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.
Friday, July 23, 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.
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