Cape Medical Billing: Providing Expert Medical Billing Solutions

Like Cape Medical Billing on Facebook

Call Today 888-MED-BILR

March 2009 Client Newsletter


As everyone knows, there are two parts to getting ahead with money – making it and saving it! This article will discuss some ways to consider how to watch the money you do collect.
· For office payments – patient co-pays, deductibles, and coinsurance – require that 2 people be involved in reconciling at the end of the day. The collector (front desk usually) of the $ should NEVER be the depositor. There should be a form that the front desk completes each day showing who paid, how much was paid, and in what form (cash, check, credit card, 2 chickens, etc.). These total office payments should match the amount reported on each Charge form and be attached to the daily charges when sent to CPB. The bank deposit ticket should match that form, minus any deductions, which the provider approves. CPB is part of an independent check and balance on your behalf in this case – total office payments should match your deposit form which matches what CPB enters and reconciles.
· When insurance & patient statement payments arrive, who opens and deposits them? If it isn’t you, it should be opened by 1 person and deposited by another. Standard accounting practice.
· Be sure to reconcile the total payments you receive (and record!) in the office each month with the “38” payment codes reported back to you in CPB’s Month-end Reports. They should match!
· Your money handling procedure should be a written document that you require everyone to follow EXACTLY as it is written. Be sure to ask when things do not seem right – trust your “gut!”
· Watch for embezzlement:
- Do any employees appear to be living beyond their means? Could be an indicator of something suspicious, or not.
- Does a key money handler not take vacation time claiming that s/he is too important to be gone? Could be s/he is worried about getting caught, or not.
- Are any employees being contacted by bill collectors? Desperate people will take drastic measures.
- When hiring new staff, consider doing credit checks in addition to reference checks. Statistically, a lower credit rating could be an indication of added risk for the provider.
- Physician offices are great places to find drugs for addicts. Does an employee always arrive early or late (alone time in the office), or is chronically tardy or absent without explanation? Addicts will take desperate chances to satisfy their cravings.

Referrals, Authorizations, and “Billable Lists”

Not having valid referral or authorization, or performing services not on a provider’s “Billable List” leads to denied payment with no other recourse. These items are part of the requirements that providers contractually agree to in their Participation Agreements. There is no appeal for treating a patient for services not on a Billable List, or without referrals or authorizations. When in doubt, send them elsewhere or realize that you are likely providing a free service. CPB makes the following recommendations:

Referrals & Authorizations
Our strong suggestion is that if a pt presents without a required referral or authorization that they be given 2 options (absent a medical contraindication otherwise):
1. Go get the referral and/or authorization and return with it before being seen. If necessary, offer to schedule a new appt. Seeing them and hoping they will return with the referral has a high failure rate.
2. Pay cash/credit card for the service before being seen & only after signing a document indicating they understand their options and are electing to pay cash for the service. This gives them an incentive to get the referral to get repaid for their payment. And if they do not, you have payment for your services.

Billable List

Patients who need a service not on a provider’s Billable List should be given the follow options:
1. Be referred to another provider,
2. Sign a document indicating their understanding that they are paying cash, in advance, for the service they are requesting.

Another important point – just because the insurer gives a Precert/Authorization # does not mean they will pay the claim. Should it mean they will? Absolutely! But they often look for other reasons not to pay – not on the Billable List, patient’s coverage expired, etc

Usually HMOs place responsibility on the provider for seeing the pt without required approvals (a Billable List is an approval – approval to provide that service and get paid for it) and without a signed document showing the patient chose to be seen/treated without the required referral. If the insurer denies payment - the EOB shows no pt responsibility and if you have no signed “ABN” type document - you may need to return any copay collected. The document needs to be very similar to an ABN & indicate:

1. Description of the service requested
2. Why the provider expects a denial (no referral or authorization, not on Billable List, too frequent, etc. )
3. The cost of being seen without the referral. Better to estimate high than low & collect the money before treating!

Then if the patient disputes anything, we are in a STRONG position to argue that the patient knew in advance the consequences of not having a valid referral by showing a copying of the signed agreement. HMO’s, PPO’s, etc. cannot deny a patient’s right to see a provider, or for you to get paid, as long as the patient has been properly informed.

Yes, we recommend collecting the payment before providing the service. If the patient won’t pay on the day of service, we can pretty much guarantee they will not pay later. But at least you will not have wasted time treating that patient and can see another patient who is covered.

Economic Stimulus Bill – Electronic Health Records (EHR’s)

The Economic Stimulus Bill is providing incentives for providers (only physicians) to begin using “certified” Electronic Health Records. These incentive payments are available for 5 years with $18,000 available for the first year with decreasing amounts each subsequent year. In total, if a physician qualifies for the maximum each year, the total value of the incentive payments will be $44,000. About 70% of the money is front-loaded into the first 2 years.

This is PER PHYSICIAN. So in a two physician practice, the amount available could be over $88,000. In a large multi-specialty group practice, the amounts would be even higher. The statutory language says the provider is eligible for an "amount equal to 75 percent of the Secretary's estimate of the allowed charges." Neither the legislative text nor the conference report accompanying the legislation clarifies what this means. Consequently, we expect that the regulations and guidance that will naturally flow from this legislation will clarify what this means.

There will be no incentive payments for physicians who begin using a certified EHR after 2014. Furthermore, physicians who fail to adopt and use EHR by 2015 will see their Medicare payments reduced.

For physicians who have high Medicaid patient volumes (i.e. 30% or higher for most specialties), the Medicaid incentives are $64,000 over 5 years. Physicians won't be able to double dip but must decide to either get the Medicare incentives OR the Medicaid incentives.

The incentives are NOT available to "provider-based" physicians - initially defined as ER, Pathology, and Anesthesiology. However, the Secretary of HHS has the discretion to add other so-called "provider-based" physicians.

The bonus is for "meaningful use" which is defined in the legislation as:

-Using certified EHR technology that includes electronic prescribing; and
-Using EHR technology that allows electronic exchange of health information.
-Eligible professionals must submit information for the period on the clinical quality measures (PQRI) and other measures selected by the Secretary of the Department of Health and Human Services (HHS).

When the provider actually purchased the EHR is not relevant to the receipt of the bonus payment. Providers already using one are ahead of the curve. HOWEVER, the system the physician uses must be CERTIFIED, which is not yet defined.

Although certification standards for EHR are in existence, new standards will be published and in place prior to the commencement of the bonus payments. While many of the current standards will likely remain in place, the new standards will address interoperability of the EHR system. YOU MUST ensure that whatever system you use, the system meets the certification requirements that are in place in 2011, not the standards in place now. I hope this was helpful!
2009 Client Newsletter Archive