Avoid Medicare Fraud Claims by Coding Correctly

How would you like an investment that returns $7.20 for every dollar you invest? Our government has found just such an investment — healthcare providers.

HHS recovered $4.1 billion in healthcare fraud monies in 2011 to achieve their astonishing 720 percent return on investment. And like any investor on a winning streak, the feds are investing more — another $350 million is allocated to anti-fraud policing under the new healthcare laws.

You may believe you are beyond reproach if you don't order a mobile scooter for every patient or dump your patient records in the nearest landfill, but you should exercise caution in these cautionary times: what the feds consider "fraud" is much broader than your definition. E&M coding, for instance is a potential target; the 99213 and 99214 office follow-up codes were the top two CPT codes in terms of both charges and unit volume in 2010. Don't let your practice be caught up in Medicare's recovery program. It's a simple matter to examine your own coding patterns and compare them to national utilization data collected by Medicare. Knowing how you compare to others within your specialty is important in assessing possible exposure to recovery efforts.

Here are a few reasons you should conduct your own internal chart audits:

Avoid being an outlier. The following chart compares the office follow-up code utilization of four family physicians (Drs. Lovett, Raitt, Nelson, and Jennings) to Medicare's like data for family physicians. Medicare and its fraud contractors have the ability to perform such meta-analyses. Drs. Lovett (red line) and Nelson (purple line) code similarly to the national average (dark blue line). Dr. Raitt (green line) uses a 99213 to code nearly ninety percent of his visits, which makes him a larger target for a chart audit. Dr. Jennings (light blue line) uses 99214 nearly 50 percent more than the national average and 99215 at almost three times the national average. She also is a target for a chart audit.

E&M utilization. While staying under the bell curve will not make you audit-proof, it does decrease the odds that you will be targeted. Medicare produces a data file that contains E&M code utilization and charges by specialty by year, with the most recent year being available here.

To use this data file, extract the unit volume for each E&M code — organized by code set (i.e., office follow-up, hospital admissions, etc.) — into a spreadsheet. Sum the total, as shown below.

Next, calculate a percentage for each code. For instance, family medicine physicians coded a 99211 3.7 percent of the time when Medical billing Services Medicare for an office follow-up visit in 2010.

Extract billing utilization data from your practice management system. Follow the same procedure to calculate the frequency for your utilization of each code.

These percentages can then be used to create a line charge, as shown earlier. While coding above, below, or at the national bell curve for your specialty does not mean you are coding accurately or not, knowing how your personal bell curve stacks up offers a clue to the likelihood of being targeted.

Coding and documentation audits. Regardless of whether your personal bell curve mirrors the national average, I urge you to have your coding and documentation audited on a regular basis. It is critical to know whether your CPT coding, ICD-9 coding, and documentation support one another. I subscribe to the "Noah's Ark" school of chart audits: at least two charts for every E&M code, at least twice a year, by at least two different certified coders. For frequently used codes such as 99213 and 99214, at least five charts should be audited.

Step One: Have your staff randomly pull the billing and chart documentation for recent patient visits for each E&M code. If you game the system by selecting which charts should be audited, you are only gaming yourself.

Step Two: Have a certified coder review each chart and provide a detailed report on your coding, billing, and documentation.

Step Three: Repeat step two, but use a different coder, preferably an outside coder. I say this not to insult certified coders but to protect you. All coders are not created equal, and E&M coding is much more art than science, in my opinion. Medicare will not give you the benefit of the doubt when reviewing your documentation, so you want these audits to be tough and instructive.

Step Four: Repeat this audit on a semi-annual basis. If you see no substantive differences in the findings of your two coders, you may elect to forego the second set of eyes. Still, I recommend that a second coder review your E&M coding at least every two years.

Summary

Remember the $7.20 return on investment the feds are getting on every dollar it invests in healthcare fraud? Medicare estimates it is but the tip of the iceberg. Because their definition of fraud and yours are quite different, it is incumbent on you and your practice to take steps to minimize exposure. Ensuring your E&M coding is in order is a prudent first — and ongoing — step.

ICD-10 Delay May Not Be Enough for Physicians

Physicians and practice administrators can breathe a little easier. On August 24, HHS officially announced the ICD-10  HIPAA compliance date delay from Oct. 1, 2013 to Oct. 1, 2014.

HHS said the decision to finalize the delay, first proposed in April, is due to the fact that providers and other entities need “more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities.”

Still, some physicians say that while they are pleased with the one-year delay, HHS should have done more.

"The AMA appreciates the administration's decision to provide a one-year delay in response to AMA advocacy, but we have urged CMS to do more to reduce the regulatory burdens on physician practices so physicians can spend more time with patients,” emergency care physician Steven J. Stack, AMA board chair, said in a statement. “The AMA recommended that CMS delay the move to ICD-10 by a minimum of two years."

The movement toward ICD-10, which will require physicians and staff to contend with 68,000 codes — five times as many as they currently deal with — comes at the wrong time, Stack said, noting that physicians are already dealing with a variety of stressors, including transitioning to new delivery and payment models.

“The implementation of ICD-10 will create more challenges for physicians when our Medicare system is broken and cannot provide adequate funding to cover the cost of these additional administrative burdens,” he said.

Medical Group Management Association and American College of Medical Practice Executives (MGMA-ACMPE) president Susan Turney said the organization also has concerns despite the delay.

The MGMA is “not confident that critical trading partners, including Medicare and state Medicaid plans, will be ready in time to conduct testing well in advance of the October 2014 compliance date,” Turney said in a statement. “We urge CMS to significantly escalate its implementation efforts by pilot testing ICD-10, ensuring health plan, clearinghouse and vendor readiness, and developing comprehensive educational resources.”

But Steve Sisko, a healthcare and business technology expert specializing in ICD-10, told HealthcareIT News, that if HHS had delayed the compliance date for more than one year, it could have harmful effects for the ICD-10 transition overall.

"A delay beyond one year would probably cause most people to mothball the entire project, while the Oct 1, 2014 deadline keeps momentum going and maintains the value of work already done,” he said.

And AHIMA CEO Lynne Thomas Gordon said that now at least, physicians and other entities have a deadline with which they can work toward.

“ICD-10-CM/PCS implementation is inevitable, but today’s news gives the healthcare community the certainty and clarity it needs to move forward with implementation, testing, and training,” Lynne said in a statement.

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source from Physicians Practice 

Five Common Denials Halting Payments to Your Medical Practice

What if I told you that over 70 percent of the denials you receive from insurance companies can be prevented? Seem a little extreme? It's not. In fact, most all denials from the insurance company come from claims going out that were either not checked for completeness, correct information, or patient eligibility. You can prevent all of this with a few tweaks in your front- and back-office areas.

Do you know why insurance companies deny your claims? This is an area for you to review on an annual basis and check to see how much better you've done than the previous year after implementing a few new policies and procedures. Here are some of the major reasons:

• Patient not eligible at time of service. This most often means that your front-/back-office staff did not obtain quality insurance verification prior to the patient coming in for a visit. It typically is due to the fact that the insurance had termed before you even saw the patient. In instances like this, you can bill the patient since they (hopefully) signed paperwork stating they are fiscally responsible for their bill. Whether or not they actually pay it, is a whole other blog posting.

• No Authorization. This also means that when verifying the insurance prior to the patients arrival, your staff did not obtain the correct (or any) authorization for the visit. It could also mean that the initial authorization was obtained, but any follow-up visits were not. You might want to check your software program to see if there are some limitations you can place to ensure a patient cannot be seen and schedule an appointment without the correct authorization.

•Benefits Exhausted. This means that when obtaining the eligibility and benefits, that dollar limits were not asked about and obtained. Insurance companies have cap amounts on some treatments and procedures. Know those before you perform them, and find out: if they have already been used within the benefit year/lifetime; if there are any pre-existing condition clauses, and/or; if the insurance is for a calendar (January 1 – December 31) year or benefit year (October 1 – September 30 for example).

• Coordination of Benefits. Is the patient giving you all of their insurance information, or are they withholding one because of, say, a high deductible that they do not want to pay? It is not up to the patient to make these decisions. The insurance companies know if they are not required to pay because there is another form of payment available.

• Need Chart Notes. This is one that your front-/back-office staff cannot control. This is simply the insurance company looking for the specific reason for the visit, treatment, or procedure. Utilizing your EHR system to its maximum will ensure that you do not end up with this reason for denial.

Overall, you have much more control over being paid than you think. Work closely with your front- and back-office staff, as well as billing department to identify where the denials are coming from. Then create the appropriate policies and procedures within your practice which will make sure these types of denials decrease today!

Source from Health care news portal

Can Physicians Apply Preventive Medicine Knowledge to EHR ?

A friendly EMR support to increase your cash flow from medicalbillingstar

As physicians, we devote a great deal of effort addressing things that might — not will, but might — happen to patients. The litany is familiar: smoking, drugs, alcohol(Drug information on alcohol), immunizations, guns in the home, accident prevention, cardiovascular risk factors, lifestyle issues, etc.

The list is endless; there are almost an infinite number of things that might happen. We call it preventive medicine. The goal is to prevent diseases and injuries before they exert their damaging effects. It's not a new idea. It was Ben Franklin who said: "An ounce of prevention is worth a pound of cure." The problem is that the patients feel fine and find it difficult to understand our concern. Nevertheless, we keep trying to get them to take the risks and the warnings seriously. Why bother?

First of all, we bother because we have studied medicine. We have the knowledge and we understand the underlying theory that allows us to feel confident that the risks are real and that intervention can alter the outcome. Beyond that there are several other reasons to bother:

1. We believe that the risks, although low, are high enough to warrant concern;
2. Society will be better off (as with vaccines) even if the individual gets only minimal benefit; and
3. When something we could have prevented happens, we will blame ourselves and the patients may blame us for not having tried.

How often do efforts at prevention work? Not often enough. People are notoriously resistant to suggestions that they change their behavior.

It's human nature not to worry about unseen hazards. There is no evidence that doctors do any better than the average patient in this regard.

Are there other kinds of unseen risks, not related to disease, about which we could be doing something? One is EHR. If you have been reading these articles, or practically EHR commentary on the web, you should, by now, have a general idea what they are. Some have a theoretical basis while others have been learned in the school of hard knocks. I'm not going to repeat them here because I have described a number of them in the past and will continue to do so in the future. Practically every day, articles appear that discuss the risks, bad results, cost overruns, and disruptions to work flow and productivity that could be avoided by heeding some of the advice that is offered.

There is a collective (but not organized) effort on the part of those with knowledge and experience to make the “patients” — healthcare organizations and practitioners — aware of the risks that they face and to suggest ways in which they might reduce or avoid those risks. So far the “patients” continue to react with disbelief when apprised of the risks. Perhaps the disbelief can be traced to the lure of incentive payments, the feeling that it is no longer possible to deliver healthcare without a certified computer system, the desire to keep up with the times (or the Joneses), and/or the belief that computers can solve problems. It is the rare practitioner or facility that chooses to stop following the pied pipers of EHR and take a seat in the bleachers.

To gain some perspective, it would be worthwhile to read "Is One Company About to Lock Up the Electronic Medical Records Market?"

It's very disturbing. This article describes a major vendor that favors the goal of dominating the market over technical excellence or a concern for the lifetime medical record. (Do they really think that they will still be around 100 years from now and that we will still want whey have to offer?) The vendor has done a superb job of identifying and selling to the customer’s expectations, with the understanding that those expectations rarely emphasize technical factors or the impact on productivity.

A market dominated by a single vendor poses a risk. When the cost of an EHR is astronomical, the customer may become financially unstable. Perhaps most damaging to the future of EHR is the risk that the development of new EHR science and innovative EHR products will be stifled. It would not be the first time that market domination caused problems, if you remember IBM, AT&T and Microsoft. They were all broken up because their market dominance was deemed to be anti-competitive and anti-innovation.

There is a choice: Turmoil now, while your sanity and finances are relatively intact, or turmoil later, when the unthinkable happens and leaves you broke and crazy. I'm raising these issues because I don't want to wind up hating myself for not making an effort.

 Source from Healthcare News Portal

New HHS rule targets HIPAA, standardization the goal

Whatever may be the rules MedicalBillingStar changes according to it in caring the physcians as well as patients in their revenue growth by our medical billing services

HHS Secretary Kathleen Sebelius announced Friday a final rule establishing a health plan identifier (HPID), that officials say will boost standardization within HIPAA transactions and increase the efficiency of health billing processes. 

The final rule, established by the Office of E-Health Standards and Services (OESS), also includes a data element that functions as an “other identity” identifier (OEID), which is designated for non-health related entities or individuals that still need to be identified for standard transactions. 

The rule is one of a series of changes required by the Affordable Care Act to cut red tape in the health care system and will save up to $6 billion over ten years, according to HHS officials.

“These new standards are a part of our efforts to help providers and health plans spend less time filling out paperwork and more time seeing their patients,” said Secretary of Health and Human Services Kathleen Sebelius in a press release. 

Currently, when a care provider bills a health plan, that plan may use a wide range of different identifiers that do not have a standard format. Officials say this results in health care providers running into a several time-consuming problems, such as misrouting of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility. HHS officials say today’s rule will greatly simplify these processes.

HHS says the primary purpose of the HPID and the OEID is for use in the HIPAA standard transactions. The most significant benefit of the HPID and the OEID is that they will increase standardization within the HIPAA standard transactions. 

“The adoption of the HPID and the OEID will increase standardization within HIPAA standard transactions and provide a platform for other regulatory and industry initiatives,” HHS wrote in the final rule summary. “Their adoption will allow for a higher level of automation for health care provider offices, particularly for provider processing of billing and insurance related tasks, eligibility responses from health plans, and remittance advice that describes health care claim payments.”

From the HHS Fact sheet:

Cost and Benefits
The HPID is expected to benefit health care providers, producing savings from two indirect consequences of implementation of the HPID: the cost avoidance of a decrease in administrative time spent by physician practices interacting with health plans, and a material cost savings through automation of processes for every transaction that moves from a manual transaction to an electronic transaction.

Over ten years, the projected net savings of implementing HPID for the entire health care industry is approximately $1.3 billion to $6 billion.

Compliance requirements
Health plans, excluding small health plans, are required to obtain HPIDs by two years after the effective date, in 2014. Small health plans are required to obtain HPIDs three years after the effective date, in 2015.  All covered entities are required to use HPIDs where they identify health plans that have HPIDs in standard transactions four years after the effective date, in 2016.

Source from health care news portal

ICD-10 delay where Groups express support over it

MedicalBillingStar is moving across the forth coming process on ICD-10 codes.

The Department of Health and Human Services' Aug. 24 decision finalizing a one-year delay for the ICD-10 switchover has elicited both favor and concern among industry groups. 

 

The Medical Group Management Association (MGMA), for example, is one organization that has expressed concerns over HHS’ decision to push the compliance date for ICD-10 – which includes some 155,000 codes for new procedures and diagnoses – back to Oct. 1, 2014, citing increased physician burden as a significant worry. 

“Despite the additional year for ICD-10 implementation, MGMA remains concerned that the Centers for Medicare & Medicaid Services (CMS) has mandated this new code set without having undertaken the necessary due diligence to ensure it will not create debilitating cash flow disruptions for physician practices,” said Susan Turney, MD, president and CEO of MGMA-ACMPE. 

“We are not confident that critical trading partners, including Medicare and state Medicaid plans, will be ready in time to conduct testing well in advance of the October 2014 compliance date. We urge CMS to significantly escalate its implementation efforts by pilot testing ICD-10, ensuring health plan, clearinghouse and vendor readiness, and developing comprehensive educational resources,” added Turney.  

MGMA-ACMPE represents upwards of 22,500 members, both professional administrators and leaders of medical group practices, and more than 280,000 physicians.

Other groups, however, have expressed support for the ICD-10 compliance date pushback. 

The College of Healthcare Information Management Executives (CHIME), for instance, expressed positive sentiments regarding the ICD-10 delay. “Overall CHIME applauds the efforts of HHS to quickly and decisively signal a commitment to ICD-10 conversion and we urge the Department to develop a clear path forward, with benchmarks, so that healthcare industry stakeholders can make the conversion in 2014," said CHIME president and CEO Rich Correll.

Back in April, CHIME submitted comments urging the CMS to keep the one-year ICD-10 delay, as they said anything longer would be disruptive to any efforts moving toward the change. “CHIME is pleased that CMS understood the importance of finalizing its proposed one year delay for compliance to ICD-10,” Correll added.

CHIME is an executive organization, representing upwards of 1,400 CIO members and 70 healthcare IT vendors and firms.

Other group responses aired more on the end of neutral acceptance.
The American Health Information Management Association (AHIMA), for example, pledged it support for the healthcare community in light of the ICD-10 ruling, despite not originally being in favor of the delay.

“We were not in favor of a delay at all, from the very beginning," said Melanie Endicott, director, HIM Solutions at AHIMA. "But since there is a delay, we’re glad it’s just one year.”
HHS' ruling "gives the healthcare community the certainty and clarity it needs to move forward with implementation, testing and training,” said AHIMA CEO Lynne Thomas Gordon. “We realize that a few are still apprehensive about the implementation process, and that is why AHIMA remains committed to assisting the healthcare community with its transition to a new code set that will lead to improved patient care and reduced costs."
Endicott cited the heightened costs of providing one more year of additional training and education for providers and coders alike as a downside to the ICD-10 delay. “We feel that were a lot of healthcare entities that were ready for the Oct. 1, 2013, and delaying it a year is just causing increased costs to them,” she said.
With the new decision, however, AHIMA, which represents more than 64,000 specially educated Health Information Management professionals worldwide, is gearing up to provide increased education and resources to all the different medical settings.
The Healthcare Information and Management Systems Society (HIMSS) also released a statement, writing that the ICD-10 compliance delay "provides clarity that will allow organizations to properly allocate their resources to meet the new deadline.  Given the role ICD-10 has in providing impactful data that will support quality improvements needed for healthcare transformation, HIMSS supports active participation by all community partners in preparation for the ICD-10 transition."


source from healthcare news portal.

Crisis Management at Physicians Medical Practice Issues.

What Kinds of Issues Are Doctors Facing?

Don't Give up physicians ,Leave your worries to MedicalBillingStar for our leading medical billing services

Most doctors wrongly assume that any exposure or unwelcome publicity will be limited to issues surrounding their practice; that’s unfortunately not the only case. A review of news articles that cite doctors being, sued, arrested, or investigated covers a wide spectrum and extends in some cases even to members of their family and employees. The news loves to throw in, "A prominent local doctor was arrested tonight…"

The first and most obvious warning is simple; don’t do things, or allow others to do things that you can control, that place you and your practice in a negative light. Even a simple altercation with a neighbor or a DUI becomes newsworthy when a physician is involved and even more so if that doctor is locally prominent. Common examples of things that will get you on the news and detract from your credibility and professional standing:

• Driving while intoxicated or any drug- or alcohol(Drug information on alcohol)-related offense (or even behavior), including while traveling, flying, or on vacation. Think you are out of eye shot? I’ll bet you already know which congressman from the Southwest was just embarrassed for skinny dipping in Israel on a state trip;

• Any offense involving sexual conduct, or misconduct especially with a patient but this seems to be a no-holds-barred category and you will be named in even remote cases involving the conduct of family members and employees that has nothing to do with you; and

• Any investigative report or government, law enforcement, or task force investigation on issues like billing, prescriptions, or ID theft. Regardless of what they actually find, (or don’t find), just being mentioned is pejorative.

An Action Plan for Doctors

What should you do if you find yourself in the limelight? Public relations experts’ opinions vary widely on the best defensive course of action and damage control, but most agree on all the following guidelines:

• Have an Information Officer (IO). This simply means appointing a lead source of contact and information for the media and the public. Pick carefully, it may not always be the best idea to represent yourself in this capacity. Pick someone objective, articulate, informed, and who has the judgment and authority to answer questions on your behalf. Make your staff and family aware of the IO and their role and welcome them to politely refer questions to that person.

• The best defense is a good offense. Put out good information that you control through the IO, make sure it is true and factual and properly disseminated, you want it found first.

• If it’s an issue involving legal misconduct of any kind that requires you to have legal representation, or likely will require you to, check with your lawyer first. Don’t make any public statement either verbally or in writing. Innocent utterances, in your opinion, can certainly be twisted or used against you. In some cases, if your attorney has the personality and control it may be appropriate to have him be your IO, especially in cases involving potential civil or criminal liability.

source from physicians practice.