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    8 Ways to Improve Patient Collections

    This entry was posted in Blog on
    June 14th, 2017

    You didn’t go to medical school to bill healthcare claims. Your skills are best used caring for patients, treating illnesses, and performing surgeries. However, your practice must have money copayto run smoothly. Improving patient collections is what MPMR does best! Here are 8 ways to improve patient collections.


    No. 1: Collect Upfront


    We work with your front office staff to collect as much upfront as possible. The out-of-pocket expenses for patients is no longer just a small portion of the bill. Many high deductible policies require patients to pay $3,000 to $5,000 before the physician gets paid. It is not uncommon for fully insured patients to owe a portion or all the total bill. Collections before procedures and surgeries will save your practice the expense of billing and collection calls afterwards.


    No. 2: Be Polite but Firm


    Discuss the bill with the patients, and tell him/her what must be paid before the surgery. The best policy is to be polite but firm. The billing department can educate patients on their contractual coverage, and explain the insurance policy, which is a contract between the insuring party and the insured party. Certain financial obligations are dictated in this contract.


    No. 3: Obtain Physician Support


    Before procedures or pre-surgery office visits, the physician should not advise the patient to medical billing company“not worry about the bill until after the surgery.” This can cause misunderstandings on how fees are to be collected. To prevent this, discuss fee-up-front policies with the physicians in the practice.


    No. 4: Determine Deductive Levels


    The amount owed on the deductible varies, relating to services the patient has paid for and what is not been paid. The deductible amount may be determined by contacting insurer, as some patients will insist that they have paid more than the insurer has reported. Office staff can allow patients to bring in receipts showing payments have been made, but should contact the billing office to verify payment postings.


    No. 5: Educate Patients concerning Co-Insurance Estimates


    When medical billing specialists provide patients with an estimate of how much co-insurance they may owe, they should explain that the final amount can differ from the estimate. The co-insurance is the patient’s share of the total bill, and it is usually shown as a percentage. Educate patients before surgery, procedures, treatments, or services, so they will be no confusion when the final bill arrives.


    No. 6: Set up a Payment Plan


    When patients cannot pay the full amount of the deductive, or the co-pay, before treatment, services, or surgery, the billing professional can suggest a short-term payment plan. This is usually around 90 days, or three monthly payments. High-deductible policies have made it necessary to make these payment plan arrangements. Monthly payments are often made through checking accounts, debit cards, or credit cards, and the plan should include an initial down payment.


    No. 7: Use a Healthcare Credit Company


    Healthcare credit companies pay the provider the full amount (minus a fee) before the service or right afterwards. The patient pays back this loan through an established payment plan. Many patients on a fixed income level will need this service to have certain procedures and surgeries.


    No. 8: Use a Promissory Note


    As a last resort, the office staff can have the patient sign a promissory note, and pay the facility as they are able. If possible, collect a down payment before surgery. Most billing facilities do not charge interest, as they do not want the physician office to look like a commercial banking institute.


    What is Value-Based Reimbursement?

    This entry was posted in Blog on
    June 14th, 2017

    A Value-Based Payment Modifier, also called a Value Modifier, provide for differential payment to a provider, or group of physicians, under the Medicare Physician Fee Schedule (PFS). The Value Modifier is based on the quality of care given compared to the cost of care during a performance period.


    The Value-Based Modifier is an adjustment made to all Medicare payments regarding services and items under the PFS. Beginning in 2018, it is applied to certain non-physician eligible professionals who bill under the Taxpayer Identification Number (TIN), as well as being applied at the TIN level to physicians.


    CMS, MSSP, and the Bundled Payments for Care Program Initiative


    The Centers for Medicare and Medicaid Services (CMS) began moving toward value-based reimbursements (VBRs) in 2006. The CMS introduced the Physician Quality Reporting System (PQRS), which offered incentives to physicians and other providers for reporting on quality measures. This incentive is 2% of estimated total allowed charges for covered Medicare Part B Physician Fee Schedule (PFS) services. In 2015, negative payment adjustments replaced the incentive payment plan. Over the past 10 years, there has been a shift from fee-for-service (FFS) to value-based reimbursement.


    CMS also has introduced the Medicare Shared Savings Program (MSSP), which allows providers to share losses and savings (relative to established benchmarks) related with identified Medicare beneficiary populations. CMS started accepting applications from physicians to participate in the Bundled Payments for Care Program Initiative in 2011. This program gave a set reimbursement amount for a defined episode of care, and it encouraged physicians to focus on the most beneficial cost-effective care. According to CMS, 85% of Medicare FFS payments are linked to value and quality. In addition, 20% of Medicare payments are based on an alternative delivery method.


    Commercial Payers


    Recently, a group of commercial payers joined forces and formed the Healthcare aetnaTransformation Task Force. This organizations plans to have 75% of their businesses operating under VBR models by the year 2020. Included in this is Aetna, Blue Cross Blue Shield of Massachusetts, Ascension Health, Partners HealthCare, Trinity Health, Providence Health & Services, Advocate Health Care, and Dignity Health.


    In 2014, the Catalyst for Payment Reform found that 40% of all commercial in-network payments were value-oriented, which mean they were either related to performance or designed to eliminate waste. The other 60% were traditional FFS, capitated or partially capitated methods, and bundled payments. Capitated and bundled payments are tied to quality, so the total percentage of commercial payments linked to quality is around 55% or more.


    Claiming Your Earnings and VBR


    What drives a healthcare organization to seek population health management solutions is a revenue issue. When reimbursement is down, problems occur with staffing, purchasing, and other financial aspects of the facility. Revenue problems are often created by a shift to value-based payment models. The shift can affect the organizations revenue by:


    • The PQRS program reduces FFS payments by 2% for not reporting quality measurements on Medicare populations.
    • The impact of the value-based modifier includes increases in payment for low-cost, high-quality providers by around 5%, and reduction for others around 1%.
    • Most P4P programs involve financial incentives that depend on the meeting or exceeding of quality measurement thresholds.
    • Bundled payments cap a hospital, provider, or organization’s revenue for certain procedures and services. Successful bundled payment methods can increase capacity, volume, revenue, and margin.
    • Global risk (partial or full capitation) is a logical extension of a shared savings program. This allows for more responsibility on the organization to manage certain populations, promote primary care, and deliver appropriate care to improve outcomes, reduce cost of care, and maintain the population health.
    • Shared savings programs usually represent upside risks, but successful execution can lead to significant bonus payments to the healthcare organization.

    Making Electronic Claims More Efficient

    This entry was posted in Blog on
    June 14th, 2017

    The Health Insurance Portability and Accountability Act mandated the use of standardized electronic claims to improve the efficiency of a physicians’ healthcare claims submissions. The doctor_computerstandardized electronic claim has been widely adopted in the industry, with more than 92% of health plans and providers using this by 2013. Health plans and physicians recognize the importance of electronic claims submission for the efficiency, speed, and accuracy of claim processing.


    Before Claim Submission


    The American Medical Association (AMA) has proposed certain guidelines for submitting electronic claims. The following steps will assure successful claims submissions:


    • Verify patient eligibility – Before the scheduled office visit, you should verify if the insurance is valid, and if or not the patient can receive the treatment or service. The physician cannot obtain payment if the patient’s insurance coverage has lapsed, or if the service or procedure is not covered by the plan. This involves checking eligibility before for every patient appointment.


    • Complete prior authorization – When the patient is eligible for the treatment or service, the physician’s clams may be denied if the office staff does not obtain prior authorization. This requires sending necessary documentation and reason for the service to the health plan for approval.Top Medical Billing Companies


    • Provide quality documentation – For a successful claim, the physician should adequately support the services with clinical documentation. This is used to justify the level of service coded and billed to the health insurance plan. Quality documentation helps maximize practice revenue and enables the physician to establish the need for much higher service levels.


    • Be aware of deadlines – To receive proper reimbursement in a timely fashion, the practice and billing specialists should be aware of all deadlines regarding health plan claim submission.


    • Provide accurate data entry – The medical practice should take necessary steps to avoid data entry errors. Basic data entry errors during the registration process can mean claim denials. Errors in insurance member numbers or patient demographics could necessitate data recollection, re-entry, and resubmission.


    Tips for Successfully Completing the Claims Process


    Regarding claim submission, there are things you can do to ensure successful completion of the electronic claims process. This facilitates efficient billing. According to the AMA, you should:


    • Code with maximum specificity and accuracy – This involves correct and optimal use of ICD-10 and CPT codes, which ensures proper payment for all services provided. The practice can obtain further information about ICD-10 codes, which were recently put in effect.


    • Compare appointment schedule to claims – The physician practice could easily

    overlook a particular patient service when billing. For each of the patients, the billing specialist should reference the appointment schedule, which enables staff to make sure all services performed were submitted to the health plan for payment.


    • Include claims attachments – As a medical practice becomes familiar with a certain health plan’s policies and requirements, staff members become aware of the standard documentation requests related to individual procedures. The billing specialist can speed up the claim process by submitting attachments with documentation at the time of the claim submission.


    Follow-Up on Electronic Claims


    After a physician practice has submitted a billing claim, there is still some work to be done. Physician practices and billing specialists will take additional steps to maximize efficiency by:


    • Utilizing pre-audit/claim scrubbing services – Many practice management system vendors and clearinghouses offer pre-audit (claim scrubbing” capabilities. These services find errors before the claim is accepted into a health plan’s adjudication system. These services allow the practice to rework errors and prevent payment delays.


    • Track submitted claims using status request transaction – Regarding electronic claims, the practice can acknowledge the transaction to confirm the claim has been received. Practices will know when the health plan pays, rejects, or holds a claim.

    2014 CAQH Index™ Electronic Administrative Transaction Adoption and Savings, www.caqh.org/sites/default/files/explorations/index/report/2014Index.pdf



    The Issue of Overpayments and How to Handle Them

    This entry was posted in Blog on
    June 14th, 2017

    When extra money shows up when you are doing the laundry, it’s an unexpected good thing. You may not always remember how it got there, but it is yours now that you found it. However, when extra money comes from billing, and you have no idea how it got there, it is an issue of overpayment. According to the Office of Inspector General (OIG), billing companies must institute procedures that provide for accurate and timely reporting to both the healthcare program of overpayments and the provider who receives the money.


    The federal government maintains that when a provider/office receives money to which they are not entitled the billing company should find the proper owner and assist in the return of the money. Processing and returning overpayments is not optional, and this is a federal mandate. If not handled right, overpayments will create costly issues for the billing company and the provider.


    What is the Cause?


    Medical billing personnel should first look at why overpayments happen, and what should be done to handle them. There are four common contributors to overpayments: the healthcare provider, the patient, the billing company, and the payer. Any or all can contribute to the overpayment process. Causes include:


    • Using incorrect contract payment rates
    • Miscalculating deductibles
    • Use of incorrect patient demographics
    • Applying claims to the wrong account
    • Receiving duplicate payments
    • Using incorrect contract payment rates


    In today’s healthcare industry, payments often end up dumped together in a large electronic pile. Therefore, overpayments are hard to identify and process, especially with the constant pressure to get new payments posted, new billing statements issues, and new claims processed. The “new work” is often the reason a billing company misses the overpayment.


    Identifying and Returning Overpayments


    The OIG has issued specific compliance guidelines for medical billing companies. The billing party is responsible for identifying and assisting clients return overpayments. In addition, billing personnel work with the providers and healthcare facilities to investigate anything known to be amiss. In the evidence of misconduct, such as an unreported overpayment, the OIG says to:


    • Refrain from submitting claims that are questionable.
    • Notify the client in writing within 30 days of the questionable payment receipt.
    • Work with the client to resolve the misconduct.
    • Refrain from submitting inappropriate claims.


    The Affordable Care Act was passed in 2010, creating an express duty that healthcare providers report and return any and all overpayments received from the Medicare or Medicaid programs. This was to be done within 60 days from the date of the overpayment. In 2016, the Centers for Medicare & Medicaid Services (CMS) published the “Final Rule” to clarify the 60-Day Rule. The Final Rule stats that an overpayment has not been identified until the supplier/provider/facility has determined evidence of an overpayment. CMS believes reasonable diligence includes proactive compliance activities by billing professionals as well as timely investigations made in response to the overpayment.


    The False Claims Act and Fraud and Enforcement Recovery Act


    Overpayment reporting typically first falls to the provider or healthcare facility. If the provider does not act, a billing company has the responsibility. According to the False Claims Act, any person or group who knowingly causes or presents a false claim can be held liable. The liability is imposed for presentment of a claim, without having any proof of awareness by the submitting party.


    With the Fraud and Enforcement Recovery Act of 2009 (FERA), the legislation expanded and eliminated the requirement for intent to be established. FERA proposes with a “reverse false claims provision” that a third-party billing company has knowledge of an overpayment, the decision to continue working with the client who does not issue refunds could be called “knowingly and improperly avoiding or decreasing an obligation to refund monies.” The billing company may be implicated regarding overpayments if billers fail to make the client aware or address the problem.