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.
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.
Monday, December 7, 2009
An Update...
by Cheryl Nash
As of this writing, the actual rates have not been released. However it appears that the proposed 20% decrease has been reversed. It is also projected that ablations will show an approximate 1% increase.
Until the final release happens, we will not be able to identify any changes (up or down) to the other primary codes used in phlebology. We do expect, at this time, for most of the codes to follow a similar pattern of zero to 1% increase.
The stability in rates may be short lived as phlebology work and other units are up for review for 2011. When coupled with the pending legislative changes in Congress, it should prove to be an interesting and dynamic year. We will try to keep you updated as we hear of any proposed, pending or actual changes.
As of this writing, the actual rates have not been released. However it appears that the proposed 20% decrease has been reversed. It is also projected that ablations will show an approximate 1% increase.
Until the final release happens, we will not be able to identify any changes (up or down) to the other primary codes used in phlebology. We do expect, at this time, for most of the codes to follow a similar pattern of zero to 1% increase.
The stability in rates may be short lived as phlebology work and other units are up for review for 2011. When coupled with the pending legislative changes in Congress, it should prove to be an interesting and dynamic year. We will try to keep you updated as we hear of any proposed, pending or actual changes.
It is all about.... ME!
by AJ Riviezzo
All too often professional organizations like Physicians, Attorneys and Accountants spend a good bit of their marketing dollars talking about themselves. How good they are, what sort of equipment or state of the art something or other. But ask yourself a quick question. When you are considering purchasing a service, do you really care about them?
What you really want to know is how whatever you will be purchasing will help YOU.
It is no different for your phlebology practice. The bulk of your information and marketing content should be about the patient. What results they will experience. How you will reduce their pain, swelling, edema, and discomfort. What they should expect. Will their insurance cover the procedure or what is the cost to them.
Review your own marketing literature and your website. If it starts out with a lot of I's and not many You's, perhaps a re-write is in order.
All too often professional organizations like Physicians, Attorneys and Accountants spend a good bit of their marketing dollars talking about themselves. How good they are, what sort of equipment or state of the art something or other. But ask yourself a quick question. When you are considering purchasing a service, do you really care about them?
What you really want to know is how whatever you will be purchasing will help YOU.
It is no different for your phlebology practice. The bulk of your information and marketing content should be about the patient. What results they will experience. How you will reduce their pain, swelling, edema, and discomfort. What they should expect. Will their insurance cover the procedure or what is the cost to them.
Review your own marketing literature and your website. If it starts out with a lot of I's and not many You's, perhaps a re-write is in order.
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