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Unlike other service industries, healthcare has a complicated medical coding system for the services provided. For example, in accounting one hour of service is a specific cost. A simple tax return is another specific cost. In healthcare, it is rare that we can easily quote that a service will be a specific cost. This is due to the way that we are required to code the services we provide and then bill for them. The rules are dictated by outside agencies on how providers document patient encounters in a specific way, code the encounter a certain way, and then the payers may contradict that. Just another fun day in the world of healthcare coding and billing!
To optimize the coding step of the revenue cycle, medical practice administrators must
- determine who will be responsible for knowing the documentation requirements for the medical codes being used,
- assure that the documentation meets these requirements and
- that the code combinations also meet insurance regulations.
Once responsibility is assigned, how each of these steps will be accomplished must be determined.
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.
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.
Medical coding is an extremely important part of any medical practice. Having the proper experience and know-how will lead to accurate reimbursements and a compliant office. However, without that knowledge medical coding can dam the cash flow and suffocate the financial situation of your practice. Here are 3 very common problems with medical coding.
1. Clean Claims - Without a doubt things will happen and some of your claims will get submitted without having everything correct. This happens very frequently, and being able to submit a clean claim will help you get paid faster, more accurately and avoid any issues with compliance.
In a recent article Crystal Miner discussed Claims Submission with our readers. The importance of having a defined process is critical to submitting a clean claim. I know you are thinking, "Obviously!" well, that is obvious, however, most people set a process in place and do not improve upon that process. If you are still getting a lot of claims denied, ask yourself a few questions. Why are they getting denied? Who is responsible for that part of the process? How can we remedy that and get cleaner claims submitted? Answering these questions and continuing to improve the process will no doubt allow you to overcome this common problem and achieve a higher rate of 1st pass submissions.