Friday, December 19, 2008
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Better not pout, I’m telling you why…and it is not that Santa Claus is coming to town, it’s that
All Eyes are on You!
I received a telephone call this week from someone telling me that she submitted a claim to an insurance company for payment. The insurance company denied the claim because no prior authorization was obtained prior to the date of service. She stated that she did verify insurance…AFTER DELIVERY, because the Practitioner delivered the device WITHOUT going thru the Insurance Department for Proper Patient Processing first…Ugh!
Although the claim was under $500, and no Prior Authorization was required, the claim was still denied because the Insurance Company documented the Insurance Verification telephone call with the date and time. Now the appeals process has got to begin, causing a lengthy delay in payment, when it should have been paid the first time!
Better watch out…not going thru the Proper Patient Processing Procedures can come back to hurt your checkbook! Insurance Companies will do anything possible to hold up claims for payment, so Protect your Practice…go thru all the Proper Patient Processing Procedures BEFORE you ever provide services to your patient. Don’t get caught in a trap!
Have a great weekend everyone! Stay Safe & Warm this Holiday Season.
Monday, December 15, 2008
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If you are wondering why I haven't blogged over the last few months, the answer is simply...I have been swamped traveling on business, writing manuals, onsite employee training & development, and then moving half way across the country between September and November. Whoa, what a year! I must say I am looking forward to ringing in the New Year...or am I?
Compliance, Mandated Facility Accreditation, Facility Accreditation Exemptions, Facility Accreditation Non Exemptions, Emergency Evacuation Plans and now...the "Red Flag Regulations" Identity Theft Compliance Program. What in the world could be next?
Initially, healthcare providers were not aware that they had to comply with the New Red Flag Regulations compliance program, simply because healthcare providers are not bankers, credit unions, nor other entities that extent credit…WRONG!
Recently, it was announced and made clear that Healthcare providers actually DO fall under the category of the "Red Flag Regulations" compliance, since healthcare providers are typically extending credit on patient accounts, especially when you are billing the patient, insurance company, etc. for reimbursement.
What does that mean for healthcare providers/suppliers? If you don't have one, you must put together a Patient Identity Theft Compliance Program and adopt or write your policies and procedures for how your business will protect patient's identity. This is more than the HIPAA regulations, so don't be fooled! There is much more...Ugh!
The original November 1, 2008 deadline for compliance has been changed to May 1, 2009.
Here are a few links that you can copy and paste in your browser to read more.
http://www.ftc.gov/opa/2007/10/redflag.shtm
http://www.whitehouse.gov/news/releases/2003/12/20031204-3.html
What do you suppose is next???
Wednesday, September 10, 2008
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Today is actually a "Good Day" when it comes to insurance and verification of eligibility and benefits. Yesterday, well that is another story and I would have to say it was an "Ugly Day".
Seems that all the insurance verifications that I called about today was in high favor relating to patient benefits and eligibility. One plan actually pays at 90/10 for out of network benefits and another at 95/5 for out of network benefits. These days, those are actually good percentages!
With that being said, there are times when healthcare providers must take the good, bad and the ugly when accepting insurance payments. The really good insurance plans help offset the bad ones. So, is it worth it to accept some plans that you previously thought would not be in your best interst? Perhaps, especially when you consider all patients and not just a few.
Here's hoping that all of you have a "Good Insurance" week!
Tuesday, September 09, 2008
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Following the CMS conference call last week, I decided to email specific questions to the CMS staff to clarify a few valid points pertaining to FA Exemption. I did receive an email response; however, I also received a telephone call later today to discuss some of my questions and concerns in greater detail. I applaud the CMS staff for taking the initiative to call me to discuss and clarify important facts. After the telephone conversation with a member of the CMS staff, here are some of the facts that you should be aware of:
1. Orthotic Fitters are Not Exempt from Facility Accreditation
2. Mastectomy Fitters (non custom) are Not Exempt from Facility Accreditation
3. Durable Medical Equipment Providers are Not Exempt from Facility Accreditation
4. O&P Providers and/or Pedorthists May Not be Exempt from Facility Accreditation IF THEY ALSO PROVIDE ANY TYPE OF DME, MASTECTOMY FITTER PRODUCTS AND ORTHOTIC FITTER PRODUCTS.
5. DMEPOS providers are NOT EXCLUDED from Facility Accreditation altogether, at this time, JUST UNTIL SEPTEMBER 30, 2009...just as I suspected was the case.
6. It is my opinion that DMEPOS providers should proceed with Facility Accreditation to avoid potential risks of Facility Accreditation mandates after the rule making changes. It will become more clear that the Newly Revised Quality Standards for DMEPOS providers are going to be more complexed, and some facilities may have to be re-surveyed after the Newly Revised Quality Standards are finalized next year (2009.)
7. Again, the Revised Quality Standards will come out in early 2009, and will be available for public comment for approximately 45 days. After the 45 days are exhausted, CMS will take all comments into consideration and make a final ruling relating to the Revised Quality Standards, and these new standards will go into force immediately thereafter, in 2009.
8. Most major insurance companies and/or managed care organizations are mandating Facility Accreditation for all DMEPOS providers, in order to participate in, and have billing privledges and be paid, in or out of network. In fact, I received a call today from a non network provider where BCBS told the provider that they would not pay his claim without Facility Accreditation. This actually happened today!
With all this being said and noted, it may not be in your best interest to have a facility that is not accredited by one of the approved accrediting organizations, as this could come back to haunt you later.
Be Proactive, Take Charge of your Practice and one step ahead of the challenge!
I attended a conference call last week, conducted by the CMS staff, relating to Facility Accreditation
"Changes and Revisions" of the DMEPOS Quality Standards. Prior to attending the conference call, I received an email alert on August 21, 2008 relating to the open door forum conference call, which included a new subparagraph that was added and would be discussed during the call. Here is the new subparagraph that was added to MIPPA section 154(b)subparagraph(F):
Background:
MIPPA section 154(b) added a new subparagraph (F). This subparagraph states that eligible professionals and other persons are exempt from meeting the September 30, 2009 accreditation deadline until CMS determines that the quality standards are specifically designed to apply to such professionals and other persons. MIPPA also states that CMS may exempt such professionals and persons from the quality standards based on their licensing, accreditation or other mandatory quality requirements that may apply.
Needless to say, after the conference call had ended, there were A LOT of happy providers, and A LOT of angry providers!
Why? (There’s that question again) The reason some were happy is that the NON DME providers are now “Exempt” from the previous mandated Facility Accreditation, with the appropriate Licensing and/or Certification indicating companies have qualified professionals on staff to provide these services.
The reason DMEPOS providers are angry is that so many providers went to extreme measures to get their practice in tip top shape to pass the Accreditation process, and receive Accreditation Certification, in order to maintain their Medicare Supplier Billing Number, to bill Medicare. Many have gone through the lengthy process and paid THOUSANDS of dollars to prepare for inspection. Others have paid the hefty accreditation application fees and now wonder if they should proceed and follow through, or count it a loss and say “forget it, cancel my application.”
With that being said, many may ask the question…Was it worth it to get Facility Accreditation, or proceeding with the process, for your business? You bet it was and is! Furthermore, I would personally recommend that you not only get it, but you keep it current when renewal comes around again.
The fact is…during the conference call, CMS staff indicated that CMS is changing administration within the next six (6) months, and undergoing a New Rule Making process right now, to identify and change the DMEPOS quality standards, to determine and specify things like…”what qualifies a DMEPOS supplier from Facility Accreditation Exemption”. The revised quality standards are supposed to be completed in early 2009, and then placed for public comments for a period of at least 45 days, before the final draft is complete. So, by September 30, 2009 the revised Quality Standards and new standards ruling for DMEPOS providers should be complete and set in place.
CMS staff also indicated that the revised quality standards may be broken down into categories of professionals, dispensing products and who is qualified to fit and deliver these products.
I could go on and on about this, but I will stop for now. I do believe that smart business people will keep their facility accreditation current, and that all other DMEPOS providers keep going through the process to get it.
The reason I say this is because CMS can come back at any time and make another change, demanding it once again, then you may be one scurrying through the process all over again...ultimately, leading to major frustration! Furthermore, Accreditation and Quality Assurance Programs ADD value to your, or any practice.
In my opinion, Facility Accreditation is a no brainer…a smart move to protect you and your business!
How many times have you heard, or even said, “Because I Said So” when asking the question, Why? I know as a child, my parents would simply reply in this same manner when I asked Why. In fact I have to admit that I have even used the response with my children as well, a time or two…although seldom.
The fact is, asking the right questions can sometimes lead to getting the right answers to satisfy the why factor. In addition, when answering the question at once, you leave less room for the same question to come up again and again at a later date, which may ultimately lead to further frustration from both parties.
For example, I recently verified insurance for a couple of patients to determine eligibility and coverage of benefits for a Knee Orthosis. When speaking with a customer service representative from the insurance company, sometimes I believe they are programmed to give you very basic information about the patient’s eligibility and coverage, and try to leave it at that. This is where your expertise comes into play…I let the CSR give me the low down on the basic coverage and benefits, and then I was in hot pursuit to inquire about more specifics about the coverage and benefits.
I proceeded to ask if there were any limitations, exclusions and/or provisions on their plan pertaining to Orthotics. That is when the CSR came back with the answer…Prefabricated Knee Orthosis are not a covered benefit under the patient’s benefit plan. Hmmmmmmm, I thought. Had I not asked, they would not have told. Had the practitioner fit a prefabricated KO, then the claim would have been denied. If the claim had been denied, then you would probably have a very angry patient who finds out later that they may have to pay for the brace out of their own pocket, or they would have a legitimate argument to avoid paying the bill because you or your staff may have told the patient that the Knee Brace was covered, when in reality it wasn’t for a prefabricated KO.
In a nutshell, it is alright to ask “Why” when you feel that you need further explanation. This is especially important when you’re dealing with insurance companies to verify insurance. The key is to “ask the right questions” so that you can determine if you will be paid for your services. Are you asking the right questions pertaining to the type of service(s) that you plan to provide to your patients? If not, you could be in a heap of trouble!
Thursday, July 31, 2008
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Well, I am back in my office from a very long two (2) week trip from teaching a couple claims and billing seminars and meeting with a new client. Exhausted from the trip, but excited about getting back in the swing of things of processing patient's paperwork, insurance, yada...yada...yada.
I've spent the last couple of days verifying numerous patient's insurance, which requires a lot of time on the telephone. I find it very interesting that most insurance companies no longer tell you if a particular HCPCS Code is covered under the patient's insurance plan; therefore, it is imperative to probe and ask additional questions to the "customer service advocate" so you give them very little room to deny a claim for payment.
I find it somewhat of a joke that insurance companies fail to provide explicit details to the patient's medical coverage, when requested by the caller...which is me. I believe it can be considered a "trick" if you don't ask the right questions.
Sad thing??? Many times providers and their staff do not know what specific questions they should be asking the insurance company pertaining to their services, products and/or medical devices.
Worse than that??? A patient receiving a statement from the provider for payment on services that may not have been covered, and the patient may not have been notified in advance that these services may be denied.
Gotta stay on top of your game...the insurance companies are!!!
Wednesday, July 23, 2008
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I had the honor of eating dinner with my clients last night, but little did I know that we were to have an honored guest eating with us...a well known attorney from the Chicago area. While chatting over dinner, parity in Indiana became the topic of conversation. Rep. Mike Murphy's name came up as helping pass parity in the State of Indiana. (go to this website to read more about Mike @ http://www.in.gov/legislative/house_republicans/homepages/r90/)
No sooner than his name being mentioned, our dinner guest picked up his phone and called Mr. Murphy! Wow, so my clients had the opportunity to THANK Mr. Murphy for his hard work and congratulated him for a job well done. Mr. Murphy seemed passionate about this parity mission and getting the parity laws passed in Indiana. The O&P industry cannot thank Mr. Murphy enough for his efforts. THANK YOU AGAIN, MIKE MURPHY!!!
We need more Mike Murphy's in our industry to help pass parity laws in every state. If you want to know more about parity and what I'm talking about, you can read more such as this paragraph from the amputee coalition's website @ http://www.amputee-coalition.org
"Today, nearly 2 million Americans live with the absence or loss of a limb and estimates indicate that this number is likely to grow as a direct result of diabetes and vascular diseases and the overall aging of our population. It is estimated that over 185,000 amputations are performed each year. We therefore anticipate a drastic increase in the number of amputees in this country in the years to come".
Thanks again to all who are involved in this mission!
Tuesday, July 22, 2008
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On July 15, 2008, the new law went into affect on H.R. 6331 Medicare Improvement for Patients and Providers Act of 2008.
What this means for the world of Orthotic, Prosthetic and Durable Medical Equipment Suppliers, at this time, indicates that the DMEPOS Competitive Bidding Program has been terminated.
Although, I believe the termination of this cumbersome competitive bidding program can be thought of as a victory to healthcare providers in some respects, I can't help but think about the waste of time and money spent over the last several years to get the program up and running. Not only that, but the time, energy and expenses incurred by providers to submit bids to participate in the program on the first round, and even into the second round, can be viewed as "Time Wasted".
If claims were submitted under the competitive bidding program, suppliers may have to have all of their claims re-adjusted. I recently read an email from one of the DME MAC Jurisdictions indicating that "Suppliers may have to call in to have their claims adjusted" for some of these claims. Ugh! What a nightmare!
And what about our patients? Does this cause more confusion for them to understand all of this nonsense? Of course it does!
In a nutshell, I believe the government should get better control on how they plan to implement these healthcare programs BEFORE they ever plan to put them into action! In my opinion...Our time, investment and tax dollars are being wasted!!!
If you would like to read more about this new law, visit this website @
http://www.govtrack.us/congress/bill.xpd?bill=h110-6331
Saturday, July 12, 2008
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In America, we are “supposed” to have a choice as to who and where we receive our medical care from, right? We have a choice alright, but many times there’s an additional price that we have to pay for that choice!
For example…let’s say that you (the patient) have found a great healthcare provider and you wish to obtain your medical care from this particular healthcare provider, only to find out that your insurance may not pay for any or all of their services, because;
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The Healthcare Provider is not a contracted in network healthcare provider within the insurance company’s preferred provider network; and/or
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You insurance plan may not include “out of network” benefits
These two scenarios means that a patient will have to pay part or all of the charges incurred, out of their own pocket!
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No “Out of Network” Benefits = Patient pay 100% of out of pocket charges incurred for services rendered from a healthcare provider who is not in network with your insurance company
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With “Out of Network” Benefits = Patient pay a higher percentage of out of pocket for charges incurred for services rendered from a healthcare provider who is not in network with your insurance company
The healthcare provider explains this information to the patient, the patient may or may not agree, and many times the patient ask the healthcare provider to “get in network and become an in network provider.”
The simple truth is, and patients need to understand, that it’s just not that easy, although it would be nice to be that easy.
Healthcare providers must weigh the cost and benefits associated with becoming an “In Network Provider.” The challenges that healthcare providers face and must take into consideration, are:
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Willingness to accept lower reimbursement rates from the insurance company, many times the discounted rates are much lower than the Medicare Allowables
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Many insurance companies tell healthcare providers that “they already have enough providers” within a particular area or region
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Insurance Credentialing for healthcare providers can be a long, drawn out and tedious process
The problem(s) with the above scenarios consist of;
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Lower Reimbursement Rates – Healthcare providers may not be reimbursed at a level that covers cost associated with their products, services and office overhead expenses
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Insurance Credentialing - Healthcare providers may not have the knowledge, skills and expertise in, what I refer to as “The Sales Game” to convince the insurance company why they should accept a healthcare provider as on “In Network Provider” and/or the insurance negotiation process
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Enough Providers - Many times this is just not the truth! Insurance companies tend to categorize healthcare providers based on their scope of practice and specialty. For instance, Orthotic and/or Prosthetic (O&P) healthcare providers are typically linked in the same category with Durable Medical Equipment (DME) suppliers, and DME suppliers tend to be a "dime a dozen.” There seems to be an abundance of DME suppliers all over the US, and most of these DME suppliers DO NOT offer Orthotic and/or Prosthetic (O&P), custom fabricated and/or prefabricated, medical devices. I know this for a fact because I actually research and call each and every one of the contracted providers to inquire about the products and services they offer, when I conduct my research for my clients. The results identify that 95% of DME suppliers DO NOT provide any type of O&P devices, and yet both specialties (DME and O&P) are linked in the same category...go figure!
In my opinion, someone needs to wake up and realize that Orthotics and/or Prosthetics (O&P) should be placed in a separate category and/or specialty, than Durable Medical Equipment (DME).
Why? Because providing custom fabricated orthosis/prostheses requires more substantial training, education, knowledge and skill, from a certified and/or state licensed practitioner, to successfully evaluate, cast, measure, fabricate, then fit and deliver the orthosis/prostheses to their patients, than a DME supplier.
I am not undermining DME suppliers, I respect what they do…however, Durable Medical Equipment (DME) is typically “medical equipment” that a patient can purchase or rent, such as; wheelchairs, canes, crutches, diabetic suppliers, respiratory & oxygen, hospital beds, etc.
Think of it this way…if you were/are a patient, and an amputee for example, would you want your custom fabricated prosthesis to be considered “medical equipment?” The prosthesis is actually a replacement of a member of your body that may have been amputated for whatever reason. A replacement device that can allow a patient to ambulate, and/or function in the same and/or similar manner as the patient was before the amputation occurred, a normal functioning state, if you will. That takes "professional" education, training, knowledge, skill and expertise...more so than a clerk who pulls an item off the shelf and delivers to a patient. They are simply not the same specialty!
Moving on…many times those who are not “thoroughly” informed, can only assume that Orthotic and/or Prosthetic (O&P) devices are just as simple as ordering Durable Medical Equipment (DME).
In fact, many times ordering physicians will write a prescription for their patient, hand it to their patient and tell them to take the prescription over to the Orthotic and/or Prosthetic (O&P) provider and pick up their device.
The truth is, there’s much more involved with providing Orthotic and/or Prosthetic (O&P) devices to patients than sending a patient over with a prescription and allowing the patient to assume the Orthotic and/or Prosthetic (O&P) device(s) is something the patient can go in, pick out and pick up. Especially, if the O&P provider wants to be reimbursed for their service, master medical policy(s) and maintain DMEPOS compliance.
That’s a wrap for this week…more to come later! Please tell me your thoughts on the “Feedback” comment space. I would love to hear what you have to say about this blog topic.
Until next time, have a fun and safe weekend!