April 2017 Client Newsletter
AUDITS, AUDITS, AND MORE AUDITS
In case you haven't noticed, CMS, Blue Shield plans, and numerous other insurers have ramped-up the "audit machine." In what may be one of the more shocking audit results which were released on March 23, Noridian, the Jurisdiction A DME MAC, conducted supplier audits on Knee and Spinal orthoses for the period October 2016 through January 2017. DENIAL rates were:
- L1832- 100% denied! (272 of 273)
- L1833 - 98% denied! (1,027 of 1,053)
- L0648 - 87% denied! (555 of 639)
- L0650 - 92% denied! (797 of 868)
In each case, Medicare will process automatic refunds from the provider.
Physicians are undergoing similar audits though with somewhat higher pass rates. Save to say, if you aren't being really careful now to document the services you performed in the medical record, and making sure it is properly signed, now would be the time to start. I can tell you from experience that auditors are trained to deny for ANY reason that does not meet basic medical records or procedure specific requirements. You can literally have 99 out of 100 items documented, yet fail due to one item.
There is value in using "buzz words" that are easy for auditors to recognize. If an LCD requires you to "perform an objective assess of the fit of the shoe and insert" - it makes it easy for the assessor if a section of the medical record uses those exact words. Ditto terms like "Color Doppler was performed..." because most auditors not clinically trained so do not understand other terms.
ELIGIBILITY - CHECK WHEN MAKING THE APPOINTMENT & UPON ARRIVAL
In the current insurance environment, it is vital to check the status of a patient's eligibility at the time the appointment is made and again upon arrival for the appointment.
Under the Affordable Healthcare Act, (AKA Obamacare), patients have a "grace" period in order to pay their claims. If that "grace" period is during a visit to your office and the patient does not pay the premium for that month, your claim will be denied. We have seen instances where the premium was paid for the month the appointment was made, but then was not paid for the month of the appointment. It could have been discovered if eligibility had been checked on the service date.
Other patients also lose their insurance for various reasons, or have LARGE deductibles that have not been met. The only way you will know the status is by checking eligibility.
For those with the Healthpac Scheduler, it is quite easy (and FREE!) to check that eligibility. Let us know if you need any training. If the patient's insurance is questionable, best to ALWAYS require a larger payment on the service date commensurate with the services received that day. It is easier to refund an over-payment than send an account to collections.
VETERANS ADMINISTRATION PAYMENT Q & A
Just FYI, billing the VA can be very frustrating and payment is very slow. We are not suggesting that you not see these patients, just letting you know the payments are not very timely compared to other insurers.
However, as the VA tries to outsource more of their services, this may be an opportunity for you to treat these patients close to their home. These patients have sacrificed for their country and deserve quality, local care. There continues to be a local "push" in southern NJ for local providers. Let me know if you are interested in becoming a VA provider.
MGMA FAQs ANSWER
TOP MIPS QUESTIONS ON REPORTING:
Q: Do I earn a higher MIPS score for reporting longer than 90 days?
A: While practices are welcome to report data over longer intervals of time to improve their numerator for certain measures, there is no inherent benefit to a clinician's or practice's MIPS score for reporting data for longer than 90 days in 2017. In other words, if two practices both perform the same on a particular measure and one reported for the full year while the other reported for 90 consecutive days, both would receive the same score.
Q: Can I choose which 90 days of data to report?
A: Yes, practices may choose any window of time they would like to report up to a full year, as long as it is consecutive and a minimum of 90 days. Practices may choose different reporting periods for each of the performance categories.
Just a reminder to be sure you are participating in one of the Medicare Quality programs which are available to independent providers as well as groups. Solo providers do not need to sell their practice to a group and become employees in order to meet the requirements. 2017 is a transition year with relaxed requirements that are easy to meet in order to avoid a cut in 2019.
Not meeting the MIPS requirements in 2017 will result in a 4 percent decrease in Medicare payments in 2019. The penalty increases in 2020 to 5 percent, 2021 is 7 percent and 2022 and beyond is 9 percent. Meeting the requirements either avoids a decrease or allows as much as the same amount of increase.
Call Rich if you would like to discuss.