Auto-post….Friend or Foe?

My answer is both. While auto-post is a definite time saver, it is to be used with respect. The allowed amount should be correct based on your contract. If you don’t already know this information, do yourself a favor–study your contracts and make sure the correct allowable is entered in your system.

If the allowable is less than your contracted amount, your system should flag the entry for follow up. In a timely manner, contact the payer to have the line item reprocessed for the correct amount.

As easy as it is to use auto-post, the payment report still must be reviewed.

Whether it’s a denial or an incorrect payment amount, this is one step you really can’t ignore or put on the back burner, as most payers have timely filing deadlines for denials or adjustments.

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Tennessee Medical Association Breaks New Healthcare Ground With Legislative Win

Provider Stability Act First of its Kind in the U.S.

NASHVILLE – Tennessee doctors are praising a new state law that adds much-needed financial predictability in contracts between health plans and healthcare providers. The Provider Stability Act passed unanimously in both chambers of the Tennessee General Assembly and was signed by Governor Haslam on April 5.

Senate Bill 437/House Bill 498 was sponsored by Sen. Bo Watson (R-Hixson) and Rep. Cameron Sexton (R-Crossville). It requires health insurance companies to give a 60-day notice to a healthcare provider when reimbursement rates change, if such changes are a result of a policy change at the sole discretion of the payer. It also limits fee schedule changes to once in a 12-month period, and requires a 90-day notice of those changes.

The Tennessee Medical Association, which represents more than 9,000 Tennessee physicians, has pushed the measure since 2014.

No other state currently has these types of provisions in place.

“This is a huge win for physicians and all healthcare providers in Tennessee,” said TMA President Keith G. Anderson, MD of Memphis. “TMA listened and has responded to members’ growing frustrations by bringing some stability and predictability to the marketplace.”  Medical practices, hospitals, health systems and other healthcare providers enter into contracts with health plans to spell out exactly what will the insurer will pay for healthcare services provided to patients covered by that health insurance plan. The contracts are routinely written to allow insurers to lower payment at any time, for any reason.

“The intent of the Provider Stability Act from the very beginning was to have health plans honor network contract provisions and stop the one-sided, ‘take-it-or-leave-it’ rate cuts that threaten physicians’ financial stability, and disrupt patient care,” said Dr. Anderson. “When doctors cannot afford to incur an unexpected change in reimbursement from a health plan they may be forced to stop providing a procedure or drop out of the network altogether. Patients suffer by having to pay higher “out-of-network” fees for the same service if they want to continue seeing their doctor, or find another doctor who is in their insurer’s network. The new law will reduce these scenarios and help protect the important patient-physician relationship.

TMA said passage of the Provider Stability Act was made possible by member physicians, medical practice administrators and others who made calls, wrote letters and emails and visited Capitol Hill to speak directly with legislators about the issue. Several other organizations also supported the effort, including the Tennessee Hospital Association, Tennessee Medical Group Management Association, Tennessee Radiological Society, Tennessee Chiropractic Association, Tennessee Orthopaedic Society, Tennessee teaching hospitals, practice administrators and nurses.

Learn more about TMA’s legislative efforts at tnmed.org/legislative.

About the Tennessee Medical Association
TMA is the state’s largest professional association for physicians, serving more than 9,000 members. We improve the health of Tennessee by bringing all physicians together in efforts to continually improve effectiveness of physician care and ensure proper policy to serve the best interests of patients and the profession. tnmed.org

CONTACT:     Dave Chaney
Tennessee Medical Association
615.460.1671 | dave.chaney@tnmed.org

 

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Don’t do it…don’t do it…

Don’t see patients until you know enrollment in their network is complete. Physicians are notorious for seeing patients at a new location, opening a new practice or performing new procedures without checking with the billing department first. I recently heard of a physician who started seeing patients in a new state, and then submitted charges to the billing department. You can imagine the shock and surprise when they received the billing tickets. To say things were kicked up in to high gear is an understatement!

You should allow a minimum of 3 -4 months to get all the credentialing in order, and you must be prepared to face some delays. In some instances, you will need to credential your group and then link individual providers to that group. Make sure you have qualified personnel or outsource this project because credentialing is not for the faint of heart.

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Denials

Let’s chat about denials. As I’m sure you know, claim denials can cause huge problems for your practice. Filing the claim is the easy part, the tricky part is working the denials that come in. Through absolutely no fault of your own, denials–both legitimate and in error–are going to happen. They range from an easy fix, such as wrong DOB for patient, to a procedure that’s not medically necessary, and then many times the denials are in error. I recently saw one insurance company deny anesthesia claims for coronary artery bypass graft because of medical necessity. Obviously that claims processor has never had open heart surgery! The point is this totally necessary claim will cost man-hours to get it paid, when it should have been paid automatically. Regardless, you must work these denials, or I can guarantee that your practice will suffer.

When we are called in to help a practice, one of the most common problems we see is that the denials are not being worked. And, keep in mind, most payors have a timely filing limit for denials. It’s not fun, and while it’s time consuming, it’s also necessary. Nothing should be billed that you don’t expect to be paid. Therefore, no line item should adjusted off without good cause, and the payor’s “DENIED” is not a valid reason.

–Pam Stopher, CPC, ACS-AN
Park Medical Management, Inc.

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TMA Offers Guide for New Credentialing Law

From the Mid-South MGMA:

New legislation that impacts the insurance credentialing process for physicians goes into effect January 1, 2016. A new TMA resource provides a helpful guide to the new law. For several years, the TMA advocated for passage of legislation that would permit physicians going through the credentialing process with health plans to be reimbursed for services provided to those health plan members during the credentialing process.

The rationale was that at least 99% of physicians are eventually credentialed with health plans, but the process can take several weeks, even months, to complete. Practices overwhelmingly expressed that they would gladly risk having to reimburse the plan if their physician was not eventually credentialed. In 2015, legislation passed to address this situation. TMA has created a comprehensive guide to the new law. The TMA legal department also produced this video to explain the new law, which can be found here.

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ICD-10: The Beginning of a New Coding Era

Well, here we are on October 1, 2015, the beginning of a new coding era. The world is still round, the sun is still shining and Congress didn’t stop ICD-10 implementation at the 11th hour as some had hoped.

At this point we’ve all studied, practiced, tested and done all we know to do to prepare for this day. The truth is that we won’t really know the full impact of ICD-10 for a few weeks, once the payors have started processing claims and they are actually adjudicated. We’ll all feel much better once we see DOS 10/1/15 on the ERAs and and big fat PAID stamp in red at the top.

In a few years, we’ll all look back and vaguely remember that we were hesitant to make the switch.

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Anesthesia Providers are Part of the ICD-10 Process

This article will discuss the difficulty anesthesia providers will have determining the correct ICD-10 code given the level of specificity required. Because we have no access to previous medical history, we will rely heavily on information from the surgeon. With ICD-10 there is no way to know how much information is actually needed to code correctly until trying to code the case. Therefore, it is my opinion that the best way to determine the code is to have the anesthesia provider choose the code before billing is submitted. There are a number of ways for the provider to choose the correct code, from using the ICD-10 in book form to automated systems that allow the provider to “drill down” until a billable code is reached. With the available technology, this has proven to be the simplest way.

Will this do away with the need for certified coders? Absolutely not. It is  crucial that the code chosen by the anesthesia provider be reviewed before the claim is submitted. Providers should be trained and educated in the appropriate aspects of ICD-10. Anesthesia covers a multitude of diagnosis categories so we must train in all categories. The providers we have met with understand the logic behind having them code it themselves and are very open to this mindset. As we start to train groups it has become imperative that they query the surgeon in order to choose the correct code. This has proven to be educational for the surgeons also and made them realize the need for better documentation for their own coders. And the countdown begins, just 43 days until October 1!

–Pam Stopher, CPC, ACS-AN

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Anesthesia Billing

For the next few months we will focus on anesthesia.

Anesthesia is a most unique specialty in many ways. From patient registration to claim payment, it’s unlike any other. Because anesthesia typically doesn’t see patient demographic information until after the procedure, you need to work quickly once you have received the information, whether electronic or paper.

Invest in the manpower it takes to:

  • verify the insurance information given (policy #, insurance carrier, insured’s name and date of birth, etc.)
  • check deductible (We always recommend holding the anesthesia claim until deductible has been met, of course, keeping timely filing in mind.)
  • verify patient mailing address
  • check for outstanding balances

If procedure is elective (total joint replacement, gastric bypass, etc.), contact the patient two days after surgery to give the name of your anesthesia group to advise them of your policies and procedures. Let them know you’ll be glad to file their insurance, making sure the insurance company has paid all they were obligated to pay, before sending a bill for their balance.

Once the carrier has made payment, call the patient to let them know their balance and see how they want to pay the balance. We find many times they will pay right then over the telephone. If not, help them arrange a payment plan. We have found this process very effective and recommend it to all practices.

If the patient’s demographic indicates self pay, contact them immediately to determine if this information is correct and either arrange a payment plan, or hopefully, obtain insurance information not given at time of admission

Time spent prior to claims filing is well worth the effort.

Next month we’ll cover self-pay cases…

Pam Stopher

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Preparing for ICD-10

October 1, 2015 is just a little more than six months away, and we had better be ready. It seems that the annual delay will not happen this year, and like it or not–here it comes. Best practices and their billing services will do everything possible to embrace this change, if for no other reason than to see to it that our practices have a normal monthly income. At this time, we are preparing to renew our efforts of implementation and testing to be ready on October 1. We encourage you to do the same.

The hardest part will be for those of us who know so many codes by memory, as we will have to erase that memory card and start clean. Yes, there are more characters in the code to learn, but ongoing learning helps keep the brain busy and alive.

So, hang on, ICD-10 here we come!

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