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Wednesday, October 24, 2012

Audit alert: Notable items in the 2013 OIG work plan

Oct. 1, 2012 represents the start of the federal fiscal year. That makes now a good time to look at the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) work plan for the current fiscal year, especially as it relates to physician services under the Medicare program. Knowing what the OIG is examining can sometimes provide a useful “heads up” on issues that Medicare itself may focus on during the coming 12 months.

First, OIG has no fewer than five items on its work plan aimed at diabetes testing supplies:

  • Supplier compliance with payment requirements for blood glucose test strips and lancets,
  • Effectiveness of system edits to prevent inappropriate payments for blood-glucose test strips and lancets to multiple suppliers,
  • Potential questionable billing for test strips in 2011,
  • Improper supplier billing for test strips in competitive bidding areas,
  • Supplier compliance with requirements for nonmail order claims.

Although most of these items are aimed at suppliers, it is reasonable to expect that such attention may prompt those suppliers to be more demanding of physician prescribers. Given the incidence of diabetes among family medicine patients, family physicians are among the most common prescribers of such supplies.

For those practices that have office laboratories, the OIG’s work plan has at least three items of interest:

  • Billing characteristics and questionable billing in 2010,
  • Reasonableness of Medicare payments compared to those by state Medicaid and Federal Employees Health Benefit programs,
  • Part B payments for glycated hemoglobin A1C tests.

Finally, in the particular area of physician services, the following items stand out:

  • Noncompliance with assignment rules and excessive billing of beneficiaries,
  • Error rate for incident-to services performed by nonphysicians,
  • Place-of-service coding errors,
  • Evaluation and management (E/M) services—potentially inappropriate payments in 2010.

Regarding the last item on this list, the OIG work plan states:
We will determine the extent to which the Centers for Medicare & Medicaid (CMS) made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.

The OIG’s review will focus on 2010 services, but it is reasonable to expect that this will be an area of focus going forward. Since E/M services represent the “bread and butter” of family medicine, and in light of the increasing use of EHRs in family medicine practices, this is one area that probably merits an internal review for most family medicine practices now and in the future.

Of course, the OIG’s work plan is more extensive than just the items listed above, so a scan of the table of contents for that work plan would probably be in order to see if there are other items that may be relevant to your particular practice.  Explanations of all items are included in the OIG work plan.

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, October 12, 2012

No shows = lost revenue

Medical practices average a 5 to 7 percent no-show rate, according to the Medical Group Management Association (MGMA). No-show appointments are a reality of every medical practice. While you may not be able to eliminate them, there are ways to reduce no-shows and the negative effect they have on your practice.

Maintain patient access. The longer you require a patient to wait to be seen, the more likely they will find care from another provider, especially if it is something they need to be seen for right away such as an ear infection or strep throat. In these cases many patients do not call to cancel the future appointment with you, they just don’t show up as they have received care somewhere else.

Make sure you have assigned acute appointment slots in your schedule every day to see these patients the same day they call. Seeing just one more patient per day can accumulate into a large amount of additional revenue each year.  According to Michael O'Connell's MGMA Connexion article, "10 ways to manage better during difficult financial times," adding just one more patient to your schedule each day can add $25,000 to the annual bottom line for primary care (estimating $100 for a new patient visit).

Remind patients. Remind patients that they have an appointment with your practice. Assign staff to remind patients at least 48 hours in advance of their appointment or consider using an automated appointment reminder service if it makes financial sense for your practice.

Require appointment confirmations when appropriate. Long appointments such as procedures or complete physicals take up a lot of time on a physician’s schedule. For these types of encounters you may want to require that the patient confirms the appointment with you. Confirming long appointments can prevent huge gaps that can have a negative effect on your day. Confirmations can be done using automated reminder systems or personally asking patients to call back to confirm the appointment rather than leaving a message and hoping they received it.

Manage chronic offenders.
Identify the patients who chronically miss appointments. Place a note in the patient’s record for the schedulers to see during the scheduling process. If a chronic no-show patient requests an appointment, try double-booking them with a quick visit or give them an appointment at the end of the day where the missed appointment will not disrupt patient flow.

Dismiss chronic offenders from your practice.
Patients that repeatedly no-show for appointments can be terminated from your patient panel. Develop a policy for your practice to dismiss these patients and be consistent with every patient. For example, allowing a specific number of no-shows prior to dismissal gives the patient an opportunity to accidentally miss appointments before being terminated from the practice. Three missed appointments prior to termination is a reasonable policy to put in place.

Consider charging no-show fees.
If you have tried other methods to decrease your no-show rates and are not seeing results, you may want to implement a policy to charge a fee for patients that do not show up for appointments to recoup some of that lost revenue. 
There are some important aspects to consider before moving forward with a no-show fee policy:

  • Some payers allow charges for no-shows.  Is your office capable of tracking who can and cannot be charged the no-show fee?
  • What is your patient population like? Can the average patient afford to pay the fee for a no-show appointment? Will they ignore these charges and make it difficult for you to collect the fee? You don’t want the implementation of a no-show policy to lead to a more complicated problem of collecting the fees from your patients.
  • Will the amount of the fee charged compensate for the amount of time it takes to bill and collect from no-show patients, or will you be losing money on this effort?
  • Your patients may seek care from another physician. If the patient does not approve of the no-show fee, they may leave your practice voluntarily and you could lose that patient and the revenue of future visits.

How do you keep no-shows from ruining your day in your medical practice? Click on “Comments,” below, and share your ideas and best practices.

–Renae Moch, MBA, CMPE, Practice Management Strategist for the American Academy of Family Physicians

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