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August 2016 Client Newsletter

Discussions With Patients About Insurance Coverage
--or Lack of It
We occasionally receive calls from patients who tell us "The doctor said it was covered 100%." Sometimes we doubt it is true, but when it occurs repeatedly, it likely is what they are being told.
That is not a good statement to make to patients due to:
  • The many variations of insurance plans insurance companies sell
  • High deductible plans
  • In-network vs. out-of-network coverage
  • Etc.
 A better phrase would be: 
"We will be happy to file the charges with your insurance but how it is adjudicated is up to your insurer based on your coverage.  We treat you clinically- our treatment recommendations are based on what is best for you.  The financial part is between you and your insurance company."
This is true even when benefits are "verified" - we can literally call two or three different reps at an insurer and get two or three different answers.  The above phrase puts the burden back on the patient and insurance company where it belongs.  Providers have no role in selecting a patient's coverage so don't allow patients to make it your responsibility.  Providers are wise to avoid addressing all financial issues. 
At the end of the day, aren't you worth being paid for your services?
 Deductibles - High or Otherwise
 High deductible plans continue to be challenging for practices.  Patients often take a lower cost insurance with a high deductible - but then are not prepared for the reality of the out-of-pocket expense. 
We recently received a question from a patient:  "My insurance applied $432 to my deductible and I would like to negotiate a discount." 
The insurance laws, federal and state, are clear - if the patient pays less than the deductible applied by insurance, the insurance must be notified so they can adjust the amount applied to reflect the actual payment.  Plus, insurers have ALREADY negotiated a discount off your fees - why would a provider want to lower the fee again? 
You could offer this option:
a). You may use your high-deductible insurance; we'll collect what we think you'll be charged now, at the time of service (using a real-time claims estimator if available.)  That amount, as best we can tell, is going to be $X and 75% (or an amount the provider chooses) is payable today.  Once insurance adjudicates the claim, we will bill any balance to you or refund any over-payment.
b). You may exercise your HIPAA privacy right to opt out of us filing anything with your insurance today.  (  p. 5626-5628 for the applicable regulation.)   In that case, your cash price up front and total for today's visit is $Y.  We will not file your insurance, today or ever.   If you want to file your own insurance, feel free.  In this case, there would be no need to send a charge form to Cape Medical Billing. 
You can't charge them $Y in cash, then send an insurance claim and allow them to get credit for $X against their deductible.  Or more commonly, you can't file a claim, have the insurance remit say you need to collect $X, and then accept your usual self pay rate of $Y.  Doing so would be considered an "illegal inducement" which encourages overuse of medical services and is also considered fraud. 
If you are in-network with a plan, you can honestly state to the patient: 
"You are already getting a discount from our usual charges to match the plan's allowable and that our contracts require that we collect the deductibles, co-pays and co-insurance." 
If you read your agreements, that is always included.  Further, the agreements also usually state that not collecting is grounds for termination of the agreement. 
It is also noteworthy that not collecting co-pays or other cost-sharing amounts applied by insurers is also considered an illegal inducement - it encourages over-utilization since the patient has no personal financial expense.  The only safe exception is financial hardship. 
The AMA has a two-page article about Professional Courtesy - let me know if you would like a copy forwarded to you. 
Hearing Impaired Patients
As you may know, providers are required by law to provide an interpreter for hearing impaired patients.  Often the cost is greater than the insurance payment. 
Recently I learned of a company called Vineya which supplies certified interpreters via a computer link similar to GoToMeeting, but at a much lower cost than other interpreter sources (reportedly $15 per 15 minutes with no minimum).
Prepare for MIPS: Review value modifier feedback reports 
on cost and patient outcomes
Earlier this year, the Centers for Medicare and Medicaid Services (CMS) released the 2015 Mid-Year Quality and Resource Use Reports (QRURs), which display CMS-calculated cost and hospital admission and readmission data collected between July 1, 2014 and June 30, 2015 and are used to determine performance in the Value-Based Payment Modifier (VBPM). Due to CMS' lack of transparency and the complexity of the VBPM methodology, practice executives who have downloaded their QRURs have often found their practice-specific results surprising.
Don't be left in the dark; reviewing your practice's QRUR is a critical step to understanding CMS' interpretation of your practice's cost and quality performance relative to national benchmarks.

With MIPS set to replace the PQRS, Meaningful Use and VBPM programs starting in 2017, the information in these reports will continue to be relevant as the agency is expected to evaluate practices on comparable outcomes and cost measures in future quality reporting programs.

Authorized individuals can access their group's 2015 Mid-Year QRURs via the CMS Enterprise Portal.
DME MAC A Transition July 1st
The DME MAC A transition from NHIS to Noridian occurred on July 1st without any issues.
2016 Client Newsletter Archive