Many changes either taking effect in 2013 or requiring preparation in 2013 for implementation in 2014 can have a huge financial impact on the health of your practice. Are you ready? This is the time to take stock of the resources you already have and those which you will need to consider.

Medicaid Reimbursement

With a new influx of lives being added to the Medicaid pool of patients, many PCP and Internists are going to see a large increase of new patients. So in order to compensate physicians for the new workload, fees for evaluation and management services as well as immunization services will be increased to 100% of Medicare allowables for 2013 and 2014.

Supply and Demand

With more patients being added to our system, due to the individual mandate and the increase of Medicaid qualified individuals, some physicians will see a heavier load of patients in their practice. Adding the fact that many of these patients are new to the system and therefore will require more work, practices need to have a plan in place as to how they will be adapting.

OIG 2013 Work Plan

The OIG will be taking a close look at claims from 2002 to 2011 billed with G modifiers (GA, GY, GX and GZ) to determine erroneous payments issued to physicians. These modifiers are used by practice when submitting claims to Medicare, indicating that a denial is expected for these services. However, in a review performed by the OIG, they found that a significant amount of claims submitted with these modifiers were paid in error. There is potentially $4 million of erroneous payments.

ICD-10

What was to be an effective date of October 1, 2013 has now been extended to October 1, 2014. However, practices will need start preparing for the changes soon or at least have an implementation plan in place. Many practices will wait until the last minute to start the planning and preparation because the deadline may once again be extended. However, with the complexity of the new coding system, there are certain areas that your practice may want to consider preparing, to aid in a smoother transition.

So what do these four issues have in common? They all have a potential to impact your practice financially. Too often medical practices choose to ignore changes to the until it is too late. The time to prepare your practice is now.

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.