With the increase in recent years of patient deductibles and copays, the burden of patient collection has shifted to the front end of the visit. The Front Desk Team is now responsible to know what they need to collect from patients at the time of the visit. It was not that long ago when clinics and patients expected insurances to cover most services performed. Thus, little was collected at the time of the visit and most was left for the Billing Team to collect from insurance companies. It was also expected that patients know which specialty services their insurances did not cover. I remember having and seeing signs posted in waiting rooms specifically telling patients “There are over 1,000 different insurance plans, we cannot know the specifics of yours. Please call your insurance carrier and be aware of your coverage and copays.” This is the case no longer. 

High performers in healthcare have found that the best method for enhancing their patient collections is to perform insurance eligibility checks and gather copay/coinsurance/deductible information before the patient arrives for their visit. A recent Navicure article notes that ‘one of the most important components in today’s revenue cycle is patient eligibility checks and verification.’ However, to know that a patient is eligible for their insurance is only part of the battle. Clinics must then be the ones to inform the patients of their copays, coinsurance, and deductibles. Allowing a patient to arrive for the appointment uninformed can lead to either negative experience for the patient or a negative financial experience for the clinic.

 Appointment scheduling is the most complex, non-regulated, system in a clinic. Why? Because we made it so. The process has become so complicated for most scheduling teams that they need a decision tree whenever it comes time to schedule an appointment. I’ve seen the instructions for scheduling be 16 pages for an eight-provider office and a spreadsheet that was printed on legal-size to assure that every scenario was covered! No wonder the clinical staff is often complaining that the schedule has been “messed up.” It should be noted by everyone in the clinic that the schedule is the gateway to revenue. The more complicated and convoluted this step, the less likely the schedule will be fully utilized and potential revenue will go right out the door. Therefore, the goal should be to reduce the complexity of appointment scheduling thereby optimizing the schedule for full revenue potential.

Whether you are dealing with a commercial payer, Medicare, or Medicaid, there are certain types of improper claims that should be avoided if you want to reduce your risk of a medical coding audit. That bit of wisdom comes from an entity that ought to know: the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG).

The OIG has released a roadmap to help new physicians avoid medical billing fraud and abuse in the Medicare and Medicaid programs. But this advice also broadly applies to how you approach reimbursement from commercial payers, and can also serve as a helpful reminder for physicians with years of experience in practice.

The agency warns, sternly, about consequences, noting in bold type that “when the federal government covers items or services rendered to Medicare and Medicaid beneficiaries, the federal fraud and abuse laws apply.”

When it comes to medical coding errors, the broad categories of “fraud” and “abuse” have distinct meanings. Fraud involves intentional misrepresentation. Abuse means “the falsification was an innocent mistake, but nonetheless representative,” according to the AMA’s Principles of CPT® Coding, ninth edition.

When you showed up at the hotel on your last vacation, did you have to fill out any information about yourself? For example, where you live, your phone number, or your credit card information? Probably not. You just said your name and gave them your driver’s license and credit card. In return, they said, “Sign here please,” for paperwork that says, “I will not destroy my room,” and gave you your room key. These steps all occurred while asking you how your trip was, why you were there and was there anything they could do to make your stay more enjoyable.

It has been a long time since hotels had new arrivals filling out all their personal information when they came in the door. We have been filling this all out online or over the phone for years. The hotels have our contact information and our payment information before we ever arrive. In most cases, if you don’t show or cancel in time they use that information to charge you a fee. Why aren’t we doing this in healthcare? It is expected everywhere else. Hotels, car rentals, sometimes even restaurants for large reservations. What makes the doctor’s office so different? What can we do to make it easier for our patients and ourselves?

Fraud. Scary word, right? Well it happens a lot, and if you are not careful it might be happening at your practice right now. “Get a free scooter!” You may remember those words uttered on a commercial that ran continuously a few years back. In August of 2014, the Washington Post broke a story on how the government paid billions of dollars for Medicare recipients to get a free motorized wheelchair. The perpetrators of this scam were intentionally defrauding the government by using loopholes to make huge profits on markups for these chairs.

The wheelchair scam example is an outlier, but it is what most people think about when the topic of fraud is brought to the forefront, but that is just one high profile case. There are many instances of unintentional errors that can occur due to lack of understanding of the many regulations and nuances of medical billing. Consider auditing your providers for compliance and finding opportunities for improvement.

Here are 4 reasons why:

1. Billing Mistakes: still the provider's problem

Medicare and Medicaid audits are an extremely popular topic. Imagining the possibility of having your practice or hospital audited for its billing practices is a daunting thought. How simple it can be for a practice to overlook a coding change to IDC-10 or suddenly fall behind the latest PHI requirements.

Failure to stay on top of the changing landscape can lead to major financial problems down the road and the need to pay back unallowable funds. Daily we hear of OIG audits that are the results of missing a coding change or improper practice policies that can be catastrophic to the financial well being of a healthcare organization. 

A few weeks ago The AAFP released its initial summary(2 page PDF) of the proposed 2019 Medicare physician fee schedule which, for the first time, also includes recommended changes that would affect CMS' Quality Payment Program in 2019.  Is this good or bad for you? Let me share some quotes from the AAFP website that can be found here: https://www.aafp.org/news/government-medicine/20180724mpfssumm.html

2018 is more than halfway over. "Finishing Strong" will start to be a common message through out organizations all over the country. Goals will be set, measured, and some will be met, some will be exceeded and most will fail. What makes a good goal. What goals should you be setting for your revenue cycle and your medical coding? 

2018 is more than halfway over. "Finish Strong" will start to be a common message throughout organizations all over the country. Goals will be set, measured, and some will be met, some will be exceeded...Most will fail. What makes a good goal? What goals should you be setting for your revenue cycle? 

Before we get into specific goals, lets quickly what sets apart the structure of a good goal versus the structure of a poorly set goal. We call them "SMART" Goals. Specific, Measurable, Attainable, Relevant, and Time-Bound. 

Specific - In terms of revenue cycle and medical coding, you should choose the particular metric you want to improve, like coding related denials, Days in AR, or Overall Medical Coding reimbursement revenue. You should also identify the team members working towards the goal, the resources they’ll have, and their plan of action.

Measurable - If you want to gauge your team’s progress, you need to quantify your goals, like achieving an X percentage increase in Denials, AR, or Reimbursement.

This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2019 to implement changes arising from our continuing experience with these systems. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this proposed rule would update and refine the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. The proposed rule also includes requests for information on promoting interoperability and electronic health care information exchange, improving beneficiary access to provider and supplier charge information, and leveraging the authority for the Competitive Acquisition Program (CAP) for Part B drugs and biologicals for a potential CMS Innovation Center model. In addition, we are proposing to modify the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure under the Hospital Inpatient Quality Reporting (IQR) Program by removing the Communication about Pain questions.

In today’s regulatory revenue cycle climate the stakes are too high to ignore the importance of a medical coding compliance plan.  Engineering a solid plan can help protect practice professionals from penalties.  Creating and adhering to a plan can make the difference in fraud and abuse determinations.