Thursday, November 12, 2009
Wednesday, September 16, 2009
Blue Cross and Blue Shield of Illinois
And you are asking yourself, why should I care about Blues of Illinois since I do not live in Illinois. Unfortunately, United Airlines employees have Blues of Illinois, along with a few other large employer groups, who may come to see you. Also the Blues of Illinois guidelines have been adopted by Blues of Oklahoma, Blues of Texas, and Blues of New Mexico.
Doppler Study Requirements for Ablation: As of 5/15/09, Blues of Illinois does not require any conservative therapy prior to an ablation but preauthorization is typically required (if not performed in conjuction with any other surgical procedures). However, your doppler ultrasound examination must document “…condition of the deep and superficial systems of the extremity including saphenofemoral junction, saphenopopliteal junction, greater saphenous vein, lesser saphenous vein, and perforator veins as well as the precise location and extent of the varicosities to be treated. This study must document an outward flow lasting more than 500 milliseconds in either the saphenous veins or the perforating veins.”
Follow Up Procedures: If you perform any other surgical intervention such as sclerotherapy or stab phlebectomy on this patient, there must be an observation period of at least four months with at least one follow up visit documented by the provider to show there are still areas needing treatment. You must re-preauthorize these services before treatment.
Phlebectomy/Sclerotherapy during an Ablation: The doppler study noted above must meet the same requirements. Conservative treatment must be followed for a period of four months prior to any ablation coupled with additional procedures. During the conservative therapy time period, the patient must try compression stockings, elevation of limbs, walking, weight loss, and when possible, NSAIDS. All of these conservative treatment elements must be included in your progress notes. The patient must have the initial examination and one follow up visit towards the end of the four month time span noting no improvement.
Documentation: You will be required to send your findings, notes and treatment plan for pre-authorization. You will also have to submit the treatment notes and other documentation after billing for your services. Unfortunately, the records will now be going to your local Blues and then be forwarded to Blues of Illinois. This process has significant issues. Blues of Illinois will not typically allow you to send records directly. One way to get around this is to have your patient call and see if the medical records are on file. If not, the patient can be given by Blues a fax number for sending the records. You can then submit the records on the patient’s behalf. Remember, the insurance is the patient’s insurance and you should not hesitate to involve them once the claim starts to go a bit ‘sideways’.
Exceptions to the Four Month Period of Conservative Treatment:
1. Only one four month period of conservative treatment is required prior to initiating surgical treatment even if using multiple modalities on the same patient.
2. The four month requirement is waived if the clinical findings are skin changes ascribed to venous disease, skin changes in conjunction with healed ulceration, and any active ulceration.
AJ Riviezzo, MBA
American Physician Financial Solutions
Your Phlebology Billing/Consulting Experts
719.233.0099 www.apfsbilling.com
Great Patient Outcomes Deserve Great FinancialIncomes
Doppler Study Requirements for Ablation: As of 5/15/09, Blues of Illinois does not require any conservative therapy prior to an ablation but preauthorization is typically required (if not performed in conjuction with any other surgical procedures). However, your doppler ultrasound examination must document “…condition of the deep and superficial systems of the extremity including saphenofemoral junction, saphenopopliteal junction, greater saphenous vein, lesser saphenous vein, and perforator veins as well as the precise location and extent of the varicosities to be treated. This study must document an outward flow lasting more than 500 milliseconds in either the saphenous veins or the perforating veins.”
Follow Up Procedures: If you perform any other surgical intervention such as sclerotherapy or stab phlebectomy on this patient, there must be an observation period of at least four months with at least one follow up visit documented by the provider to show there are still areas needing treatment. You must re-preauthorize these services before treatment.
Phlebectomy/Sclerotherapy during an Ablation: The doppler study noted above must meet the same requirements. Conservative treatment must be followed for a period of four months prior to any ablation coupled with additional procedures. During the conservative therapy time period, the patient must try compression stockings, elevation of limbs, walking, weight loss, and when possible, NSAIDS. All of these conservative treatment elements must be included in your progress notes. The patient must have the initial examination and one follow up visit towards the end of the four month time span noting no improvement.
Documentation: You will be required to send your findings, notes and treatment plan for pre-authorization. You will also have to submit the treatment notes and other documentation after billing for your services. Unfortunately, the records will now be going to your local Blues and then be forwarded to Blues of Illinois. This process has significant issues. Blues of Illinois will not typically allow you to send records directly. One way to get around this is to have your patient call and see if the medical records are on file. If not, the patient can be given by Blues a fax number for sending the records. You can then submit the records on the patient’s behalf. Remember, the insurance is the patient’s insurance and you should not hesitate to involve them once the claim starts to go a bit ‘sideways’.
Exceptions to the Four Month Period of Conservative Treatment:
1. Only one four month period of conservative treatment is required prior to initiating surgical treatment even if using multiple modalities on the same patient.
2. The four month requirement is waived if the clinical findings are skin changes ascribed to venous disease, skin changes in conjunction with healed ulceration, and any active ulceration.
AJ Riviezzo, MBA
American Physician Financial Solutions
Your Phlebology Billing/Consulting Experts
719.233.0099 www.apfsbilling.com
Great Patient Outcomes Deserve Great FinancialIncomes
Thursday, August 13, 2009
Medicare "Red Flags"
When billing to Medicare, there are a few issues of which you should be aware to ensure you are not sending claims that can create a ‘red flag’. With the new RAC audits that are coming, it is important to not send claims that can focus attention on your practice. Even if Medicare denies a claim, it is still in their system to help establish invalid or fraudulent billing patterns.
1. Follow Up Evaluation and Management (E&M) Codes – 9921X (1-5) –
There are two problem scenarios when billing E&M codes. They are:
A. Billing an Established Patient visit code in a global period. Medicare will always deny these claims unless the patient is seen for a completely different problem that is not related to the global period. To establish it is a different problem, the diagnosis must reflect the new chief complaint. Your documentation will need to reflect the new evaluation, diagnosis, and treatment plan of the new chief complaint. Do remember that a stab phlebectomy carries a 90 day global period and sclerotherapy carries a 10 day global period.
B. Billing an Established Patient visit code with a procedure. Medicare typically denies these codes as well because the re-evaluation of the patient must be ‘over and above’ the usual post-operative care associated with the procedure that was performed. For example, if the patient is coming in for a three month follow up appointment and you decide to perform sclerotherapy secondary to an ablation, you should not bill an additional E&M code as performing sclerotherapy is not unusual at the three month juncture.
2. Hematoma Billing (10140 and 10160) –
The treatment of a superficial hematoma is now considered part of the normal complications following a venous ablation and/or sclerotherapy procedure and will not be separately reimbursed by Medicare. A deep hematoma, typically with ultrasound guided needle placement, is still reimburseable as it is not a ‘normal’ complication.
3. Unbundling a Bundled Service (Billing for an ultrasound – 93971/76942 – during an ablation) –
The codes 36475 and 36478 are bundled codes which means the ultrasound services as well as the needle guided imagery and other additional services are included in the ablation code. Billing for the separate components is improper and will not be reimbursed. However, billing for a second insertion (36476 or 36479), stab phlebectomy, or sclerotherapy is allowed.
Some commercial payers follow Medicare guidelines while most others use them only as a basis. Our recommendation is to continue billing for those services like superficial hematomas to the commercial payers but not to Medicare. As we do not want the physician to double check the payer before treating a patient and coding, the onus should be on the billing department to ‘leave out’ inappropriate line items when billing Medicare.
1. Follow Up Evaluation and Management (E&M) Codes – 9921X (1-5) –
There are two problem scenarios when billing E&M codes. They are:
A. Billing an Established Patient visit code in a global period. Medicare will always deny these claims unless the patient is seen for a completely different problem that is not related to the global period. To establish it is a different problem, the diagnosis must reflect the new chief complaint. Your documentation will need to reflect the new evaluation, diagnosis, and treatment plan of the new chief complaint. Do remember that a stab phlebectomy carries a 90 day global period and sclerotherapy carries a 10 day global period.
B. Billing an Established Patient visit code with a procedure. Medicare typically denies these codes as well because the re-evaluation of the patient must be ‘over and above’ the usual post-operative care associated with the procedure that was performed. For example, if the patient is coming in for a three month follow up appointment and you decide to perform sclerotherapy secondary to an ablation, you should not bill an additional E&M code as performing sclerotherapy is not unusual at the three month juncture.
2. Hematoma Billing (10140 and 10160) –
The treatment of a superficial hematoma is now considered part of the normal complications following a venous ablation and/or sclerotherapy procedure and will not be separately reimbursed by Medicare. A deep hematoma, typically with ultrasound guided needle placement, is still reimburseable as it is not a ‘normal’ complication.
3. Unbundling a Bundled Service (Billing for an ultrasound – 93971/76942 – during an ablation) –
The codes 36475 and 36478 are bundled codes which means the ultrasound services as well as the needle guided imagery and other additional services are included in the ablation code. Billing for the separate components is improper and will not be reimbursed. However, billing for a second insertion (36476 or 36479), stab phlebectomy, or sclerotherapy is allowed.
Some commercial payers follow Medicare guidelines while most others use them only as a basis. Our recommendation is to continue billing for those services like superficial hematomas to the commercial payers but not to Medicare. As we do not want the physician to double check the payer before treating a patient and coding, the onus should be on the billing department to ‘leave out’ inappropriate line items when billing Medicare.
Medicare Audit Changes
Due to new healthcare legislation designed to catch overpayments, Medicare recently ‘hired’ several different organizations to begin auditing Medicare claims. There are a number of items of which you should be aware as they can impact – in a very negative fashion – your practice.
These organizations, generically called Recover Audit Contractors (RACs) are paid – and only paid by – a percentage of what they find! This means they are motivated financially to find problems and recoup money from you. Here’s what they are allowed to do…
A. They can request records/bills of up to 10 claims per NPI number (please keep in mind that any incorporated practice has at least two NPI numbers – one for the facility and one for the physician) every 45 days.
B. They can go back to October 1, 2007 in their search.
C. You have 45 days in which to respond to their request.
D. They will then do a chart-to-bill and bill-to-chart audit of those 10 (or 20) records
E. If they find something – and they only get paid if they find something – you can appeal the decision (and normally should).
F. If they show claims were paid in error, you have to either remit payment to them for the amount or they will deduct the monies beginning on day 41 from your current Medicare payments.
We highly recommend that you begin to audit your charts now before the RAC does it for you! We also recommend that someone else besides your normal biller conducts the audit. If you use a billing company, ask if they have the expertise to perform a bill-to-chart/chart-to-bill audit. Also ask if someone else besides the normal biller for your account will be performing the audit. If you use an in-house biller, we strongly recommend that you use an outside agency to conduct your review. It is simply too easy to assume what you have done is correct (sort of like proofing your own writing).
I will be sending out more information on some common billing/coding errors in regards to phlebology practices in the very near future. Do feel free to call or email with any questions about the above.
If a RAC audit team contacts you, you should also engage a company that specializes in assisting practices through a RAC audit. I am working with one right now and happy to give you their name/telephone number if you end up needing some support.
Blatant Advertisement – As I noted above, you should engage someone to do a chart-to-bill/bill-to-chart audit. American Physician has the expertise to provide these services to you. We have a certified coder, access to physician and sonography input if needed, and years of phlebology billing experience. For the sum of $450 we will perform the chart-to-bill/bill-to-chart audit, provide a written report, and telephonically review the report with you regarding any recommendations. If you are an existing billing client of APFS, the audit is free and we will ensure it is conducted by one of our team members who does NOT routinely perform your billing services. Please contact me at 719.233.0099 if you have questions or wish to schedule an appointment.
These organizations, generically called Recover Audit Contractors (RACs) are paid – and only paid by – a percentage of what they find! This means they are motivated financially to find problems and recoup money from you. Here’s what they are allowed to do…
A. They can request records/bills of up to 10 claims per NPI number (please keep in mind that any incorporated practice has at least two NPI numbers – one for the facility and one for the physician) every 45 days.
B. They can go back to October 1, 2007 in their search.
C. You have 45 days in which to respond to their request.
D. They will then do a chart-to-bill and bill-to-chart audit of those 10 (or 20) records
E. If they find something – and they only get paid if they find something – you can appeal the decision (and normally should).
F. If they show claims were paid in error, you have to either remit payment to them for the amount or they will deduct the monies beginning on day 41 from your current Medicare payments.
We highly recommend that you begin to audit your charts now before the RAC does it for you! We also recommend that someone else besides your normal biller conducts the audit. If you use a billing company, ask if they have the expertise to perform a bill-to-chart/chart-to-bill audit. Also ask if someone else besides the normal biller for your account will be performing the audit. If you use an in-house biller, we strongly recommend that you use an outside agency to conduct your review. It is simply too easy to assume what you have done is correct (sort of like proofing your own writing).
I will be sending out more information on some common billing/coding errors in regards to phlebology practices in the very near future. Do feel free to call or email with any questions about the above.
If a RAC audit team contacts you, you should also engage a company that specializes in assisting practices through a RAC audit. I am working with one right now and happy to give you their name/telephone number if you end up needing some support.
Blatant Advertisement – As I noted above, you should engage someone to do a chart-to-bill/bill-to-chart audit. American Physician has the expertise to provide these services to you. We have a certified coder, access to physician and sonography input if needed, and years of phlebology billing experience. For the sum of $450 we will perform the chart-to-bill/bill-to-chart audit, provide a written report, and telephonically review the report with you regarding any recommendations. If you are an existing billing client of APFS, the audit is free and we will ensure it is conducted by one of our team members who does NOT routinely perform your billing services. Please contact me at 719.233.0099 if you have questions or wish to schedule an appointment.
Billing 93965 with 93970
This multiple scan billing question has come up and caused a little controversy. Let me try to make it a little clearer.
First the basics:
93965 is defined as Non-invasive physiologic studies of extremity veins, complete bilateral study (e.g. Doppler waveform analysis with responses to phleborheography impedance plethysmography). This is a non-imaging study in response to compression and other maneuvers.
93970 is defined as Duplex scan of lower extremity veins including responses to compression and other maneuvers, complete bilateral study. This is both an imaging and non-imaging study. It includes the collection of BOTH physiologic in the form of Doppler analysis of bi-directional blood flow, the spectrum analysis, and B-mode imaging.
The two services are done with different equipment. 93970 is a study done with newer technology, more comprehensive and inclusive of the old study performed when billing 93965. Because they are different tests, done on different machines, they are technically not subject to a Correct Coding Initiative edit by Medicare, and can be billed together on the same day.
However, it is considered unnecessary testing to order both services on the same day when one service is sufficient to diagnose the patient (93970) as it is the more comprehensive test. CMS (Centers for Medicare and Medicaid services) considers the practice of performing both to be fraudulent billing.
One example is the FL Whistleblower case: Case No. 2:00-CV-558-FTM-29DNF
Radiology Regional Center (RRC), agreed to pay a 2.5 million dollar settlement on 06/23/2004 for filing false Medicare claims. The suit alleged that RRC billed for two venous or arterial studies on the same date that were not properly billable. Codes sited in this case as not being allowed to be billed together included, but were not limited to, 93965/ 93970 and 93965/ 93971.
A quote from this case: “This settlement again demonstrates the United States commitment to protecting federal funds from fraud,” said Peter D Keisler, Asst. Attorney General in charge of the civil division. A strong deterrent from ordering, and billing unnecessary testing…”
More research found multiple settlement cases for billing in the same fashion around the country. The penalties for this type of billing can amount to extremely large fines and possible revocation of license to practice medicine. Both consequences are not worth the few extra dollars this type of billing will net.
The inherent problem is not the question of if these services CAN be billed together, but if they SHOULD be billed together. According to CMS, it is not a condoned practice to order additional testing that is ultimately not needed to diagnose and treat a patient. If you do insist on performing both tests, then your documentation must reflect that both tests were performed, and have a definitive reason for doing so.
Written by:
Cheryl A. Nash, CIBS
Director of Operations
American Physician Financial Solutions
A.J. Riviezzo, MBA
Chief Executive Officer
American Physician Financial Solutions
First the basics:
93965 is defined as Non-invasive physiologic studies of extremity veins, complete bilateral study (e.g. Doppler waveform analysis with responses to phleborheography impedance plethysmography). This is a non-imaging study in response to compression and other maneuvers.
93970 is defined as Duplex scan of lower extremity veins including responses to compression and other maneuvers, complete bilateral study. This is both an imaging and non-imaging study. It includes the collection of BOTH physiologic in the form of Doppler analysis of bi-directional blood flow, the spectrum analysis, and B-mode imaging.
The two services are done with different equipment. 93970 is a study done with newer technology, more comprehensive and inclusive of the old study performed when billing 93965. Because they are different tests, done on different machines, they are technically not subject to a Correct Coding Initiative edit by Medicare, and can be billed together on the same day.
However, it is considered unnecessary testing to order both services on the same day when one service is sufficient to diagnose the patient (93970) as it is the more comprehensive test. CMS (Centers for Medicare and Medicaid services) considers the practice of performing both to be fraudulent billing.
One example is the FL Whistleblower case: Case No. 2:00-CV-558-FTM-29DNF
Radiology Regional Center (RRC), agreed to pay a 2.5 million dollar settlement on 06/23/2004 for filing false Medicare claims. The suit alleged that RRC billed for two venous or arterial studies on the same date that were not properly billable. Codes sited in this case as not being allowed to be billed together included, but were not limited to, 93965/ 93970 and 93965/ 93971.
A quote from this case: “This settlement again demonstrates the United States commitment to protecting federal funds from fraud,” said Peter D Keisler, Asst. Attorney General in charge of the civil division. A strong deterrent from ordering, and billing unnecessary testing…”
More research found multiple settlement cases for billing in the same fashion around the country. The penalties for this type of billing can amount to extremely large fines and possible revocation of license to practice medicine. Both consequences are not worth the few extra dollars this type of billing will net.
The inherent problem is not the question of if these services CAN be billed together, but if they SHOULD be billed together. According to CMS, it is not a condoned practice to order additional testing that is ultimately not needed to diagnose and treat a patient. If you do insist on performing both tests, then your documentation must reflect that both tests were performed, and have a definitive reason for doing so.
Written by:
Cheryl A. Nash, CIBS
Director of Operations
American Physician Financial Solutions
A.J. Riviezzo, MBA
Chief Executive Officer
American Physician Financial Solutions
Ultrasound Reimbursement
Decrease in Ultrasound Reimbursement
Medicare has come up with a somewhat sneaky way to reduce your reimbursement for bilateral and unilateral duplex ultrasounds (codes 93970 and 93971). Here’s how:
In 2006, Medicare implemented the Outpatient Prospective Payment System (OPPS) to curb facility based outpatient reimbursement which includes ultrasound services. Unfortunately for the individual physicians, Medicare has extended that OPPS program to some services rendered by physicians at an in-office setting.
For phlebology practices, the most noticeable result is a reduction in the technical component reimbursement by Medicare for the above ultrasound services. The technical portion is being reduced by approximately 50% or a total reduction of about 25% dependent upon your geographic area. This reduction started this past year and may only now be noticed dependent upon your Medicare service area.
The only good news to this story is that commercial payers still use RBRVS (Resource Based Relative Value System -- or Really Bad Reimbursement Very Slowly) as their basis for payment and do not use the OPPS model for re-calculating your reimbursement. As such, commercial payers have not followed Medicare in reducing reimbursement for duplex ultrasounds.
If you have a question on this or any other topic, please send me an email with your question.
Medicare has come up with a somewhat sneaky way to reduce your reimbursement for bilateral and unilateral duplex ultrasounds (codes 93970 and 93971). Here’s how:
In 2006, Medicare implemented the Outpatient Prospective Payment System (OPPS) to curb facility based outpatient reimbursement which includes ultrasound services. Unfortunately for the individual physicians, Medicare has extended that OPPS program to some services rendered by physicians at an in-office setting.
For phlebology practices, the most noticeable result is a reduction in the technical component reimbursement by Medicare for the above ultrasound services. The technical portion is being reduced by approximately 50% or a total reduction of about 25% dependent upon your geographic area. This reduction started this past year and may only now be noticed dependent upon your Medicare service area.
The only good news to this story is that commercial payers still use RBRVS (Resource Based Relative Value System -- or Really Bad Reimbursement Very Slowly) as their basis for payment and do not use the OPPS model for re-calculating your reimbursement. As such, commercial payers have not followed Medicare in reducing reimbursement for duplex ultrasounds.
If you have a question on this or any other topic, please send me an email with your question.
Medicare and Affiliated Products
MEDICARE AND AFFILIATED PRODUCTS:
There exists some confusion, both by the practice and by the patient, as to what Medicare or other Medicare related benefits a person may have. While this document will not solve all of the issues, we believe that some background information may be of use to you.
Medicare: If a patient has classic Medicare, a few rules apply. First, Medicare does have conservative therapy mandates now of compression stockings having been worn (at any time in the past) for ninety days or more. Second, the patient may have a Medicare deductible. Third, the patient will be subject to the 20 percent co-insurance.
You have to be accepting Medicare patients and the practice has to be contracted with Medicare. It is a good idea to make sure the physician is properly ‘linked’ to the practice or you can have some claims difficulties.
Medicare Advantage: This is NOT Medicare per se. The patient’s Medicare is replaced by a commercial plan. PacifiCare’s Secure Horizon’s is a classic example of a Medicare replacement plan. If you see a patient card that has the word Advantage on it or the patient is of Medicare age and is presenting what looks like a commercial insurance card, you should be aware of the following:
a. You must be contracted with that payer
b. You almost always have to preauthorize the services
c. You will almost always have to submit notes and a letter of medical necessity (even if preauthorized).
d. The patient may have a deductible, copayment or even a coinsurance that will need to be collected.
Medicare Supplemental: The patient’s primary insurance is still Medicare. These types of policies cover the deductible and coinsurance that classic Medicare leaves as the patient’s responsibility. Almost all of these plans cover the patient responsibility portion up to 100% of the Medicare allowable amount. You do not have to be contracted with these various Supplemental plans. If the patient has informed Medicare, the secondary plan should be automatically notified by Medicare (commonly called ‘crossover’) when a claim is adjudicated. It is essential to review your Medicare Explanations of Payments (EOP) to ensure the crossover was completed. If not, you will need to bill the Supplemental plan directly with a copy of the Medicare EOP. Examples of this type of plan are the United Health Care AARP Plan and Mutual of Omaha’s Supplement Plan.
Commercial Insurance: Some Medicare patients still have a standard commercial plan as their secondary insurance. Like a Supplemental plan, you do not have to be contracted in order to bill for the patient’s deductible or coinsurance. However, unlike a Supplemental plan, there is no guarantee that the patient’s Medicare deductible or coinsurance will be paid as the Commercial Insurance plan may have a deductible, copayment or coinsurance to which the patient is still liable. Patient’s can be quite adamant and agitated when their secondary insurance does not act like a Supplemental plan.
It is no wonder some of our seniors are a bit confused when it comes to Medicare and the various products out there. Many times the patient does not realize they have signed up for a Medicare Advantage plan which can sometimes severely limit the physicians they may see.
Please call me if you have any questions regarding the above or any other questions.
Yrs.
AJ Riviezzo, MBA
American Physician Financial Solutions
Your Phlebology Billing/Consulting Experts719.233.0099 www.apfsbilling.com
There exists some confusion, both by the practice and by the patient, as to what Medicare or other Medicare related benefits a person may have. While this document will not solve all of the issues, we believe that some background information may be of use to you.
Medicare: If a patient has classic Medicare, a few rules apply. First, Medicare does have conservative therapy mandates now of compression stockings having been worn (at any time in the past) for ninety days or more. Second, the patient may have a Medicare deductible. Third, the patient will be subject to the 20 percent co-insurance.
You have to be accepting Medicare patients and the practice has to be contracted with Medicare. It is a good idea to make sure the physician is properly ‘linked’ to the practice or you can have some claims difficulties.
Medicare Advantage: This is NOT Medicare per se. The patient’s Medicare is replaced by a commercial plan. PacifiCare’s Secure Horizon’s is a classic example of a Medicare replacement plan. If you see a patient card that has the word Advantage on it or the patient is of Medicare age and is presenting what looks like a commercial insurance card, you should be aware of the following:
a. You must be contracted with that payer
b. You almost always have to preauthorize the services
c. You will almost always have to submit notes and a letter of medical necessity (even if preauthorized).
d. The patient may have a deductible, copayment or even a coinsurance that will need to be collected.
Medicare Supplemental: The patient’s primary insurance is still Medicare. These types of policies cover the deductible and coinsurance that classic Medicare leaves as the patient’s responsibility. Almost all of these plans cover the patient responsibility portion up to 100% of the Medicare allowable amount. You do not have to be contracted with these various Supplemental plans. If the patient has informed Medicare, the secondary plan should be automatically notified by Medicare (commonly called ‘crossover’) when a claim is adjudicated. It is essential to review your Medicare Explanations of Payments (EOP) to ensure the crossover was completed. If not, you will need to bill the Supplemental plan directly with a copy of the Medicare EOP. Examples of this type of plan are the United Health Care AARP Plan and Mutual of Omaha’s Supplement Plan.
Commercial Insurance: Some Medicare patients still have a standard commercial plan as their secondary insurance. Like a Supplemental plan, you do not have to be contracted in order to bill for the patient’s deductible or coinsurance. However, unlike a Supplemental plan, there is no guarantee that the patient’s Medicare deductible or coinsurance will be paid as the Commercial Insurance plan may have a deductible, copayment or coinsurance to which the patient is still liable. Patient’s can be quite adamant and agitated when their secondary insurance does not act like a Supplemental plan.
It is no wonder some of our seniors are a bit confused when it comes to Medicare and the various products out there. Many times the patient does not realize they have signed up for a Medicare Advantage plan which can sometimes severely limit the physicians they may see.
Please call me if you have any questions regarding the above or any other questions.
Yrs.
AJ Riviezzo, MBA
American Physician Financial Solutions
Your Phlebology Billing/Consulting Experts719.233.0099 www.apfsbilling.com
Friday, February 20, 2009
Summertime Blues
A concern many practices may face is a drop in patients during the hot summer months when wearing hose is no fun. There is, though, one group of potential patients who only want services done during the summer… school teachers.
Because they have two to three months off between school years, school teachers typically have elective procedures done at that time. They are also very aware of their legs and leg pain as they stand throughout the work day.
The time to reach out to teachers is while they are still in school. There are three way to specifically target market to school teachers.
1. Contact the administration department for the school district. Try to obtain an appointment to make an informational pitch about venous disease. They may then allow you to put information in the break room of the schools, as a paycheck stuffer, or in some other fashion.
2. If the above does not go forward, you may also reach out to the union representative for the school district. The union representative has a vested interest in ensuring the health and well-being of their members. Again, try to obtain an appointment with the union representative. Better yet, try to get them to come to your facility. If they believe you offer something worthwhile for their members, they may assist you in delivering information to the teachers.
3. Finally, look at your former satisfied patients. Is one a school teacher? Work with them to find out ways in which you can do an outreach directly to the school teachers.
Because they have two to three months off between school years, school teachers typically have elective procedures done at that time. They are also very aware of their legs and leg pain as they stand throughout the work day.
The time to reach out to teachers is while they are still in school. There are three way to specifically target market to school teachers.
1. Contact the administration department for the school district. Try to obtain an appointment to make an informational pitch about venous disease. They may then allow you to put information in the break room of the schools, as a paycheck stuffer, or in some other fashion.
2. If the above does not go forward, you may also reach out to the union representative for the school district. The union representative has a vested interest in ensuring the health and well-being of their members. Again, try to obtain an appointment with the union representative. Better yet, try to get them to come to your facility. If they believe you offer something worthwhile for their members, they may assist you in delivering information to the teachers.
3. Finally, look at your former satisfied patients. Is one a school teacher? Work with them to find out ways in which you can do an outreach directly to the school teachers.
Friday, January 30, 2009
Practice Standards
Below are some practice guidelines for your consideration. Most of these are in regards to your receivables but there are a few operational guidelines as well. For phlebology practices, the number of claims that 'age' due to notes requests and denials will always be higher than the non-specialty standards noted below.
1. Visits without charges as a percentage of total visits.
0%
2. Copay collections as percentage of total copay office visits.
Greater than or
equal to 95%
3. EDI claims as a percentage of total claims billed.
Greater than or
equal to 90%
4. Charge entry lag period.
Equal to or less
than one business day
5. Claims passing claims edits as a percentage of total claims.
Greater than or
equal to 98%
6. Appointment no show rate.
Less than or
equal to 3%
7. Appointment bumped rate.
Less than or
equal to 3%
8. Net A/R days (non-specialty).
Less than or
equal to 40 days
9. Collections as a percentage of net revenue.
Equal to or
greater than 100%
10. Collections as a percentage of gross revenue (non-specialty).
Equal to or
greater than 60%
11. Third party A/R aging greater than 90 days from last activity date.
Less than or
equal to 10%
12. Denials as a percentage of net revenue (including “incidental to” services).
Less than or
equal to 2%
13. Claims with no activity greater than 90 days from last activity date.
0%
14. Credit balances.
Less than or
equal to 2 A/R days
15. Average patient wait time after office arrival.
Less than or
equal to 15 minutes
Published in HFM, July 2007, Magazine for the Healthcare Financial Management Association. Written by David C. Hammer. Posted by kind permission by Mr. Hammer.
1. Visits without charges as a percentage of total visits.
0%
2. Copay collections as percentage of total copay office visits.
Greater than or
equal to 95%
3. EDI claims as a percentage of total claims billed.
Greater than or
equal to 90%
4. Charge entry lag period.
Equal to or less
than one business day
5. Claims passing claims edits as a percentage of total claims.
Greater than or
equal to 98%
6. Appointment no show rate.
Less than or
equal to 3%
7. Appointment bumped rate.
Less than or
equal to 3%
8. Net A/R days (non-specialty).
Less than or
equal to 40 days
9. Collections as a percentage of net revenue.
Equal to or
greater than 100%
10. Collections as a percentage of gross revenue (non-specialty).
Equal to or
greater than 60%
11. Third party A/R aging greater than 90 days from last activity date.
Less than or
equal to 10%
12. Denials as a percentage of net revenue (including “incidental to” services).
Less than or
equal to 2%
13. Claims with no activity greater than 90 days from last activity date.
0%
14. Credit balances.
Less than or
equal to 2 A/R days
15. Average patient wait time after office arrival.
Less than or
equal to 15 minutes
Published in HFM, July 2007, Magazine for the Healthcare Financial Management Association. Written by David C. Hammer. Posted by kind permission by Mr. Hammer.
January/February Marketing Tip
MARKETING TIP:
It is cold and flu season for the PCP’s so they are pretty busy this time of year. However, now is a good time to reach out to other types of providers.
OB/Gyn practices can be a good source of referrals. Try to stop by and visit with the practice manager and the referral coordinator. Better yet, try to have a lunch-and-learn between physicians about varicose veins and how the cosmetic varicose veins can be an indicator of underlying reflux. One thing to be careful about here is cosmetic services. More and more OB/Gyn practices are adding cosmetic services. You do not want to talk about competing services or you will never get a referral for some of the other services you provide.
Podiatry can be another good source of referrals. Patients often go to see a podiatrist for ankle pain or even ulcers. Their pain ends up being reflux. It is easy enough to establish a bit of reciprocity by allowing the podiatrist to place some of their cards or flyers in your office in exchange for referrals and placing cards/flyers in their office. I also recommend inviting the podiatrist to watch an EVLT or two. They typically will not actually come but… as podiatrists are not MD’s/DO’s, they are also not always treated well by the hospital, surgery centers, and physicians. Inviting them to your office to watch a procedure or two generates a lot of good will.
Finally, I have heard of some good success working with wound care centers. If you have one anywhere near you, I would recommend establishing a meeting with their facility administrator and their medical director. Let them know you really do not want to treat the ulcers per se; but that you can likely treat the underlying issues that are causing the ulcer(s). I’ve seen some pretty dramatic results of ulcers being treated not only for the ulcer but for the reflux causing the ulceration. Share some of those stories or pictures with them.
It is cold and flu season for the PCP’s so they are pretty busy this time of year. However, now is a good time to reach out to other types of providers.
OB/Gyn practices can be a good source of referrals. Try to stop by and visit with the practice manager and the referral coordinator. Better yet, try to have a lunch-and-learn between physicians about varicose veins and how the cosmetic varicose veins can be an indicator of underlying reflux. One thing to be careful about here is cosmetic services. More and more OB/Gyn practices are adding cosmetic services. You do not want to talk about competing services or you will never get a referral for some of the other services you provide.
Podiatry can be another good source of referrals. Patients often go to see a podiatrist for ankle pain or even ulcers. Their pain ends up being reflux. It is easy enough to establish a bit of reciprocity by allowing the podiatrist to place some of their cards or flyers in your office in exchange for referrals and placing cards/flyers in their office. I also recommend inviting the podiatrist to watch an EVLT or two. They typically will not actually come but… as podiatrists are not MD’s/DO’s, they are also not always treated well by the hospital, surgery centers, and physicians. Inviting them to your office to watch a procedure or two generates a lot of good will.
Finally, I have heard of some good success working with wound care centers. If you have one anywhere near you, I would recommend establishing a meeting with their facility administrator and their medical director. Let them know you really do not want to treat the ulcers per se; but that you can likely treat the underlying issues that are causing the ulcer(s). I’ve seen some pretty dramatic results of ulcers being treated not only for the ulcer but for the reflux causing the ulceration. Share some of those stories or pictures with them.
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