Medicare Appreciation Month
by Marcy Riviezzo and AJ Riviezzo
Unless we have completely scarred you off from seeing Medicare patients, January is a good month for treating your Medicare patients. The reason for this is deductibles. Your commercial patients have typically just entered their new deductible cycle for the year. They may be reticent to begin treatment on something that is a bit elective. Medicare members typically have a secondary policy that absorbs their small deductible.
Reach out to your referring PCP's. Let them know that January is your Medicare appreciation month. It is an 'excuse' to re-market to these physicians, their office manager, and their referring coordinator.
Also reach out to your existing patients and database. Send a letter to all of your current and former Medicare patients thanking them for having chosen your practice for receiving their care. In it you can mention it is Medicare Appreciation Month and that you would be happy to meet their friends or neighbors if they have a need for your services. You might offer them a $10 gift card (see above limitations) for any of their referrals as a further thank you.
Finally, there are likely some retirement communities in your area. Find out if they have a physician day or similar program in which you can participate. Spend an hour or two explaining venous disease and answering the communities questions. You can bring a portable ultrasound machine and show how it works by using a volunteer. This type of outreach has proven very successful for a number of practices.
Tuesday, December 14, 2010
Free Screenings
Federal Anti-Kickback Laws
by AJ Riviezzo, MBA
Our last email contained information regarding ZPIC audits. This generated a discussion with Dr. Calcagno regarding potential concerns with performing free screenings on federal health care program patients (Medicare, Medicaid, TriCare, CHAMPUS, VA, CHP or Indian Health Service). It turns out there is some cause for concern. The Office of the Inspector General (OIG) is potentially concerned with free screenings as it may constitute an impermissible kickback to the patient.
The OIG does allow a nominal incentive to be given. The nominal value is typically set at $10.00 per item or $50 total per year per 65 Fed. Reg. 24400, 24410-24411 dated April 26, 2000. A pretty low value which I am sure has not been adjusted for inflation.
Our recommendation is to establish a value for your 'education services' at $10.00. In essence, that is what the free consultation is... education services. You are providing a small bit of information about the underlying issues and current treatment methodologies for their possible condition. As a matter of course, you adjust these services down to zero for all patients.
A thank you to Dr. Calcagno for creating such an interesting discussion.
by AJ Riviezzo, MBA
Our last email contained information regarding ZPIC audits. This generated a discussion with Dr. Calcagno regarding potential concerns with performing free screenings on federal health care program patients (Medicare, Medicaid, TriCare, CHAMPUS, VA, CHP or Indian Health Service). It turns out there is some cause for concern. The Office of the Inspector General (OIG) is potentially concerned with free screenings as it may constitute an impermissible kickback to the patient.
The OIG does allow a nominal incentive to be given. The nominal value is typically set at $10.00 per item or $50 total per year per 65 Fed. Reg. 24400, 24410-24411 dated April 26, 2000. A pretty low value which I am sure has not been adjusted for inflation.
Our recommendation is to establish a value for your 'education services' at $10.00. In essence, that is what the free consultation is... education services. You are providing a small bit of information about the underlying issues and current treatment methodologies for their possible condition. As a matter of course, you adjust these services down to zero for all patients.
A thank you to Dr. Calcagno for creating such an interesting discussion.
Diagnosis Coding
A New Delay Scenario
by Cheryl Nash and AJ Riviezzo
When coding (diagnosis) for a diagnostic ultrasound and new patient visit, we recommend coding with the patient's presenting complaints and symptoms. For example, if the patient has swelling of the legs as well as pain in the legs then you would use the ICD-9 codes for these two elements (729.81 and 729.5 respectively). After you have reviewed the patient's condition and made a medical diagnosis you then begin using a more comprehensive diagnosis like Varicose Veins of Lower Extremities with Other Complications of Edema, Pain and Swelling (454.8).
United Healthcare and payers who use Ingenix as their data source for coding are now beginning to hold any claims with a primary diagnosis of Pain in Limb (729.5). They are automatically generating a letter to the patient as if the patient was in an accident. The patient is supposed to note the accident date and time and return the form. Since there was no accident, many of the patients are disregarding the letter. Throughout this process, your claim remains unpaid. I do remember when automation was supposed to help drive down health care costs...
We are, therefore, recommending a primary diagnosis (should the patient have these symptoms) of venous insufficiency (459.81) with pain in limb being your secondary or tertiary diagnosis. This will help ensure your claim is paid in a timely fashion without the delays associated with an accident investigation.
by Cheryl Nash and AJ Riviezzo
When coding (diagnosis) for a diagnostic ultrasound and new patient visit, we recommend coding with the patient's presenting complaints and symptoms. For example, if the patient has swelling of the legs as well as pain in the legs then you would use the ICD-9 codes for these two elements (729.81 and 729.5 respectively). After you have reviewed the patient's condition and made a medical diagnosis you then begin using a more comprehensive diagnosis like Varicose Veins of Lower Extremities with Other Complications of Edema, Pain and Swelling (454.8).
United Healthcare and payers who use Ingenix as their data source for coding are now beginning to hold any claims with a primary diagnosis of Pain in Limb (729.5). They are automatically generating a letter to the patient as if the patient was in an accident. The patient is supposed to note the accident date and time and return the form. Since there was no accident, many of the patients are disregarding the letter. Throughout this process, your claim remains unpaid. I do remember when automation was supposed to help drive down health care costs...
We are, therefore, recommending a primary diagnosis (should the patient have these symptoms) of venous insufficiency (459.81) with pain in limb being your secondary or tertiary diagnosis. This will help ensure your claim is paid in a timely fashion without the delays associated with an accident investigation.
Tuesday, November 16, 2010
Review the Payer Guidelines
Knowledge is Essential
by Cheryl Nash and AJ Riviezo
Most commercial insurances and Medicare have clinical guidelines they review one to two times per year. It is essential that you are operating under the most current guidelines. As the United example shows, the changes can be dramatic and result in denials.
One way to ensure you are reviewing your top payers on a regular basis is to see if they have a 'Next Review Date' listed on the current guidelines. You can place a note on your calendar to go to that payer's guidelines and see if there is a new publication of the guideline or if the date has been changed. Key elements to review are changes in documentation requirements, changes in medical necessity requirements, and changes in conservative therapy. Be sure to read the fine print. Sometimes the changes are in the addendums or are a few words hiding in the middle of what appears to be an unchanged paragraph.
by Cheryl Nash and AJ Riviezo
Most commercial insurances and Medicare have clinical guidelines they review one to two times per year. It is essential that you are operating under the most current guidelines. As the United example shows, the changes can be dramatic and result in denials.
One way to ensure you are reviewing your top payers on a regular basis is to see if they have a 'Next Review Date' listed on the current guidelines. You can place a note on your calendar to go to that payer's guidelines and see if there is a new publication of the guideline or if the date has been changed. Key elements to review are changes in documentation requirements, changes in medical necessity requirements, and changes in conservative therapy. Be sure to read the fine print. Sometimes the changes are in the addendums or are a few words hiding in the middle of what appears to be an unchanged paragraph.
ZPIC Audits
Is Phlebology Being Targeted?
by AJ Riviezzo, MBA
The new Zone Program Integrity Audits (ZPIC), which have been in the making for several years, have really begun to be conducted over the past three months. The goal of these audits is to detect fraud and abuse in Medicare claims. These audits are being done by sub-contractors on behalf of the Medicare Administrative Contractors (MAC). It also appears that these several sub-contractors are paid only on the 'found' dollars. This lends serious concerns regarding their processes and the neutrality of the review.
Further, the rules (like those surrounding the RAC audits) were never formalized by Congress. This is allowing the ZPIC sub-contractors to devise their own rules and regulations regarding the process. These rules are certainly not provider friendly to date. It has also created a significant variance between Zones on how these audits are being conducted. In one area it appears they are being treated much like the RAC audits with thirty charts being reviewed on a retrospective review. In another area, ALL claims are being reviewed with payments being denied prospectively, with virtually no feedback as to the reason why save the standard Medicare denial codes.
Attempts to gain further information have, to date, been difficult. One phlebology provider has basically been told that it is not the ZPIC contractor's responsibility to 'educate' the provider, and yet they are still holding essentially all payments prospectively. Thankfully this provider has a relatively small percentage of Medicare patients as part of their payer mix. For a provider with a large Medicare mix, this is tantamount to a forced closure.
Is phlebology being targeted? The author cannot state that it is. However, two phlebology practices are already in review that we know about. Given the small number of providers in review by these ZPIC contractors and given the even smaller percentage of all providers that perform ablations, it does give one serious pause for concern.
So what is a practice to do proactively? First, we recommend that you re-read your Local Coverage Determinations (LCD) regarding phlebology services for your area. Make sure your patients are meeting the medical necessity requirements outlined in the LCD.
Second, the LCD may also have documentation requirements that are specifically required on each chart or operative note. Please review your documentation against these requirements. You may also want to have an external agency conduct a chart-to-bill, bill-to-chart audit. Yes, you can do these on your own but it is a bit like proof-reading your own work. An outside eye will not overlook 'assumed' elements.
What are the next steps should your practice be contacted by ZPIC? The request from ZPIC will be for copies of your charts. We recommend sending, as quickly as possible, the copies requested. Typically they are requesting for a specific date of service. We recommend sending all of the documentation necessary for that specific date (e.g. Diagnostic Ultrasound, History and Physical, Operative Note, any other documentation). If they request records for multiple dates of service, send the same type of packet for each date of service. Do not assume they will copy the Diagnostic Ultrasound and attach it to each date of service. They will not do so. We also suggest that you immediately contact an attorney in your area with some ZPIC or at least RAC audit experience.
Now to the vaguely good news. Once ZPIC has denied your claims (recent experience shows a denial rate of over 95%), you can then appeal these denials through the Medicare system. Medicare has five levels of appeal that can be attempted. These are:
1. Redetermination. This goes through MAC and is basically to keep the claims open for additional appeal processes. On the average 50% of claim denials are overturned at this stage.
2. Reconsideration. These appeals go through a completely different department, usually a Physician panel, for review. These reviewers do not work for Medicare or the ZPIC contractor, and are not paid by the denial. (this is a completely independent review team).
3. Administrative Law Judge Hearing. Established for any outstanding claims over $130.00. This stage allows for a teleconference with a legal entity to discuss the medical necessity of the services, and functions like a peer-to-peer review. There is a high level of success at this stage of appeals.
4. Medicare Appeal Council Review. This is an independent team of professionals tasked with reviewing the decision made by the ALJ panel. Any contested issues found in the ALJ hearing will be reviewed here.
5. District Court. Established for any claims over $1260.00. You may request a review in district court.
The encouraging news is that at the 3rd level of appeal, if a physician's services may not have exactly met criteria set forth by the MAC, the claims may still be considered for payment if the physician is able to state, in a concrete fashion, as to why the services were necessary and prudent.
In short, these ZPIC audits are looking to be both unpleasant and expensive with few guidelines that are required to be followed. It appears the assumption is that fraud has been committed unless proven otherwise. Review your documentation, medical necessity assumptions, and the Local Coverage Determinations soon.
by AJ Riviezzo, MBA
The new Zone Program Integrity Audits (ZPIC), which have been in the making for several years, have really begun to be conducted over the past three months. The goal of these audits is to detect fraud and abuse in Medicare claims. These audits are being done by sub-contractors on behalf of the Medicare Administrative Contractors (MAC). It also appears that these several sub-contractors are paid only on the 'found' dollars. This lends serious concerns regarding their processes and the neutrality of the review.
Further, the rules (like those surrounding the RAC audits) were never formalized by Congress. This is allowing the ZPIC sub-contractors to devise their own rules and regulations regarding the process. These rules are certainly not provider friendly to date. It has also created a significant variance between Zones on how these audits are being conducted. In one area it appears they are being treated much like the RAC audits with thirty charts being reviewed on a retrospective review. In another area, ALL claims are being reviewed with payments being denied prospectively, with virtually no feedback as to the reason why save the standard Medicare denial codes.
Attempts to gain further information have, to date, been difficult. One phlebology provider has basically been told that it is not the ZPIC contractor's responsibility to 'educate' the provider, and yet they are still holding essentially all payments prospectively. Thankfully this provider has a relatively small percentage of Medicare patients as part of their payer mix. For a provider with a large Medicare mix, this is tantamount to a forced closure.
Is phlebology being targeted? The author cannot state that it is. However, two phlebology practices are already in review that we know about. Given the small number of providers in review by these ZPIC contractors and given the even smaller percentage of all providers that perform ablations, it does give one serious pause for concern.
So what is a practice to do proactively? First, we recommend that you re-read your Local Coverage Determinations (LCD) regarding phlebology services for your area. Make sure your patients are meeting the medical necessity requirements outlined in the LCD.
Second, the LCD may also have documentation requirements that are specifically required on each chart or operative note. Please review your documentation against these requirements. You may also want to have an external agency conduct a chart-to-bill, bill-to-chart audit. Yes, you can do these on your own but it is a bit like proof-reading your own work. An outside eye will not overlook 'assumed' elements.
What are the next steps should your practice be contacted by ZPIC? The request from ZPIC will be for copies of your charts. We recommend sending, as quickly as possible, the copies requested. Typically they are requesting for a specific date of service. We recommend sending all of the documentation necessary for that specific date (e.g. Diagnostic Ultrasound, History and Physical, Operative Note, any other documentation). If they request records for multiple dates of service, send the same type of packet for each date of service. Do not assume they will copy the Diagnostic Ultrasound and attach it to each date of service. They will not do so. We also suggest that you immediately contact an attorney in your area with some ZPIC or at least RAC audit experience.
Now to the vaguely good news. Once ZPIC has denied your claims (recent experience shows a denial rate of over 95%), you can then appeal these denials through the Medicare system. Medicare has five levels of appeal that can be attempted. These are:
1. Redetermination. This goes through MAC and is basically to keep the claims open for additional appeal processes. On the average 50% of claim denials are overturned at this stage.
2. Reconsideration. These appeals go through a completely different department, usually a Physician panel, for review. These reviewers do not work for Medicare or the ZPIC contractor, and are not paid by the denial. (this is a completely independent review team).
3. Administrative Law Judge Hearing. Established for any outstanding claims over $130.00. This stage allows for a teleconference with a legal entity to discuss the medical necessity of the services, and functions like a peer-to-peer review. There is a high level of success at this stage of appeals.
4. Medicare Appeal Council Review. This is an independent team of professionals tasked with reviewing the decision made by the ALJ panel. Any contested issues found in the ALJ hearing will be reviewed here.
5. District Court. Established for any claims over $1260.00. You may request a review in district court.
The encouraging news is that at the 3rd level of appeal, if a physician's services may not have exactly met criteria set forth by the MAC, the claims may still be considered for payment if the physician is able to state, in a concrete fashion, as to why the services were necessary and prudent.
In short, these ZPIC audits are looking to be both unpleasant and expensive with few guidelines that are required to be followed. It appears the assumption is that fraud has been committed unless proven otherwise. Review your documentation, medical necessity assumptions, and the Local Coverage Determinations soon.
United Health Care Update
Positive Change for Once
by Cheryl Nash and AJ Riviezzo
United Health Care, effective October 25th, 2010, has again revised their medical policy guidelines for ablations. The submission of color photographic prints is no longer required. Also, the submission of US prints is no longer required. It appears their system could not handle the massive amount of data they were receiving thus forcing a change.
The best news coming out of the new policies is that compression stockings are no longer required as a part of conservative treatment. A completed questionnaire addressing the degree and severity of pain still must be submitted for authorization. This questionnaire can be found at: https://www.unitedhealthcareonline.com
The bad news is that diameter sizes have not changed... it is still 5.5mm for GSV, 5mm for SSV. Only one measurement is required. If bleeding or ulceration is present vein sizes of a lower diameter will be accepted.
Perforator size for treatment has dropped to 3.5mm. Additionally, the notes must document the presence of venous stasis ulceration for laser or RF ablation of the perforator.
There are some other requirements so please read the policy for some of the various nuances.
by Cheryl Nash and AJ Riviezzo
United Health Care, effective October 25th, 2010, has again revised their medical policy guidelines for ablations. The submission of color photographic prints is no longer required. Also, the submission of US prints is no longer required. It appears their system could not handle the massive amount of data they were receiving thus forcing a change.
The best news coming out of the new policies is that compression stockings are no longer required as a part of conservative treatment. A completed questionnaire addressing the degree and severity of pain still must be submitted for authorization. This questionnaire can be found at: https://www.unitedhealthcareonline.com
The bad news is that diameter sizes have not changed... it is still 5.5mm for GSV, 5mm for SSV. Only one measurement is required. If bleeding or ulceration is present vein sizes of a lower diameter will be accepted.
Perforator size for treatment has dropped to 3.5mm. Additionally, the notes must document the presence of venous stasis ulceration for laser or RF ablation of the perforator.
There are some other requirements so please read the policy for some of the various nuances.
Friday, October 22, 2010
PAD Requirements
A Growing Trend
by Cheryl Nash and AJ Riviezo
Some payers are requiring a rule out of peripheral artery disease to be contained in the history and physical prior to granting an authorization. One way to add this element is through a pedal pulse examination. Another is to have your RVT (or you as the case may be) perform an ultrasound peripheral arterial examination. The codes for these studies are 93925 bilaterally and 93926 for a single leg examination. The relevant diagnosis code is 459.81 - venous insufficiency.
One concern to consider is the amount of time each patient will be spending prior to any real treatment if you couple an ultrasound arterial examination with a venous examination and the history and physical. Some patients may not be willing to spend that much time being 'worked up'. Discussing the reasons for the amount of time and what each elements helps determine will assist in alleviating this concern.
by Cheryl Nash and AJ Riviezo
Some payers are requiring a rule out of peripheral artery disease to be contained in the history and physical prior to granting an authorization. One way to add this element is through a pedal pulse examination. Another is to have your RVT (or you as the case may be) perform an ultrasound peripheral arterial examination. The codes for these studies are 93925 bilaterally and 93926 for a single leg examination. The relevant diagnosis code is 459.81 - venous insufficiency.
One concern to consider is the amount of time each patient will be spending prior to any real treatment if you couple an ultrasound arterial examination with a venous examination and the history and physical. Some patients may not be willing to spend that much time being 'worked up'. Discussing the reasons for the amount of time and what each elements helps determine will assist in alleviating this concern.
Marketing Thought...
Lunch and Learn with Bariatric Surgeons
by AJ Riviezzo, MBA
When establishing your referral base of physicians, one specialty niche to consider targeting is bariatric surgeons. Patients who receive lap band and other bariatric surgeries frequently have venous insufficiency surface as an issue. Their weight issues were masking the signs and symptoms until they have lost a sufficient amount of weight. A course of stockings to meet conservative therapy guidelines may be required as many of these patients have likely not been wearing compression stockings.
There are some bariatric surgeons who also dabble in phlebology so please ensure you are not marketing to a competitor.
by AJ Riviezzo, MBA
When establishing your referral base of physicians, one specialty niche to consider targeting is bariatric surgeons. Patients who receive lap band and other bariatric surgeries frequently have venous insufficiency surface as an issue. Their weight issues were masking the signs and symptoms until they have lost a sufficient amount of weight. A course of stockings to meet conservative therapy guidelines may be required as many of these patients have likely not been wearing compression stockings.
There are some bariatric surgeons who also dabble in phlebology so please ensure you are not marketing to a competitor.
Quick Information Regarding Ablation of Other Elements
Quick Information Regarding Ablation of Other Elements
by AJ Riviezo, MBA
We are frequently asked if one can perform an RF or laser ablation for a tributary, anterior accessory or perforator - and receive payment for the work.
The answer is, like most everything regarding insurance, perhaps.
First, the vein to be ablated must meet the minimum guidelines that are in place by the payer for the saphenous veins. For example, they may require the vein to be at least 3mm in diameter, showing evidence of reflux, and the patient has to have met conservative treatment guidelines.
Second, please note that many payers believe this procedure should be performed concurrently with an ablation of the saphenous vein. The codes for a second insertion/ablation are 36476 and 36479 for RF or laser. You should have a progress note stating why the patient needs this ablation versus alternative treatment, and why you are recommending this to be a staged procedure.
Next, should you determine that there is a need to stage the procedure and not perform it during the ablation of the saphenous vein, we recommend reviewing the patient insurance carrier's guidelines regarding ablations. Some, like Anthem Blue Cross/Blue Shield, are very clear that they will not authorize the service. Their guidelines note usage of sclerotherapy to resolve these issues after an ablation of the saphenous vein. You will not have to review these guidelines every time but we do recommend reviewing them at least quarterly to check for any changes. Some payers, like Blues of Illinois, changes their guidelines at least once per year.
If you have an authorization (if required), the CPT code used for these ablations is the same as for a saphenous ablation - 36475 for RF ablation and 36478 for laser ablation. Documentation of the procedure is essentially the same save for noting as to why this is a staged procedure.
by AJ Riviezo, MBA
We are frequently asked if one can perform an RF or laser ablation for a tributary, anterior accessory or perforator - and receive payment for the work.
The answer is, like most everything regarding insurance, perhaps.
First, the vein to be ablated must meet the minimum guidelines that are in place by the payer for the saphenous veins. For example, they may require the vein to be at least 3mm in diameter, showing evidence of reflux, and the patient has to have met conservative treatment guidelines.
Second, please note that many payers believe this procedure should be performed concurrently with an ablation of the saphenous vein. The codes for a second insertion/ablation are 36476 and 36479 for RF or laser. You should have a progress note stating why the patient needs this ablation versus alternative treatment, and why you are recommending this to be a staged procedure.
Next, should you determine that there is a need to stage the procedure and not perform it during the ablation of the saphenous vein, we recommend reviewing the patient insurance carrier's guidelines regarding ablations. Some, like Anthem Blue Cross/Blue Shield, are very clear that they will not authorize the service. Their guidelines note usage of sclerotherapy to resolve these issues after an ablation of the saphenous vein. You will not have to review these guidelines every time but we do recommend reviewing them at least quarterly to check for any changes. Some payers, like Blues of Illinois, changes their guidelines at least once per year.
If you have an authorization (if required), the CPT code used for these ablations is the same as for a saphenous ablation - 36475 for RF ablation and 36478 for laser ablation. Documentation of the procedure is essentially the same save for noting as to why this is a staged procedure.
Monday, August 30, 2010
United Healthcare Authorization Process Update
More Requirements by UHC
by Cheryl Nash and AJ Riviezo
Over the past few weeks we have obtained further clarification from Dr. Jeff Mason, Senior Medical Director for United Healthcare (UHC). One of the key questions needing clarification was "pictures of what exactly?". UHC, per Dr. Mason, would like to receive the following from the diagnostic duplex ultrasound:
1) Images (black and white, or color) that show the anatomy and size of the vein at sections relevant to the case. These images can be submitted in hard-copy prints, or, preferably, in a digital file. We do not need a record of the entire exam --- several "snapshots' are enough.
2) We need speed and direction of blood flow information, either from a color doppler print(the colors represent direction and speed of flow) or locations (denoted by cursors) where flow readings were taken.
3) We need a report of the exam including results of the above size of vein and degree and timing of reflux, that is signed, hard copy or electronically, by a physician.
UHC has also already modified their policy regarding the surface skin photos. They now want a ruler showing size next to the problem area(s) as well as the patient name. One group is taping the patient name as a flag on the ruler. Another group has the patient stand in front of a white board and the patient name is written on the white board.
If you or your team have questions regarding any of the new UHC processes, do feel free to call us. We are happy to try and explain the processes as we understand them. No charge. We are all in this boat together! Please ask for Cheryl at 719.955.9128 ext. 203.
by Cheryl Nash and AJ Riviezo
Over the past few weeks we have obtained further clarification from Dr. Jeff Mason, Senior Medical Director for United Healthcare (UHC). One of the key questions needing clarification was "pictures of what exactly?". UHC, per Dr. Mason, would like to receive the following from the diagnostic duplex ultrasound:
1) Images (black and white, or color) that show the anatomy and size of the vein at sections relevant to the case. These images can be submitted in hard-copy prints, or, preferably, in a digital file. We do not need a record of the entire exam --- several "snapshots' are enough.
2) We need speed and direction of blood flow information, either from a color doppler print(the colors represent direction and speed of flow) or locations (denoted by cursors) where flow readings were taken.
3) We need a report of the exam including results of the above size of vein and degree and timing of reflux, that is signed, hard copy or electronically, by a physician.
UHC has also already modified their policy regarding the surface skin photos. They now want a ruler showing size next to the problem area(s) as well as the patient name. One group is taping the patient name as a flag on the ruler. Another group has the patient stand in front of a white board and the patient name is written on the white board.
If you or your team have questions regarding any of the new UHC processes, do feel free to call us. We are happy to try and explain the processes as we understand them. No charge. We are all in this boat together! Please ask for Cheryl at 719.955.9128 ext. 203.
Marketing to Males
Or... How to Herd Cats
by AJ Riviezzo, MBA
As the data above shows, very few men are coming in for phlebology services. The reasons are fairly evident and are not unique to phlebology. The question then becomes: "How do we capture a few more of these reticent males?" Below are some ideas for your consideration.
1. Pain and Performance: The bulk of the phlebology marketing tri-folds and brochures are geared towards women in both their look and language. Understandably so. I recommend creating a separate brochure specifically for men. This will typically cause a re-write of your brochure as men will not respond to the aesthetic elements most marketing pieces contain. The men will respond to two elements.
The first is pain. Your services can reduce the pain and swelling in their legs. The information should contain a bit of clinical information describing how that happens. Very straight forward information. Stress that this is an ailment and not a cosmetic procedure. The second element is performance. By having healthier, pain free legs the gentleman will be able to golf, walk their dog, hike, lift weights, bike, and other activities at a higher performance level.
2. Pictures: Consider adding some more male pictures to your website and especially your 'male' brochure. Again, have them focus on performance by showing pictures of healthy legs climbing a cliff, biking, dog walking, and the like. You may want a separate page on your website stylized 'For Men' or similar heading that contains your more male oriented information.
3. Build It and They Will NOT Come: Your male patient is not typically looking for your service. You need to determine how best to go to them. If you have had a few patients that work for a male dominated industry with a union (electrical, pipe fitters, carpenters, meat cutters, etc.) and the patient is happy with their outcome; ask them who you should contact in the union. Many unions have a preferred provider book. They may allow you to do a Lunch and Learn or other speaking engagement at one of their meetings. You may be able to place brochures in the commons areas.
Another possibility is to get your brochures out to various activity venues. Bicycle shops may be willing to keep your information on a brochure rack or on the counter. High end running shoe stores may also be a possibility. Gyms that cater primarily to men may be willing to have you place your brochures. You may even be able to meet with the trainers. A quick review of signs and symptoms with the trainers and you now have three or four people looking at legs for you! Work a reciprocity agreement so to speak by carrying their brochures in your office.
A third possibility is health fairs. Yes, they are sometimes boring and not always much fun. Having information that caters specifically to men will help you at the health fair. The man may or may not be there to meet with you or your team... but their spouse is. Their wife then has something they can take back to them for their review.
by AJ Riviezzo, MBA
As the data above shows, very few men are coming in for phlebology services. The reasons are fairly evident and are not unique to phlebology. The question then becomes: "How do we capture a few more of these reticent males?" Below are some ideas for your consideration.
1. Pain and Performance: The bulk of the phlebology marketing tri-folds and brochures are geared towards women in both their look and language. Understandably so. I recommend creating a separate brochure specifically for men. This will typically cause a re-write of your brochure as men will not respond to the aesthetic elements most marketing pieces contain. The men will respond to two elements.
The first is pain. Your services can reduce the pain and swelling in their legs. The information should contain a bit of clinical information describing how that happens. Very straight forward information. Stress that this is an ailment and not a cosmetic procedure. The second element is performance. By having healthier, pain free legs the gentleman will be able to golf, walk their dog, hike, lift weights, bike, and other activities at a higher performance level.
2. Pictures: Consider adding some more male pictures to your website and especially your 'male' brochure. Again, have them focus on performance by showing pictures of healthy legs climbing a cliff, biking, dog walking, and the like. You may want a separate page on your website stylized 'For Men' or similar heading that contains your more male oriented information.
3. Build It and They Will NOT Come: Your male patient is not typically looking for your service. You need to determine how best to go to them. If you have had a few patients that work for a male dominated industry with a union (electrical, pipe fitters, carpenters, meat cutters, etc.) and the patient is happy with their outcome; ask them who you should contact in the union. Many unions have a preferred provider book. They may allow you to do a Lunch and Learn or other speaking engagement at one of their meetings. You may be able to place brochures in the commons areas.
Another possibility is to get your brochures out to various activity venues. Bicycle shops may be willing to keep your information on a brochure rack or on the counter. High end running shoe stores may also be a possibility. Gyms that cater primarily to men may be willing to have you place your brochures. You may even be able to meet with the trainers. A quick review of signs and symptoms with the trainers and you now have three or four people looking at legs for you! Work a reciprocity agreement so to speak by carrying their brochures in your office.
A third possibility is health fairs. Yes, they are sometimes boring and not always much fun. Having information that caters specifically to men will help you at the health fair. The man may or may not be there to meet with you or your team... but their spouse is. Their wife then has something they can take back to them for their review.
Who Are Your Patients
A Quick Demographic Study
by AJ Riviezo, MBA
A new practice was asking for some information about patient demographics. To that end, I combined the demographic data of three large phlebology practices. None of these practices specifically target Medicare members as their primary market. All of them have primarily commercial payers with some (less than 20%) Medicare in the mix. Total patient sample size is 2,306 patients. The results are interesting and give you some comparison information you can use after reviewing your own practice's experience.
Under 30 - 4%, 30 to 39 - 15%, 40 to 49 - 23%, 50 to 59 - 27%, 60 - 69 - 19%, 71 to 79 - 9%, 80+ - 3%
Almost 70% of the business was 40 to 70 years of age. This age banding was skewed a bit older than what I had expected when reviewing practices that primarily see commercial payer patients.
The male/female ratios were even more significant. Males constituted only 16% of the patient population for these practices.
I recommend giving this data and your own age/sex patient data to your marketing person or company. Armed with this, they should be able to rifle in on a more targeted marketing campaign rather than a shotgun approach.
by AJ Riviezo, MBA
A new practice was asking for some information about patient demographics. To that end, I combined the demographic data of three large phlebology practices. None of these practices specifically target Medicare members as their primary market. All of them have primarily commercial payers with some (less than 20%) Medicare in the mix. Total patient sample size is 2,306 patients. The results are interesting and give you some comparison information you can use after reviewing your own practice's experience.
Under 30 - 4%, 30 to 39 - 15%, 40 to 49 - 23%, 50 to 59 - 27%, 60 - 69 - 19%, 71 to 79 - 9%, 80+ - 3%
Almost 70% of the business was 40 to 70 years of age. This age banding was skewed a bit older than what I had expected when reviewing practices that primarily see commercial payer patients.
The male/female ratios were even more significant. Males constituted only 16% of the patient population for these practices.
I recommend giving this data and your own age/sex patient data to your marketing person or company. Armed with this, they should be able to rifle in on a more targeted marketing campaign rather than a shotgun approach.
Friday, July 23, 2010
How to Make Life More Complicated/United Health Care Changes
by Cheryl Nash
Many of you may have received a letter from United Healthcare recently detailing some significant modifications to their coverage guidelines. With the main topic of discussion being documentation this month, I feel this is an opportune time to review these changes.
The most dramatic change by United is the addition of digital photos and the color flow Doppler results in addition to the interpretation by a physician. This digital media will be requested at the time of notification/pre-authorization. A standard 10 megapixel camera (cost is between $100 and $ 300) should be sufficient. The preferred way of submitting this information will be by digital upload through a secured email. Contact your local United Healthcare provider representative to obtain your personal secured email address. The documentation can also be sent hard-copy, but they freely acknowledge that this will delay processing. We recommend securing a comprehensive way of storing this data in an easily accessible electronic file to make communication with the insurance company as smooth as possible.
Some other significant changes to the clinical requirements is the detail to be documented in the Doppler study as well as in the patient History and Physical. United will require the vein diameter with strict guidelines as to what the diameter must be for different venous issues (including perforators). They will also be requiring the duration of reflux to be written in the report. This is all in addition to the previous requirements of reflux without evidence of DVT/PAD. For patients who exhibit only signs and symptoms they have added a questionnaire to be filled out completely and sent along with a dictated H&P from the provider. This H&P will need to have a complete treatment plan and proposed outcome. As always, a trial of conservative treatment to include compression stockings will be included.
The complete clinical guidelines can be found at unitedhealthcareonline.com under the tools and resources/policies and protocols/coverage determination guidelines. The header has changed and is now listed as Ablative Procedures for Venous Insufficiency and Varicose Veins (this was formerly under Surgical and Minimally Invasive Treatment for Varicose Veins of the Leg).
Unfortunately, practices that treat varicose veins will only have a couple of weeks to get these changes into place as the new guidelines go into effect on August First, 2010.
Many of you may have received a letter from United Healthcare recently detailing some significant modifications to their coverage guidelines. With the main topic of discussion being documentation this month, I feel this is an opportune time to review these changes.
The most dramatic change by United is the addition of digital photos and the color flow Doppler results in addition to the interpretation by a physician. This digital media will be requested at the time of notification/pre-authorization. A standard 10 megapixel camera (cost is between $100 and $ 300) should be sufficient. The preferred way of submitting this information will be by digital upload through a secured email. Contact your local United Healthcare provider representative to obtain your personal secured email address. The documentation can also be sent hard-copy, but they freely acknowledge that this will delay processing. We recommend securing a comprehensive way of storing this data in an easily accessible electronic file to make communication with the insurance company as smooth as possible.
Some other significant changes to the clinical requirements is the detail to be documented in the Doppler study as well as in the patient History and Physical. United will require the vein diameter with strict guidelines as to what the diameter must be for different venous issues (including perforators). They will also be requiring the duration of reflux to be written in the report. This is all in addition to the previous requirements of reflux without evidence of DVT/PAD. For patients who exhibit only signs and symptoms they have added a questionnaire to be filled out completely and sent along with a dictated H&P from the provider. This H&P will need to have a complete treatment plan and proposed outcome. As always, a trial of conservative treatment to include compression stockings will be included.
The complete clinical guidelines can be found at unitedhealthcareonline.com under the tools and resources/policies and protocols/coverage determination guidelines. The header has changed and is now listed as Ablative Procedures for Venous Insufficiency and Varicose Veins (this was formerly under Surgical and Minimally Invasive Treatment for Varicose Veins of the Leg).
Unfortunately, practices that treat varicose veins will only have a couple of weeks to get these changes into place as the new guidelines go into effect on August First, 2010.
The Impact of Documentation on Your Practice
by Cheryl Nash
We've all heard it and we all have to do it. Documentation: The necessary evil. For a phlebology practice, each new year seems to bring more lengthy requirements and requests for records. From Ultrasound Reports to History and Physicals; Operative reports to Letters of Medical Necessity; it seems that today's phlebology specialist spends more and more time dictating, and the requirements keep changing. How does anyone keep up?!
Unfortunately, incomplete documentation is one of the most-common reasons for a phlebology claim to be denied. Many factors must be addressed for surgical treatment of varicose veins to be considered medically necessary. This is standard for all payers nationwide. Some factors are common to all payers, and while there are some variants, most have the same basic requirements. They include evidence of reflux, showing incompetence of the lesser or greater saphenous veins conservative treatment tried and failed, compressive therapy for a variable amount of time and an absence of PAD and DVT. Insurance companies review their guidelines each year and make changes as they see fit. These changes need to be monitored closely to ensure requirements are followed to the letter. Missing even one factor can cause a claim to be denied at all levels of appeal, and ultimately cause a lack of payment for the practice.
Another reason to maintain correct documentation is to protect against audit. RAC audits are being conducted by Medicare and various commercial payers, most commonly Medicare Advantage plans. The importance of protecting yourself against these audits has taken center stage. Audits are no longer a case of "if, they are a case of "when", and no one wants to be caught unprepared. In addition to auditing, there have been an increasing amount of whistleblower cases that have sparked a wave of record requests from all payers, including Medicare, to verify that the level of service billed is indeed what was performed. More, not less, documentation is the only recourse to survive an audit.
The best defense really is a good offense. Having a comprehensive knowledge of what is needed, and ensuring your standard reports to meet these requirements are key to smooth and timely reimbursement. Presenting a quick and thorough response when an insurance company requests those records will result in faster payment. One of the best ways to accomplish this is to keep a file, whether physical or electronic, of your most common payers' clinical policies on hand. It is also helpful to note when the next review date will occur. When recommending a course of treatment, have a staff member that is well-versed on these policies review the patient's insurance and the chart records to ensure each element has been met. This holds true for both follow-up services and primary surgeries.
TMI (too much information) is the rule in this specialty and a brief report that only the doctor can read is not sufficient. If the insurance company cannot read it, they will not pay it. They do not employ staff that specialize in phlebology to review records, and if they are not clear, the claim will get denied. We have all heard the cliché' "if it isn't documented, it didn't happen". This is so very true with Phlebology. The insurance company is not there to help you and does not want to pay you, so it is up to healthcare providers to actively participate in their own reimbursement. Ensuring that the claim is not denied on a documentation technicality is one of the major ways to achieve this payment goal.
We've all heard it and we all have to do it. Documentation: The necessary evil. For a phlebology practice, each new year seems to bring more lengthy requirements and requests for records. From Ultrasound Reports to History and Physicals; Operative reports to Letters of Medical Necessity; it seems that today's phlebology specialist spends more and more time dictating, and the requirements keep changing. How does anyone keep up?!
Unfortunately, incomplete documentation is one of the most-common reasons for a phlebology claim to be denied. Many factors must be addressed for surgical treatment of varicose veins to be considered medically necessary. This is standard for all payers nationwide. Some factors are common to all payers, and while there are some variants, most have the same basic requirements. They include evidence of reflux, showing incompetence of the lesser or greater saphenous veins conservative treatment tried and failed, compressive therapy for a variable amount of time and an absence of PAD and DVT. Insurance companies review their guidelines each year and make changes as they see fit. These changes need to be monitored closely to ensure requirements are followed to the letter. Missing even one factor can cause a claim to be denied at all levels of appeal, and ultimately cause a lack of payment for the practice.
Another reason to maintain correct documentation is to protect against audit. RAC audits are being conducted by Medicare and various commercial payers, most commonly Medicare Advantage plans. The importance of protecting yourself against these audits has taken center stage. Audits are no longer a case of "if, they are a case of "when", and no one wants to be caught unprepared. In addition to auditing, there have been an increasing amount of whistleblower cases that have sparked a wave of record requests from all payers, including Medicare, to verify that the level of service billed is indeed what was performed. More, not less, documentation is the only recourse to survive an audit.
The best defense really is a good offense. Having a comprehensive knowledge of what is needed, and ensuring your standard reports to meet these requirements are key to smooth and timely reimbursement. Presenting a quick and thorough response when an insurance company requests those records will result in faster payment. One of the best ways to accomplish this is to keep a file, whether physical or electronic, of your most common payers' clinical policies on hand. It is also helpful to note when the next review date will occur. When recommending a course of treatment, have a staff member that is well-versed on these policies review the patient's insurance and the chart records to ensure each element has been met. This holds true for both follow-up services and primary surgeries.
TMI (too much information) is the rule in this specialty and a brief report that only the doctor can read is not sufficient. If the insurance company cannot read it, they will not pay it. They do not employ staff that specialize in phlebology to review records, and if they are not clear, the claim will get denied. We have all heard the cliché' "if it isn't documented, it didn't happen". This is so very true with Phlebology. The insurance company is not there to help you and does not want to pay you, so it is up to healthcare providers to actively participate in their own reimbursement. Ensuring that the claim is not denied on a documentation technicality is one of the major ways to achieve this payment goal.
Thursday, July 22, 2010
Shooting While Blindfolded
Effective February 15, 2010, Blue Cross and Blue Shield of Florida will no longer pay for ultrasound guidance when performed with sclerotherapy. Their medical director seems to believe that there is no clinical reason for using ultrasound guidance. They appear to be confused between being able to treat visual veins and those deeper system perforators, anterior accessories, and the like.
While many of you are not in Florida we thought you should be aware. We are advocating for the ACP to become involved in this issue. Once one Blues program gets an idea in their head, it sometimes migrates to other Blues in the same region.
Some smaller plans have gone down this road already. We have had some success in working with the nurse case manager on these claims. When we ask them if they personally would really want a physician injecting a sclerosing solution into their leg without ultrasound guidance... we receive some assistance and then payment.
While many of you are not in Florida we thought you should be aware. We are advocating for the ACP to become involved in this issue. Once one Blues program gets an idea in their head, it sometimes migrates to other Blues in the same region.
Some smaller plans have gone down this road already. We have had some success in working with the nurse case manager on these claims. When we ask them if they personally would really want a physician injecting a sclerosing solution into their leg without ultrasound guidance... we receive some assistance and then payment.
Benefit Mis-quotes and Predetermination
Our friends at CIGNA have developed a few interesting nuances over the past year. Most of these new issues create denied claims and can leave you and the patient scrambling for a resolution.
Self-funded riders. We have seen a number of patients that have a self-funded CIGNA plan. These plans contain a rider that disallows any phlebology services. Unfortunately, if you (or the patient!) call and ask about the patient's benefits you will be assured there is no problem. If you then obtain a predetermination review on the services, you will be informed that there is no phlebology coverage. This places you and your practice in a bit of jam as the patient is being told one thing and you now know you will not be paid.
For any CIGNA patients, we now strongly recommend obtaining a predetermination prior to providing treatment. While not required, it is very difficult to determine who has a phlebology rider without this step. You can also have the patient bring this information back to their Human Resources (HR) department at their employer. Quite frequently the HR manager has no idea there is a limit on this benefit. Occasionally the HR manager will override their own plan provisions and agree to have phlebology services covered.
CIGNA is now limiting the length of sclerotherapy that can be performed. You may need to provide new proof (e.g. a new diagnostic ultrasound showing open segments) and obtain a new authorization. It is now critical to know when the authorization will expire and what services were originally approved.
Self-funded riders. We have seen a number of patients that have a self-funded CIGNA plan. These plans contain a rider that disallows any phlebology services. Unfortunately, if you (or the patient!) call and ask about the patient's benefits you will be assured there is no problem. If you then obtain a predetermination review on the services, you will be informed that there is no phlebology coverage. This places you and your practice in a bit of jam as the patient is being told one thing and you now know you will not be paid.
For any CIGNA patients, we now strongly recommend obtaining a predetermination prior to providing treatment. While not required, it is very difficult to determine who has a phlebology rider without this step. You can also have the patient bring this information back to their Human Resources (HR) department at their employer. Quite frequently the HR manager has no idea there is a limit on this benefit. Occasionally the HR manager will override their own plan provisions and agree to have phlebology services covered.
CIGNA is now limiting the length of sclerotherapy that can be performed. You may need to provide new proof (e.g. a new diagnostic ultrasound showing open segments) and obtain a new authorization. It is now critical to know when the authorization will expire and what services were originally approved.
How Not to Feel like a Drug Rep
The single easiest and cheapest form of advertising available is the Lunch and Learn with primary care physicians, podiatrists, and specialty physicians. It also appears to be the most despised form of advertising by the physicians with whom I work. Below are a few ideas for overcoming some of the objections you or your physician may have regarding the Lunch and Learn marketing idea.
The physician (possibly you) does NOT want to look or feel like a drug rep. Walking in with a bag or two of food can feel unseemly. My recommendation for overcoming this obstacle is to always bring your practice manager or one of your MA's... for several reasons. Let them, the manager or MA, leave early and purchase/bring the food.
The physician does not want to feel like a drug rep. I agree. The physician should be in a teaching mode. Many primary care physicians have patients with heavy, tired, painful legs and believe there is no recourse save for painful leg stripping. The phlebology physician is now an educator. No different than teaching interns. That is something with which most every physician is comfortable. View it as an educational opportunity!
This leads me to the second reason for bringing your office manager or MA... non-physician dialogue. While the doctors are discussing treatment modalities in a peer-to-peer setting, the office manager or MA should be determining who actually fills out the referral slips, makes the referral telephone calls, and working to educate/market to this person in that office. While educating the PCP in phlebology is great, if the referral coordinator does not know to send the patients to you, the time spent was not used wisely.
The physician (possibly you) does NOT want to look or feel like a drug rep. Walking in with a bag or two of food can feel unseemly. My recommendation for overcoming this obstacle is to always bring your practice manager or one of your MA's... for several reasons. Let them, the manager or MA, leave early and purchase/bring the food.
The physician does not want to feel like a drug rep. I agree. The physician should be in a teaching mode. Many primary care physicians have patients with heavy, tired, painful legs and believe there is no recourse save for painful leg stripping. The phlebology physician is now an educator. No different than teaching interns. That is something with which most every physician is comfortable. View it as an educational opportunity!
This leads me to the second reason for bringing your office manager or MA... non-physician dialogue. While the doctors are discussing treatment modalities in a peer-to-peer setting, the office manager or MA should be determining who actually fills out the referral slips, makes the referral telephone calls, and working to educate/market to this person in that office. While educating the PCP in phlebology is great, if the referral coordinator does not know to send the patients to you, the time spent was not used wisely.
Monday, January 18, 2010
Goal Setting
Using Personal Income as the Basis
by AJ Riviezzo
The new year is a great time to review where your practice is at and where you would like it to go. One goal that is foremost in anyone's mind is their personal income. Below is one way to create some targets and goals based on the desired personal income.
Let us assume, for discussions sake, your personal income goal for 2010 is $700,000. The numbers all flow from this goal number.
The first number we need to determine is your profit margin before physician salary. Take all of your non-physician salaried expenses and add them together. Divide that number into your total collected dollars for the year. This will generate a percentage hopefully somewhere between 50% and 75% (unless you are a new practice). Using an assumed percentage of 60% in all non-physician compensation, our 'practice' will need a total income of $1,750,000.
The second number we now need is the average income per ablation (see previous article) for last year. In this example I am using $2,500 as the average income. If you divide $2,500 into the needed total income of $1,750,000 divided by 12 it shows we have to average 58 ablations per month to achieve our desired goal.
The third number we need to calculate is how many ablations were performed on each unique patient on average. For this example the number is 2 ablations per patient. In other words, we will be treating 29 to 30 individual per month over the course of the year.
To be able to treat thirty people per month, we now have to determine how many people we have to scan. Assuming that 75% of the patients who receive an US scan show evidence of reflux, we have to scan 40 people per month to find 30 that need treatment. As not all individuals that have reflux will receive treatment, I am assuming a 10% drop rate (four people) so we actually need to scan 45 people per month to be able to treat our goal of 30.
Finally, we need to determine how many free consults actually receive a bilateral diagnostic ultrasound. If you are tracking how many free consults you are performing, you can divide this number into the number of diagnostic ultrasounds. For ease, I am assuming 80% of the free consults return for the diagnostic US. This give us another 'drop' of 11 patients per month who will not agree to have a diagnostic US performed.
Or, stated in the reverse, we now know we have to see at least 56 people in a free consultation in order to generate a sufficient number of diagnostic US's, who then go on to receive treatment. This last number is one of the keys, therefore, for ensuring you are going to meet your desired income goal for the year.
The goals and numbers for your practice will vary from the above. Do let me know if you run into any problems in calculating all the way through. I am happy to help.
Using Personal Income as the Basis
by AJ Riviezzo
The new year is a great time to review where your practice is at and where you would like it to go. One goal that is foremost in anyone's mind is their personal income. Below is one way to create some targets and goals based on the desired personal income.
Let us assume, for discussions sake, your personal income goal for 2010 is $700,000. The numbers all flow from this goal number.
The first number we need to determine is your profit margin before physician salary. Take all of your non-physician salaried expenses and add them together. Divide that number into your total collected dollars for the year. This will generate a percentage hopefully somewhere between 50% and 75% (unless you are a new practice). Using an assumed percentage of 60% in all non-physician compensation, our 'practice' will need a total income of $1,750,000.
The second number we now need is the average income per ablation (see previous article) for last year. In this example I am using $2,500 as the average income. If you divide $2,500 into the needed total income of $1,750,000 divided by 12 it shows we have to average 58 ablations per month to achieve our desired goal.
The third number we need to calculate is how many ablations were performed on each unique patient on average. For this example the number is 2 ablations per patient. In other words, we will be treating 29 to 30 individual per month over the course of the year.
To be able to treat thirty people per month, we now have to determine how many people we have to scan. Assuming that 75% of the patients who receive an US scan show evidence of reflux, we have to scan 40 people per month to find 30 that need treatment. As not all individuals that have reflux will receive treatment, I am assuming a 10% drop rate (four people) so we actually need to scan 45 people per month to be able to treat our goal of 30.
Finally, we need to determine how many free consults actually receive a bilateral diagnostic ultrasound. If you are tracking how many free consults you are performing, you can divide this number into the number of diagnostic ultrasounds. For ease, I am assuming 80% of the free consults return for the diagnostic US. This give us another 'drop' of 11 patients per month who will not agree to have a diagnostic US performed.
Or, stated in the reverse, we now know we have to see at least 56 people in a free consultation in order to generate a sufficient number of diagnostic US's, who then go on to receive treatment. This last number is one of the keys, therefore, for ensuring you are going to meet your desired income goal for the year.
The goals and numbers for your practice will vary from the above. Do let me know if you run into any problems in calculating all the way through. I am happy to help.
Billing and Collections Item
Deductibles and Plan Changes
by AJ Riviezzo
'Tis the Season for annual deductibles. Make sure your practice has a plan in place to collect at least some of the deductible amounts up front. If not, you and your billing department will be spending a lot of time and effort in chasing those dollars.
Do not forget that many employers change insurance carriers the first of the year. Be sure to ask the patient for a copy of their new card to both determine the payer and to ensure the appropriate copayment, coinsurance or deductible is collected.
Deductibles and Plan Changes
by AJ Riviezzo
'Tis the Season for annual deductibles. Make sure your practice has a plan in place to collect at least some of the deductible amounts up front. If not, you and your billing department will be spending a lot of time and effort in chasing those dollars.
Do not forget that many employers change insurance carriers the first of the year. Be sure to ask the patient for a copy of their new card to both determine the payer and to ensure the appropriate copayment, coinsurance or deductible is collected.
Annual Data Review
Looking Forward by Looking Back
by AJ Riviezzo
With the end of the year, it is a great time to assess how you have been performing and to establish some performance goals. This first section is one quick way to assess how you have been performing.
First, create a simple spreadsheet that details (for medical services) the billed charges, the collected dollars, and the number of ablations performed month-by-month. Complete this for the past three years (2007, 2008 and 2009).
The format would look something like:
Month: January, 2008 January, 2009
Billed Chrgs $500,000 $600,000
Collected $'s $165,000 $205,000
# of Ablat.'s 50 61
Month: February, 2008 February, 2009
etc., etc.
Total each category (billed charges, collected dollars, and ablations) for each year. Now you have some data with which you can work.
Second, let's analyze your data. The first step is to simply compare the three years in general. Are the numbers going up or going down. Can you identify some seasonality in your numbers or is the seasonality a known issue since you take half of December and half of July as vacation?
Next, divide the total collected dollars into the total billed charges. Unless you have changed your billed amount, this should give you a ratio that remains relatively consistent. If it is not consistent, this may indicate a problem with your collections or a major change in your payer mix. Either way, it should be investigated.
Now divide the total number of ablations into the collected dollars for the year. This will generate your average income per ablation. This dollar figure can be used in two different ways. The simple review is to see if your average income per ablation, from year to year, is trending up or down (typically slightly down due to payment changes from Medicare). The more interesting review is to compare the dollar number derived against your average Medicare allowable amount.
For example, if your average total income per ablation is $2,000 and Medicare allows $1,600, this indicates you are only generating an additional $400 in all other services pre and post ablation. This additional revenue margin may be low if you perform a large number of ablations on non-saphenous veins.
If you are primarily only performing ablations on the greater and lesser saphenous, it is an indication that either additional medically necessary services may not have been performed (such as closing of perforators using US guided sclerotherapy or stab phlebectomies) or that the aftercare plan is not being sufficient followed by the majority of your patients.
Please note that I am not advocating performing unnecessary services. Simply that you may need to review what services are being performed, and in what time frames, on an average case.
Looking Forward by Looking Back
by AJ Riviezzo
With the end of the year, it is a great time to assess how you have been performing and to establish some performance goals. This first section is one quick way to assess how you have been performing.
First, create a simple spreadsheet that details (for medical services) the billed charges, the collected dollars, and the number of ablations performed month-by-month. Complete this for the past three years (2007, 2008 and 2009).
The format would look something like:
Month: January, 2008 January, 2009
Billed Chrgs $500,000 $600,000
Collected $'s $165,000 $205,000
# of Ablat.'s 50 61
Month: February, 2008 February, 2009
etc., etc.
Total each category (billed charges, collected dollars, and ablations) for each year. Now you have some data with which you can work.
Second, let's analyze your data. The first step is to simply compare the three years in general. Are the numbers going up or going down. Can you identify some seasonality in your numbers or is the seasonality a known issue since you take half of December and half of July as vacation?
Next, divide the total collected dollars into the total billed charges. Unless you have changed your billed amount, this should give you a ratio that remains relatively consistent. If it is not consistent, this may indicate a problem with your collections or a major change in your payer mix. Either way, it should be investigated.
Now divide the total number of ablations into the collected dollars for the year. This will generate your average income per ablation. This dollar figure can be used in two different ways. The simple review is to see if your average income per ablation, from year to year, is trending up or down (typically slightly down due to payment changes from Medicare). The more interesting review is to compare the dollar number derived against your average Medicare allowable amount.
For example, if your average total income per ablation is $2,000 and Medicare allows $1,600, this indicates you are only generating an additional $400 in all other services pre and post ablation. This additional revenue margin may be low if you perform a large number of ablations on non-saphenous veins.
If you are primarily only performing ablations on the greater and lesser saphenous, it is an indication that either additional medically necessary services may not have been performed (such as closing of perforators using US guided sclerotherapy or stab phlebectomies) or that the aftercare plan is not being sufficient followed by the majority of your patients.
Please note that I am not advocating performing unnecessary services. Simply that you may need to review what services are being performed, and in what time frames, on an average case.
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