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 to 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 “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.
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.
Recently, a group of commercial payers joined forces and formed the Healthcare Transformation 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 Health Insurance Portability and Accountability Act mandated the use of standardized electronic claims to improve the efficiency of a physicians’ healthcare claims submissions. The standardized 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:
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:
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.
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:
2014 CAQH Index™ Electronic Administrative Transaction Adoption and Savings, www.caqh.org/sites/default/files/explorations/index/report/2014Index.pdf
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:
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:
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.