Showing posts with label billing. Show all posts

Monday, March 5, 2012

Proposed Rule Could Mean Trouble For Medical Practices


On February 16th, 2012 CMS posted on the Federal Registry a proposed rule that would extend the period they have to review any possible overpayments to 10 years. This new rule would implement a provision of the Affordable Care Act that is focused on identifying fraudulent activity. The current period is usually about 4 years. Extending it another 6 years could equate to huge trouble for providers.

FRAUD VS. BILLING ERROR

This new proposed rule is an attempt to enforce the False Claims Act. However, when looking back 10 years, practice management technology has changed drastically when compared to systems used widely today. Billing errors due to lack of “smart” PMs would have been a common occurrence, therefore, is it fair to go back 10 years when resources such as claims edit and claims scrubbing software were not so easily accessible to providers and their practices? Many of the claims found to be fraudulent under this new proposed rule could simply have been honest billing errors vs. an attempt to defraud CMS.

RECORD KEEPING

With this new rule, providers will be given a deadline to report and refund any overpayments which they themselves have identified. Ignoring this deadline will result in a large fine placed upon the provider. This now brings up another issue. Under Florida Law, providers need to keep a patient’s medical record for at least 5 years, but that’s it. There are some that will have these records for longer, however, when the law dictates that these should be keep for at least 5 years, how fair is this proposed rule going to be, when it’s asking for overpayments to be refunded on claims which are up to 10 years old? Additionally, with providers changing PMs frequently, it’s going to be very rare to find a practice that has had the same PM for 10 years straight.

The False Claims Act is supposed to be used to identify fraud not billing errors. With this new proposed rule, the chips are all stacked against the providers. They will not have the chance to dispute any of these supposed overpayments because most of the information is no longer accessible to them. If it passes it will be a financial disaster on small to medium sized practices whose biggest payor is Medicare. These practices will not have the financial means to be proactive in ensuring that these overpayments are disputed in time to avoid a financial penalty.



Tuesday, February 14, 2012

Potholes Continued - In Office Procedures

Having an airtight authorization process is extremely important in ensuring reimbursement for services provided in the office. Too often an in office procedure is done with out the correct verification and the services are denied for no authorization on file. However, understanding the patients' policy is also important. One important piece of advise I give  is, if your not sure if needs an authorization, just call and ask. At times, those online verification services are too vague when it comes down to services like injections, DME, fracture care, in office procedures, etc. Call the patient's healthplan and verify this. If you are told that an authorization is NOT needed, document a reference number and name. You may need this for an appeal if services are denied when the claim is processed. Other advise I give is:

VERIFY MEDICAL NECESSITY
This is often a step missed in the decision making process of an in procedure. Now, I don't expect the physician to stop what he's doing to verify if the services are medically necessary. However, someone in the office has to take this very important step. I can not stress this one enough. I small step can save your office a lot of trouble and money.

All insurance have their own guidelines for medical necessity. Take the time to explore the websites of all insurances accepted in your practice and located the policies of your most common services. Put these together in a clear and concise spreadsheet so it can be used as a reference. Too often this is not done and a practice finds themselves with a denial and no idea why. Only to find out after the fact that the diagnosis used does not support medical necessity.

VERIFY THE DEDUCTIBLE
Many times a patient's policy will have different deductibles. Today medical policies are so complex that it is very difficult to obtain all of these deductibles at the initial verification. One verifying whethere or not an authorization is needed you should also be asking if the patient has a deductible for these types of services.

COLLECT UP FRONT
Its unfortunate, but true, if you do not collect from the patient at the time of service, it is very likely that you will have a very difficult time after the fact. Collect an approximate out of pocket for the patient. If the procedure has an allowable of $214.00, and the patient has a deductible of $125.00 remaining, collect the $125.00. It's always better to give a refund than to have to chase a patient or pay a collection agency for their service.