Medicare shoots first and asks questions later

On Oct. 5, 2009, the Centers for Medicare and Medicaid Services (CMS) quietly began implementing system edits intended to assure that Medicare Part B providers and suppliers bill for ordered or referred items or services only when those items or services are ordered or referred by physician and non-physician practitioners who are eligible to order/refer such services.  The edits are an expansion of existing claims edits intended to meet the Social Security Act requirements for ordering and referring providers.  Essentially, the law requires that a provider or supplier who bills Medicare for an item or service that was ordered or referred must show the name and unique identifier of the ordering/referring provider on the claim.

That is all well and good, but CMS has interpreted that to mean that claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider and the ordering/referring provider must be in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) or in the Medicare contractor's claims processing system with the appropriate type of provider.  During Phase 1 of the implementation (Oct. 5, 2009 to Jan. 3, 2010),  if the ordering/referring provider is not in PECOS and is not in the claims system, the claim will continue to process and the Part B provider or supplier will receive a warning message on the Remittance Advice.  During Phase 2 (Jan. 4, 2010 and thereafter), if the ordering/referring provider is not in PECOS and is not in the claims system, the claim will not be paid. It will be rejected (but not denied), which means it can be resubmitted at some point, but it cannot be appealed.  For more information, you can read MedLearn Matters article 6417 on the CMS web site. 

Like seemingly all Medicare policies, this one is fraught with problems.  For instance, despite being enrolled in Medicare, if physicians and other health care practitioners are not in the PECOS database or in contractor files, those physicians, suppliers, and other health care practitioners to whom they refer and order services will not be paid. A physician or health care practitioner who enrolled in Medicare prior to 2003 when CMS began using PECOS will be required to re-enroll if they want to continue referring and ordering. As of July 2008, there were 793,346 physicians and other health care practitioners enrolled in Medicare.  According to data from an October 2009 Office of Inspector General report, there were 559,235 physicians and other health are practitioners in PECOS. Therefore, as many as 200,000 or 30 percent of all Medicare physicians and other health care practitioners are not in PECOS and will need to re-enroll, and we all know how glacial the pace of Medicare enrollment is. 

Another flaw is that some providers who commonly refer Medicare patients or order services for them do not typically enroll in Medicare.  For instance, some residents may not be enrolled in Medicare but will certainly be ordering or referring providers for Medicare purposes.  Likewise, dentists may be ordering/referring providers but otherwise have no reason to enroll in Medicare.  CMS staff indicate that they will soon be issuing instructions to deal with the dentist issue, but one wonders why CMS didn't think to do that before it started implementing the edits in question. 

Finally, physicians have no practical or convenient way to check whether the physicians or other health care practitioners who send them patients with orders or referrals are included in PECOS or other contractor enrollment records. CMS has promised to address this particular concern by making publicly available a list of eligible referral providers before January 2010, but again, one is left to wonder why they did not do so before implementing the edits.  I can only conclude that CMS staff favors the "shoot first and ask questions later" approach. 

In the meantime, downstream providers and suppliers of referred/ordered services/items are at risk of nonpayment, even though they are not responsible for the enrollment/reenrollment of physicians and other health care practitioners who legally order and refer patients to them for items or services.  That is why the AAFP, the AMA, and 54 other organizations are advocating with CMS to:

1. Take action to ensure that otherwise acceptable claims are paid without delay or need for appeals;
2. Indefinitely suspend the plan to deny these claims and instead wait at least until all practicing Medicare physicians, other health care practitioners, and residents can be revalidated and reenrolled or enrolled for the first time;  
3. Focus its efforts on ensuring a smooth and efficient revalidation process, which will require physicians and other health care practitioners to re-enroll in Medicare if they have not done so since 2003; and, 
4. Convene a high-level meeting with stakeholders to discuss concerns about ordering and referring physicians and other health care practitioners, and collaboratively develop a feasible and appropriate plan and timetable for addressing these concerns.

It remains to be seen how CMS will respond to this advocacy.  In the meantime, please be aware of the issue and how it may affect your Medicare claims beginning in January. 

Posted at 01:43PM Nov 19, 2009 by Kent Moore  |  Comments[0]

Sunny with a chance of gloom

There is potential good news on the Medicare horizon as far as family physicians are concerned.  However, the silver lining is attached to a big, black cloud that could rain on everyone's parade unless Congress intervenes by the end of the year.

On Friday, Oct. 30, the Centers for Medicare and Medicaid Services (CMS) put the final rule on the 2010 Medicare physician fee schedule on display for review and comment by all interested stakeholders.  CMS plans to publish the final rule in the Federal Register on Nov. 25, 2009.  CMS will accept comments until Dec. 29, 2009.

In the final rule, CMS finalized many of the proposals that it made in its proposed rule earlier this year.  For those of you keeping score at home, that's good news for family physicians.  In fact, in the final rule, CMS estimates that family physicians will experience a 4 percent increase in their Medicare allowed charges in 2010 as a result of the rule, all other things being equal.  That is second only to ophthalmologists and optometrists, who are projected to reap a 5 percent increase, and much better than physicians in many other specialties, who are expected to see a decrease in their 2010 Medicare allowed charges as a result of the rule.

Of course, with Medicare, there's always a catch, and the final rule on the 2010 physician fee schedule is no exception.  Under current law, the Medicare conversion factor, which translates Medicare's relative value units into payment allowances, is scheduled to decrease 21.2 percent on Jan. 1, 2010, which would more than wipe out the potential gains for family medicine noted above.  That means Congress has until Dec. 31, 2009, to intervene, as it has the last several years, to avoid this cut.  Forecasters inside the Beltway are optimistic, but as they say on Wall Street, past performance is no indication of future returns.

So, as we approach the new year, the outlook is sunny, but you might want to keep your umbrella handy, just in case.

Posted at 02:17PM Nov 05, 2009 by Kent Moore  |  Comments[0]

Crossing the finish line

In a relay race, no matter how hard all the others run, if one runner drops the baton, the team will likely lose the race. Likewise, if you provide and document a patient's care and select the correct codes and modifiers for that care, but the claim gets sent to the wrong payer, denied, and written off as bad debt, you have likely missed the goal of getting paid for services provided. There are many steps and hand-offs in the race to getting paid so you need to be sure that each runner finishes his or her leg.

Now, I am not saying that there aren’t a lot of other factors influencing the financial health of your practice, such as payer fee schedules that are set too low. However, I’ve seen firsthand, and the statistics show, that a lot of the money that physicians should collect is left behind due to lack of training and discipline in the billing process. To collect all that is due your practice, you need trained and disciplined staff using a well-designed system.

I’m not talking about expensive computer systems or consultants. Much of this comes down to the basics that haven’t changed since the days of using a typewriter and a whole lot of White-Out to produce claim forms. Good billing practices have always depended on team work and efficient processes.

Some simple steps include the following:

1. Verify the patient's insurance coverage each time a service is scheduled.
2. Know what services may not be covered or require prior approval. 
3. Get charges to the biller as soon as possible after services are provided.
4. Verify charges billed against the sign-in sheets or other records of what patients were seen each day.
5. Update insurance information every time charges are entered.
6. Research all unpaid claims and take any necessary action within 45 days of date of service.
7. Review a report of write-offs each month to determine appropriateness.

These steps illustrate that the process depends on a team of people (though in smaller practices, each person may run longer legs). The scheduler gets the initial information. The front desk staff copy the cards and update demographics. Clinical staff get any necessary prior approvals and document all charges promptly. Billing staff update information, enter charges correctly and follow-up on the account until paid. Finally, a manager or physician reviews what was paid and what was written off and makes adjustments as necessary to keep the team fit.

Need more information or some resources on billing and accounts receivable management? The AAFP has some resources to help. See the Billing & Claims section of the AAFP Coding Resources web page -- and, of course, the FPM Toolbox (click on the link titled "Billing, Collections and Claims Processing").

Posted at 12:51PM Nov 02, 2009 by Cindy Hughes  |  Comments[0]

You might be a coding and payment geek if . . .

The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people.  So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:

10.  The first thing you associate with December is the arrival of the new CPT book.

9.  You actually get excited when your new coding books arrive.

8.  You wonder why the toy doctors bag you bought your kid doesn't include a claim form.

7.  You worry your family physician is undercoding your visit.

6.  You consider the Federal Register light reading.

5.  You write to CMS more than to your own mom.

4.  You actually understand Medicare's Sustainable Growth Rate formula.

3.  You collect past issues of CPT Assistant on eBay.

2.  When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.

 And the number one sign that you might be a coding and payment geek:

1.  You actually understood the humor in this blog post!

Posted at 01:10PM Oct 22, 2009 by Kent Moore  |  Comments[0]

Flu vaccinations: Do you want fries with that?

Do you have any pediatric patients who haven't been in for a preventive care service in more than a year? Adults who aren't coming in for regular blood pressure, cholesterol or other important screenings? These patients (or their parents) may be calling your office to make H1N1 and seasonal flu shot appointments in the weeks ahead, creating opportunities to provide them with overdue preventive services.

If it's not practical for your staff to determine what services the patient needs and discuss them when the patient calls to schedule a flu shot, you might consider brief counseling at the time of the vaccine administration about the need for specific preventive services and suggest scheduling an appointment for the near future. If you're short on time, simply reminding the patient of the date of the last visit might also remind him or her that preventive or chronic care management services are overdue.

This may also be a great time to gain new patients to your practice. Creating the atmosphere of a medical home around the vaccine services, as opposed to providing drive-thru medicine, could benefit both your practice and your patients.

They say that when life gives you lemons, you should make lemonade. Maybe when life gives you an influenza outbreak, you can make opportunities to strengthen your patient relationships.

Posted at 09:48AM Oct 09, 2009 by Cindy Hughes  |  Comments[0]

Getting paid for H1N1-related services

Do you know where to obtain H1N1 vaccine for your patients and how to bill payers for its administration?

Free H1N1 vaccine kits are available through your state health agencies. The Centers for Disease Control has published a list of who to contact for information on obtaining the vaccine. If you do not wish to provide the vaccine in your practice, you can use this list to determine where to refer your patients.

Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers. Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost. For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660). Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.

Your local private payers may still be deciding on the coverage and payment for the H1N1 vaccine, but most national payers have provided some guidance. The recent creation of CPT code 90470 for H1N1 vaccine administration may cause some plans to issue revised instructions. We have requested updated guidance from national health plans and will update the AAFP resources on H1N1 with this information as we receive it. As with all services, practices should check the individual patient’s benefits when scheduling the services.

Finally, it’s important to know how to code and bill for care provided to patients who are sick with the flu. New influenza diagnosis codes took effect Oct. 1, 2009. Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or URI. Code 487.0 for reporting influenza with pneumonia is also still valid. When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.

Posted at 02:31PM Oct 02, 2009 by Cindy Hughes  |  Comments[0]

Records requests: Answer carefully

Your practice probably receives multiple requests for records each week. Unfortunately, more and more of these requests are related to your claims for payment. With ever-growing reports of waste and abuse in health care and profits to be made in recovering money paid to physicians and other providers, these requests are not going away. Whether from Medicare administrative contractors (MACs), recovery audit contractors (RACs), Comprehensive Error Rate Testing (CERT) program contractors, private payers or Medicaid plans, how your practice responds to these requests can make a big difference in your practice's financial future.

So the first question is, who responds to these requests in your practice? Do they understand the importance of sending the right records to support the services billed and doing this in the time period specified on the request? Many of you may be familiar with the CERT program that the Centers for Medicare & Medicaid Services (CMS) commissioned to review the accuracy of claims paid by their Medicare contractors. Some of the most common reasons for errors in the program are these:

1. Records not sent.
2. Records sent but not for dates or services billed.
3. Records illegible or unsigned.

If your practice doesn't provide the records to substantiate your charges, the claim is found to have been paid in error. Medicare contractors are obligated to recover money paid in error. Auditors working for private payers are incentivized to recover money paid in error.

The second question is whether you have a process for making sure that all documentation is provided to support the charges in question. If not, it is probably time to implement one. Here are some tips that might help:

• Identify a primary and back-up staff person to receive all records requests related to claims or payment.
• Create a log identifying the date the request was received, the type of records requested and the date the records were sent.
• If there is any question whether documents are legible or sufficient to support the services that were billed, the physician or other provider of services should review the records and provide a transcribed copy of the documentation in addition to a copy of the original documentation and/or a letter explaining any additional information that may have bearing on the outcome of the review. (Any addendum to the original documentation should be signed with the current date added.)
• Create a checklist to be used in confirming that copies are ready to be mailed.

Establishing a formal process for responding to requests for records may provide a framework for ensuring that all are appropriately and efficiently handled and help to identify recurring gaps in documentation. It may also protect money already paid to you as well money that you are due.

There are already too many opportunities for practices to lose money in the insurance billing process. Most practices can't afford to take lightly efforts by Medicare and others to recover money they have already been paid.

Posted at 05:34PM Sep 25, 2009 by Cindy Hughes  |  Comments[0]

Why?

I am trying to figure out why family physicians choose to contract with health plans. 

My pondering of this question is prompted, in part, by an article, "What Does It Cost Physician Practices to Interact with Health Insurance Plans," which appeared as a web exclusive on May 14, 2009, in Health Affairs. According to the article, primary care practices spent $64,859 annually per physician – nearly one-third of the income plus benefits of the average primary care physician – on interactions with health plans. The article also notes that primary care physicians, especially those in small practices, spend larger amounts of time interacting with health plans than physicians in other specialties.

Why would a family physician voluntarily spend almost $65,000 per year for the opportunity to interact with commercial health plans? What do family physicians think they are getting for their money?

The article suggests that there are benefits to these interactions. For example, the authors point out, prior authorization and formulary requirements may reduce costs and improve the quality of care by reducing the inappropriate provision of services and promoting the use of appropriate procedures and medications. That may be, but somehow, I doubt that's why family physicians buy into the process. After all, $65,000 per year would go a long way toward the purchase of an EHR with decision support tools and electronic prescribing, which might also achieve the same results with less aggravation in the long run. 

Some might suggest that family physicians don't "choose" to contract with health plans, that they have to do so for their practices to be viable. In this view, health plans are like some sort of health insurance Mafia that make family physicians "an offer they can't refuse" to ensure their practices stay open. Given the relative bargaining strength of family physicians and most health plans, this view is understandable. 

The corollary to this answer is that if a family physician chooses not to contract with health plans, he or she won't have any patients, or at least not enough to sustain the practice. The premise here seems to be that patients do not value the services of family physicians beyond the co-payment most of them currently must pay for an office visit. 

However, there are some problems with this answer and its corollary. One problem is that there are examples of family physicians who have successful cash-only practices, and I'm not talking about the kind of practices that only cater to the lifestyles of the rich and famous. Family Practice Management has highlighted some over the years; for example, see "2,500 Cash-Paying Patients and Growing" in the February 2006 issue. 

Another problem is that it's not clear where else all of these patients would go if family physicians opted out of contracting with health plans. According to a one-pager produced by the Robert Graham Center, family physicians and general practitioners provided 24 percent of the average 838 million visits per year provided by all physicians in 2003. If my math is correct, the rest of the system would have to increase its capacity by one-third to cover all of those visits, if patients decided not to see family physicians because they didn't accept insurance. I find it hard to believe that is possible.

I understand that the counterpoint here is that contracting decisions are made at the individual practice level, not the level of the specialty as a whole. In other words, family physicians contract with health plans because they are afraid that if they don't, their patients will go to their colleagues who still do. I understand that counterpoint to mean that family physicians choose to contract with health plans because their colleagues do, from which one might conclude that if their colleagues jumped off a cliff, most family physicians would do the same.   

A third problem with the "I-can't-afford-not-to" argument is that it runs contrary to what family medicine is saying and has evidence to support regarding the value of family physicians. Much of what is being discussed in the context of health care reform shows buy-in for the notion that there is value in primary care, and proposals on Capitol Hill would spend billions on primary care, including family medicine. Yet, interestingly, many family physicians seem convinced that patients won't pay more than $25 for their services. 

The only remaining answer I can discern to the question of why family physicians contract with health plans is that they are making money on the deal. In short, it must be worth more than $65,000 per year to contract with health plans. I would find this answer more convincing if family medicine did not consistently rank near the bottom of earning lists by specialty. I would also find it more convincing if the percentage of U.S. medical student graduates choosing family medicine was higher or trending upward. 

In the end, the more that I ponder the question of why family physicians contract with health plans, the less that I think I know the answer.

Posted at 09:28AM Sep 16, 2009 by Kent Moore  |  Comments[0]

The health plan two-step

Most folks have heard of the Texas two-step. The Texas two-step is danced with two quick steps and two slow steps. 

The health plan two-step is even simpler. It is one step forward and one step backward. The latest demonstration comes courtesy of Aetna. 

In February 2006, Aetna agreed to pay the full allowed amount for a standard evaluation and management (E/M) service (e.g., a problem-oriented office visit), when billed with modifier 25 and a preventive E/M service. In essence, Aetna agreed to pay the full allowed amount for both services. This was progressive compared to other payers, like CIGNA and UnitedHealthcare, who only pay the acute service at a rate of 50 percent when done at the same encounter as a preventive medicine visit. Of course, some payers completely bundle the acute visit into the preventive visit in that scenario, resulting in payment only for the preventive service.

Anyway, Aetna took the second step of the health plan two-step earlier this month. Effective Aug. 15, 2009, Aetna began applying concurrency rules when two E/M services are billed and allowed with modifier 25, meaning each additional service is paid at less than the full amount. Aetna considers the preventive medicine visit to be the primary service and payable at 100 percent of the allowed amount; it considers the eligible office, or problem-focused, E/M to be the secondary service payable at 50 percent of the allowed amount. Apparently, there are others, like Aetna, who also giveth and taketh away.

The only upside that I can find in this particular dance is that Aetna's policy is now consistent with others' policies, so you have one less exception to remember. On the other hand, as Ralph Waldo Emerson once observed, "A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines." I guess Aetna thinks a lot of it, too.

Posted at 11:07AM Aug 28, 2009 by Kent Moore  |  Comments[2]

The trouble with consultations

In a rather surprising move, the Centers for Medicare and Medicaid Services (CMS) included in the proposed rule on the 2010 Medicare physician fee schedule a proposal to remove codes for consultations from the Medicare fee schedule. Physicians instead would report the office/outpatient, hospital, or nursing facility evaluation and management (E/M) visit codes as appropriate, and these codes would be awarded higher relative value units (RVUs) in the fee schedule, resulting in  potentially higher payment. Whether these increased payments would make up for the elimination of the higher-paying consultation codes likely depends on each individual physician’s mix of consults and office/hospital visits and the percentage of established patients versus new patients.

Some physicians won't like this, as it redistributes payment for E/M services among all physicians. These physicians state that their work is always worth more money because of the additional education and training they have related to specific medical problems. What they may be missing is that Medicare is offering a carrot, an increase in RVUs for non-consult E/M codes and fewer of the coding and documentation burdens that were associated with consultation codes.

At the same time, the Medicare auditors are bringing out the sticks in the form of pre-payment and post-payment audits. Medicare's Comprehensive Error Rate Testing (CERT) Report for May 2008 specified a high "paid claims error rate" of 16.6 percent for consultation services, with a projected improper payment of $516,912,824. Incorrect coding accounted for 86.4 percent of the consultation coding errors. WPS, Medicare contractor for Iowa, Kansas, Nebraska and western Missouri is performing a widespread probe of all consultation claims submitted and requiring pre-payment submission of medical records to substantiate charges. Other Medicare contractors have also chosen consultations for review. Given the state of Medicare funding, can the administrators ignore these results and not attempt to collect (with interest) the money paid out for these consultation services? Will Medicare's Recovery Audit Contractors, who receive a percentage of all money returned to Medicare, ignore these findings? If it were me, I'd accept the carrot and hope the stick is eventually aimed elsewhere.

The proposed removal of consultation codes from the Medicare fee schedule is mostly positive for family physicians, since you seldom get the benefit of the higher payment associated with consultation codes despite doing extensive work-ups before referring patients to subspecialists for specific procedures. However, there could be a drawback in that the higher payment was an incentive for the subspecialists you refer to to promptly report back to you, as the consultation codes require. There is some danger that removal of the incentive will cause greater delays or failure of communication, making it more important than ever that your staff keep logs (automated or manual) to be sure that you are aware of all physicians caring for your patients and follow-up as needed to receive records or reports. If you don't have systems in place to help track referrals, lab tests, etc., consider downloading the AAFP's Road to Recognition guide. Though created to help physicians document the elements necessary for recognition under the National Committee for Quality Assurance's Physician Practice Connections - Patient-Centered Medical Home (PPC-PCMH), the simple tracking tools it includes may be useful in many practices. If you feel certain that you always receive timely written follow-up from consultants, using these tools will provide you with evidence of whether your feelings are matched by your results.

Posted at 04:52PM Aug 20, 2009 by Cindy Hughes  |  Comments[0]

Potentially good news on the Medicare horizon

I don't normally recommend reading the Federal Register unless you're a masochist or have trouble sleeping. However, last month, the Centers for Medicare and Medicaid Services (CMS) published its proposed rule on the 2010 Medicare physician fee schedule in the Federal Register, and there is actually some good news for family physicians in what CMS is proposing. 

Among the proposals that CMS estimates will have a positive impact on family physicians, two are most significant. One is that CMS proposes to use more current physician practice cost data in its calculation of practice expense relative value units. The other is that CMS proposes to increase the relative values of office visits and initial hospital visits in conjunction with a proposal to no longer recognize and pay consultation codes. CMS estimates that the impact of these changes would result in approximately an 8 percent increase in Medicare allowed charges for family physicians in 2010. Not surprisingly, the AAFP has commented in support of both proposals.

Of course, every silver lining is attached to a cloud. In this case, the cloud is a 21.5 percent decrease in the Medicare conversion factor for 2010 if Congress does not intervene between now and Jan. 1. Here's hoping the folks on Capitol Hill get around to that, whether or not they get around to health care reform in general. 

CMS is accepting comments on the proposed rule until Aug. 31. You can submit comments online or by other means specified in the proposed rule. 

Posted at 03:32PM Aug 12, 2009 by Kent Moore  |  Comments[0]

Mr. Jones doesn’t have insurance anymore

Imagine this scenario: Mr. Jones has been your patient for years; he has always paid the portion of your bills not covered by his health insurance. Recently he cancelled a follow-up visit for his hypertension and did not request refills of his medications. He explains that he has been laid off and can't afford the COBRA premiums that would allow him to continue the health insurance from his former employer. As Mr. Jones’ medical home, what is your role in helping him to get the medical care he needs? Do you just hope he finds another job and insurance before his health is negatively impacted? Ask him to come in but not charge for the visit? What if he needs lab testing or referral for services not provided in your office? Do you provide medication samples? What resources and policies are in place to help your and your staff handle this kind of situation? 

A recent AAFP poll indicates that family physicians and their patients are feeling the brunt of the economic downturn. As recent AAFP survey reported in AAFP News Now found that 71 percent of respondents had provided more uncompensated care during the first months of 2009, and 66 percent reported taking specific actions -- such as cutting their fees, moving patients to generic prescriptions, or providing free screenings -- to help patients.

These actions are admirable but not without potential complications. Could giving a discount be in violation of the terms of insurance contracts or legal statutes aimed at preventing inducement to receive services? What if any documentation is required? Don’t have all the answers? Here's some guidance on how to assist patients without harming your practice. 

First, physicians can offer discounts to patients who cannot afford to pay. The Office of the Inspector General made this clear as far back as 1994. The key is that the practice must have a policy for extending discounts based on the individual patient’s financial need. This policy should include verifying the patient’s household income, expenses and available assets. A standard form can be used to obtain this information. Practices should designate a person who will review the information, verify current income by checking a previous year’s tax return or current payroll and/or other income documents (e.g. unemployment benefit amount), and make a determination for either a complete write-off of a debt, percentage discount or payment plan. The Federal Poverty Guidelines are a good basis for establishing your standards for providing discounted or free care. For example, you might choose to provide discounted services to anyone whose family income is under 300 percent of the poverty guidelines for their family size, starting with a 20 percent discount on patient balances at that income level and increasing the discount percentage as the percent above the poverty guidelines decreases. 

Next, patients who lose their jobs may need information to help them make good decisions during tough times. Your practice can provide this information through the web sites listed below and by asking for any patient information handouts that might be available from your state and county health services. 

Resources to help patients who’ve lost jobs and insurance coverage:

Getting Covered: Finding Insurance When You Lose Your Job (includes information on the importance of continued coverage to avoid pre-existing clauses under future plans and on COBRA premium subsidies)

State Guides to Finding Health Insurance (includes information on state Medicaid, CHIP, and high risk pools) 

Look for more information on how to help patients with financial limitations in an upcoming issue of FPM. In the meantime, do you know of other ideas and resources for helping patients in need? If so, I hope you’ll comment and share them.

Posted at 02:43PM Jun 19, 2009 by Cindy Hughes  |  Comments[0]

The check may yet be in the mail

I know it's 2009, but Medicare's 2007 Physician Quality Reporting Initiative (PQRI) continues to make news. 

Those of you who have been following this saga may recall that a lot of physicians who thought that they should have received a bonus check for participating in the 2007 version of PQRI never did. It turns out that some of them probably should have, after all.

In a set of new PQRI frequently asked questions posted on the Centers for Medicare and Medicaid Services (CMS) web site, CMS confirmed that it is re-running the 2007 PQRI feedback reports and incentive payments. According to CMS, it investigated reported issues following delivery of the 2007 PQRI feedback reports and incentive payments and determined that several unanticipated technical issues could be corrected by conducting back-end system analytics and re-running the data. New reports are anticipated to be available in the fall of 2009.

These new reports will be available only for those eligible professionals who have qualified due to the back-end system analysis and re-running the data. That means if you already received an incentive for 2007, the re-run will not apply to you, and you will not receive an additional feedback report. For those that do qualify, feedback reports will be available via the PQRI Reports Delivery System, for which an Individuals Authorized Access to the CMS Computer Services (IACS) user name and password will be required to access.

Interestingly, there will also be a 2007 PQRI re-run for Medicare Advantage participants.  Thus, those Medicare Advantage eligible professionals who previously did not receive a bonus but are bonus eligible following the back-end system analysis and re-run of the 2007 PQRI data will potentially receive the 2007 re-run incentive.

So, if you thought you were owed a 2007 PQRI bonus check, you may still be right.  Unfortunately, you won't find out for sure until this fall.  Think of it as Christmas in October ...  from the U.S. Department of Better Late Than Never.

Posted at 03:53PM Jun 15, 2009 by Kent Moore  |  Comments[0]

Everything's up-to-date in Kansas City

Last week, I received a call from a doctor's office inquiring why her claim for a B-12 injection might have been denied by a particular payer.  She indicated that they used Current Procedural Terminology (CPT) code 90772 to report the service. 

A quick check of my 2009 CPT book identified the problem.  Code 90772 has been deleted for 2009; the correct new code is 96372. 

It never ceases to amaze and amuse me when a physician's practice is not using the current versions of a CPT, Healthcare Common Procedure Coding System (HCPCS), or International Classification of Diseases, 9th Revision - Clinical Modification (ICD-9-CM) manual.  It does not take too many claims denied because of out-of-date codes to equal or exceed what it would have cost the practice to buy current copies of the necessary coding manuals.  Indeed, the ICD-9-CM manual is available on CD-ROM from the U.S. Government Printing Office for only $19.00, and HCPCS can be accessed freely on the Centers for Medicare and Medicaid Services web site (although I still prefer to use the manual version). 

So, take a moment right now, while you're thinking about it, and pull your CPT, HCPCS, and ICD-9-CM books off the shelf.  If they are not the most current versions (i.e., 2009, as I write this), then it's time to order new ones.  This ounce of prevention for denied and returned claims should more than equal the pound of cure found in resubmitting or appealing such claims. 

Posted at 12:09PM May 28, 2009 by Kent Moore  |  Comments[1]

Mental health parity to come to Medicare

By law, Medicare payment for outpatient mental health services is limited to 62.5 percent of covered expenses incurred in any calendar year in connection with the treatment of a mental, psychoneurotic or personality disorder for an individual who is not a hospital inpatient at the time the expenses are incurred.  The limitation is typically triggered by the primary diagnosis on the claim, and the limitation essentially changes the usual 80/20 Medicare/beneficiary payment responsibility to a 50/50 split.  The physician is essentially held harmless.

For a more thorough explanation of the limitation and its implications, please see the article "Understanding Medicare's Mental Health Treatment Limitation," which appeared in the November/December 2000 issue of Family Practice Management.

Thanks to the Medicare Improvements for Patients and Providers Act (MIPPA), this limitation will be phased out over the next few years.  Specifically, Section 102 of MIPPA provides that, beginning in 2010, for expenses reflecting the Medicare approved amount that are incurred in a calendar year in connection with the treatment of outpatient psychiatric services, Medicare will begin to increase the percentage (currently 50 percent) that it will cover as follows: 55 percent of expenses incurred in 2010 or 2011; 60 percent in 2012; 65 percent in 2013; 80 percent in 2014 or in any subsequent calendar year.  Thus, MIPPA will gradually phase beneficiary coinsurance rates for outpatient mental health services down to 20 percent by 2014.

Look for the Centers for Medicare and Medicaid Services to address its implementation of this provision this summer in the proposed rule on the 2010 Medicare physician fee schedule.

Posted at 04:28PM May 13, 2009 by Kent Moore  |  Comments[0]