated But as near perfect as you can get, other than requiring a cash deposit

7 Contingent Credit Cards Also Protect Against Inaccurate eligibility verification Inaccurate benefits verification Promised payments under HSA that never materialize Copays higher than represented Deductibles higher, or not fully satisfied prior to your services Plans always use weasel words If you look at any eligibility confirmations, you will find that eligibility and benefit confirmations are not guarantees of coverage or benefits If the payer won’t guarantee, why should you be at risk?

8 Services Provided and Not billed Per AMA 7% of all services provided – documented - are not billed Lost between the completion of the medical record and the super bill Lost between the super bill and the insurance bill Get a fully integrated EHR/PMS that “scans” the medical record and sweeps all services to the bill

9 Don’t Lose To The Lag AMA up to 17% of all claims are denied for timely filing All commercial payers have timely filing limits Medicare has a tightened timely filing limit Bill within 24 hours (surgery may need 72 hours) If not paid by day 35 check payer website to very claim received by them If not paid by day 45, file a NYS Prompt Pay Complaint

10 Paid Challenged – more information requested Lost in space – see prior slide Rejected Denied Do you know what denials/rejections can be recovered using which approach? Resubmission Appeal Once Received a Claim is… Robert E. Goff 10 I’ve got claims that have been rejected more than those guys on “The Bachelorette”

11 No 1 Reason for rejection An error in the patient name and/or address Robert E. Goff 11

12 Top 10 Reasons Rejections or Denials 1.Incorrect or missing patient demographics 2.Incorrect or missing ICD-9 diagnoses 3.Incorrect of missing CPT-4 modifiers 4.Incorrect or missing CPT-4 procedure code 5.Physician Identification missing 6.Incorrect or missing place of service code 7.Missing or incorrect number of units of service 8.Claim submitted to the wrong address 9.Duplicate claim 10.Additional information needed to process the claim Robert E. Goff 12

13 Denials Another opportunity to get paid 70-80% recoverable Never accept a denial without a challenge A lost appeal is learning opportunity Most denials are recoverable by simply correcting errors and resubmitting 13

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18 The Chilling Effect Of Coding Challenges 5%-10% Lost Audit by AAPC (AM Academy of Professional Coders) – 37% of records were under coded, extrapolated to loss of $64,000 per physician. The average physician is under coding to the loss of $25,000 to $45,000 a year. Severity of illness is under reported by a factor of 20% Learn how to document and code Understand and fully use all applicable ICD codes Code checker technology is an aide not a replacement for physician decision making Compare your coding pattern with your specialty

19 When it comes to coding & documentation “Like frogs in boiling water, physicians don’t feel the heat until they are cooked ” Robert E. Goff 19 Knowing Coding Can Increase Your Income No knowing it can get you into trouble

20 How Can You Recognize Improper Coding?

21 When we add payer-based coding information, the differences may become even clearer: How Can You Recognize Improper Coding? 21

22 Missing Revenue Robert E. Goff 22

23 Variation from Peers of Dx Robert E. Goff 23

24 Mis-coding can mean more than restitution to a plan A federal judge sentenced a corporation headed by prominent dermatologist N G to five years' probation yesterday for overbilling Plan more than $178,000 for acne procedures. U.S. District Judge J. M Seabright also ordered NG, M.D. to pay a $316,642 fine and $39,720 in restitution. In a plea agreement with federal prosecutors last year, G pleaded guilty on behalf of the corporation to billing Plan for about 20,000 acne surgeries when Plan members received less expensive cryotherapy procedures. His lawyer B H said the overbilling was the result of G's office staff using the wrong billing code. G pleaded guilty because he did not properly supervise the staff to use the proper code Robert E. Goff 24

25 Wrong coding can cost you even more Robert E. Goff 25 A sad but true tale - Patients with Oxford were complaining to the billing company about being billed for a copay for well-woman visits, when the benefit plan requires no such copay. The billing company response, “you own the co-pay, $15, we checked with Oxford, and you are responsible” Ignoring this patient’s complaint, besides being bad for customer relationships, can cost the practice big. Why was there a copy to begin with? The practice was billing the well-woman visits as 99214, rather than The difference – being paid $69 vs. $109 Leaving $40 on the table for each visit. Moral of the story– learn from patient complaints, don’t be quick to dismiss them, and find a billing company that will help you, not hurt you. For this group of 5 OB/GYN – the estimated hit was in excess of $40,000 annually

26 Coding & Profiling  Coding patterns create the profile  Coding patterns will determine the “pay-for-performance” measures  Coding patterns will determine the inclusion or exclusion form “preferred” networks:  Aetna – Aexcel  United/Oxford Premium Designations  Cigna Care Network These networks are being created within the existing participation provider networks ▪ Patient is incentives to use – lower co-pays & recognition with “stars” in directories Robert E. Goff 26

27 ICD-9 Codes  Specificity  Use the 4 th and 5 th Digits where applicable  Additional disease – Is there an underlying cause that must be used with this diagnosis?  Always code left to right, underlining associated code with description.  DO NOT USE unspecified codes unless nothing else more appropriate exists Don’t let your office superbill dictate what diagnosis you use, consider writing out the diagnosis in full AND legibly so that your billing person will know which diagnosis to use. Keep medical necessity in mind. The diagnosis used should support the service(s) provided There is a huge difference in and in terms of medical necessity. GET READY FOR ICD-10

28 Modifiers Modifiers provide additional information about the services provided. There are many but these are most common to family practice. 24, -25, and -57 are all used to show that the CPT code they modify was a separate procedure and should not be bundled with other procedure codes or should not be limited because of a defined global fee period. **The complete list of modifiers is located in Appendix A of the CPT Code book. 24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period (make certain that you DO NOT show the diagnosis that is under the global period) 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. 57 Decision for Surgery

29 Now You Have Been Paid Your Done – Right? Wrong 6% of claim dollars are lost to payments less than the allowable Audit your payments Build a comparison chart Use an automated tool - RightRemit™

30 Money on the margin If you get paid 100% of billed – you may be leaving money on the table Plans pay the LOWER of the amount billed or the allowable fee If you don’t fill in the dollar amount on the claim, you will be paid -0- Robert E. Goff 30

31 Recovery Demands - Dispute “Just because we don’t have the right to offset a claim does not mean that we can’t ask for the money back. Physicians are expected to know their contract and the regulations” Loran Furbush, Oxford Just because you have been paid for a claim does not mean that you get to keep the money Payers are mining paid claims to see what they can find. Often by an outside commission based company. NYS Now requires that plans provide 30 days notice before a negative remit – Ignore at your own peril – Silence means consent Robert E. Goff 31

32 1.Bench Marking Model 2.Extrapolation Model 3.Percent of Revenue vs. Percent of Patient Visits 4.Percent of Revenue vs. Percent of Patient Model 5.Conversion Factor Model Strategic thinking – Who to grow with – Who to shrink from 32

33 33 Bench Marketing Model This is a review using the plan reimbursements for key and frequent CPT codes in comparison with your private schedule. As an alternative, you might use instead of your usual and customary fee schedule a comparison with current year Medicare. You can do this for the CPT codes on your super bill, for they should be your most frequent, or you can take a months worth of claims and use the volume from those to set your most frequent TypeCodePrivateOxfordAs % of privateAetna Aetna as a % of private Hosp Proc67038$4500$241454%250865% Cryopexy %101568% Lasers %101568% Laser %13389% Est pat %4256% Est Pat %4256% Consultation %6332% Consultation %6332% This review will provide a sense of how the payers are paying you in comparisons with your private fee schedule, or if you use Medicare instead of private, in comparisons with current year Medicare. The problem with this analysis is that there is no consideration as to your own volume. And without your actual volume, you maybe are putting too much emphasis on procedures or office visits.

34 34 Conversion Factor Model This is among the most sophisticated of the models, it brings the “value”, or the effort the physician puts into a payer down to the individual average payment per RVU, relative value units. However it is dependent upon the availability of information. You can build this chart using a conversion of each CPTs in the top 20% of codes into RVU units, then using the volume numbers for each CPT, divide by the total payments to identify the revenue that you receive from each payer on a RVU basis. CarrierTotal RVUsTotal Units/volumeTotal Payments Average Payment Per RVU Medicare $209227$29.14 United Vytra Health Net Oxford This then shows you clearly to what level you are being compensated for each element of effort using RVUs. Under this analysis the practice would do best to seek to grow Medicare and Health Net, and diminish Vytra and Oxford.

35 Official Disclaimer The information presented is for general information only and are not meant to substitute for legal advice. Always seek the advice of an attorney on legal matters. The presenter makes any recommendation as to an individual physician’s participation or non-participation with any specific health plans, insurance company or payer. Each physician is urged to give due and proper consideration to their own individual practice needs and act independently regardless of the actions or non-action of other physicians. Legal Guidance Misuse of the handouts, copy righted © material is subject to fine of $5000 per occurrence

36 Thank you - Robert E Goff


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