proudly presents Show Me the Money!

Transcription

1 proudly presents Show Me the Money! October 13, 2009

2

3 Richard Lander, MD Dr. Lander is a managing partner and pediatrician in private practice in New Jersey and is president and co-founder of Resources in Physician Management Services. He is currently a Clinical Assistant Professor of Pediatrics at UMDNJ. Along with his dedication to the care and well being of children and adolescents, Dr. Lander has made it a priority to help to ensure that pediatricians are properly remunerated for their hard work on children s behalf. He served on the national Committee on Child Health Financing and chairs the AAP Section on Administration and Practice Management (SOAPM). Dr. Lander serves on the AAP s Private Payor s Advisory Advocacy Committee and has been a consultant to the AAP Task Forces on Reimbursement, the Task Force on Obesity, and the Task Force on Mental Health. Since 1989, he has been an AAP Regional CPT Trainer and has lectured on coding and practice management for the AAP, private enterprises, and pediatric residency programs. Dr. Lander contributes to Infectious Diseases of Children, Pediatric Annals, Medical Economics, Consultants in Pediatrics and most recently Pediatric Clinics of North America. Tuesday, October 13, 2009 AGENDA 7:30am Registration, Networking, and Continental Breakfast 8am ICD-9 Updates for 2010 and Introduction to ICD-10 for am Refreshment Break 9:15am Show Me the Money! Contract negotiations, office effectiveness, office-based procedures, ancillary charges, and equipment 10:30am Refreshment Break 10:45am What Do You Mean I Owe You Money Collection issues, patient responsibility, and insurance issues 11:45am Question & Answer Session Noon Adjourn ACCREDITATION This program has prior approval of the American Academy of Professional Coders for 3.0 Continuing Education Units. Granting of this approval in no way constitutes endorsement by the Academy of the program, content, or the program sponsor. P.O. Box Kansas City, MO Phone: (816) Fax: (816) cmhninfo@cmh.edu An affiliated organization with Children s Mercy Hospital

4

5 Children's Mercy Health Network (CMHN), established in 1995, is a pediatric managed care organization with a mission to support the continuum of pediatric and adolescent healthcare in the region. CMHN's Board of Directors has more than 70 percent physician membership. Physician participation and leadership serve as essential elements for the Network's success. Both primary and specialty care providers, including independent community physicians, are involved with CMHN. Annual dues for each physician are required for membership. Participating providers in CMHN have the opportunity to take advantage of a variety of benefits which include: Representation in managed care contracts Registration for Clinical Advances in Pediatrics Educational opportunities for clinical and business office staff Access to a vaccine group purchasing program CMHN staff members include: Heather Beheler Meredith Mandel Jena Parker Executive Director Provider Relations Rep. Provider Relations Rep. (816) (816) (816) hbeheler@cmh.edu mrmandel@cmh.edu jbparker@cmh.edu P.O. Box Kansas City, MO Phone: (816) Fax: (816) cmhninfo@cmh.edu An affiliated organization with Children s Mercy Hospital

6

7 2010 ICD-9 RICHARD LANDER, MD, FAAP OCTOBER 1, 2009 WHAT'S NEW WHAT'S DELETED WHAT'S REVISED 2010 ICD-9 MORE THAN 300 AFFECTED 2010 ICD-9 IF YOU DON'T KNOW THE NEW CODE IF YOU DON'T KNOW THE CODE IS OLD IF YOU DON'T KNOW REVISED CRITERIA NO $$$$$$$$$$$$$$$$$$$$$$$ 1

8 2010 ICD-9 NEW BORN V20.31 health supervision under 8 days V20.32 health supervision 8-28 days failure to thrive in newborn NEWBORN 2010 ICD newborn feeding problems deleted feeding problems in newborns bilious vomiting in newborns other vomiting in newborns colic 2010 ICD-9 GASTROENTEROLOGY RELATED vomiting of fecal matter omphalocele gastoschisis 2

9 2010 ICD-9 AS THEY RELATE TO SPEECH WILL IT BE A COVERED BENEFIT? 2010 ICD DYSPHONIA HYPERNASALITY HYPONASALITY DYSARTHRIA 2010 ICD-9 SPEECH OTHER SPEECH DISTURBANCE SAME AS ABOVE BUT DELETED 3

10 2010 ICD-9 PSYCHOSOCIAL ISSUES NOT DSM NEED TO CHECK WITH MCO IF COVERED PSYCHOSOCIAL 2010 ICD NERVOUSNESS-replaces IRRITABLILITY IMPULSIVENESS EMOTIONAL LIABILITY PSYCHOSOCIAL 2010 ICD DEMORALIZATION & APATHY OTHER SIGNS AND SYMPTOMS INVOLVING EMOTIONAL STATE 4

11 2010 ICD-9 POSIONING AND 9 CHECK 2010 ICD-9 BOOK FOR SPECIFIC MEDICATIONS 2010 ICD-9 ***************************************** NURSEMAID'S ELBOW ***************************************** 2010 ICD NEW E TO REPORT EXTERNAL CAUSES OF INJURIES, POISONINGS AND OTHER ADVERSE EFFECTS 5

12 2010 ICD-9 MEANT AS SUPPLEMENTARY AND NOT TO BE REPORTED AS PRIMARY ICD ICD-9 E E001.0 WALKING, MARCHING, HIKING E002.1 SPRINGBOARD AND PLATFORM E003.0 ICE SKATING E 2010 ICD-9 E005.2 GYMNASTICS E005.2 CHEERLEADING E006.4 BIKE RIDING ETC,ETC,ETC 6

13 2010 ICD-9 REVISED RELATED TO KIDNEY FAILURE RESONANCE, VOICE DISORDER NONSPECIFIC-ABNORMAL RADIOLOGIC FINDINGS V65.11 PRENATAL VISIT FOR PARENTS 2010 ICD-9 DELETED THERE ARE MANY DELETED CHECK YOUR 2010 BOOK NOT FUN BUT NECESSARY! 7

14

15 2013 ICD-10 RICHARD LANDER, MD, FAAP ICD ICD-10 ORIGINALLY SCHEDULED FOR 10/11 NOW CHANGED TO 10/13 BY CMS WILL BE ASSOCIATED WITH $$$ 2013 ICD-10 WHY ICD-10 ICD-9 RUNNING OUT OF ROOM ICD-10 WILL BE ABLE TO CAPTURE NEW TECHNOLOGY AND TERMINOLOGY 1

16 SO WHAT-ICD ICD-10 U.S GOVERNMENT STATES THEY WILL AID IN CAPTURING GLOBAL HEALTH DATA AND WE ARE LAGGING BEHIND MOST OTHER COUNTRIES IN THIS TRANSITIONAL PERIOD ICD ICD-10 WE HAVE A TEMPORARY REPRIEVE BUT FEAR NOT, IT IS COMING WILL YOU BE READY? 2013 ICD-10 ICD-9: Don t we use it now and won t we always? Yes and No October 1, 2013 switch Several delays, hoping for more delays Plenty of time to make changes Will cost $$$$$$$$$$$$$$$ 2

17 2013 ICD-10 Why make the change to ICD-10 ICD-9 went from 3-5 digits No room for additional codes World has shrunk and global healthcare informatics has increased Need to capture new technologies and modalities of treatment 2013 ICD-10 Has room for 68,000 codes and expansion Allows greater specificity in reporting diagnosis Combines diagnosis and symptoms which decreases # of codes for description 2013 ICD-10 Implemented by WHO in mid-1990s to gather worldwide data United States lagging behind most countries in adoption 3

18

19 SHOW ME THE MONEY! RICHARD LANDER, M.D., FAAP HOW DO WE GET PAID? Private insurance payors Public insurance payors Self-payors Non-covered services Covered services HOW CAN WE GET PAID MORE? NEGOTIATE BETTER CONTRACTS PROVIDE MORE SERVICES YOUR OWN-PROCEDURES ANCILLARY WORK SMARTER, NOT HARDER 1

20 HOW CAN WE GET PAID MORE? CODE BETTER SEE MORE PATIENTS BECOME A PLASTIC SURGEON CONTRACT NEGOTIATIONS STRENGTH IN NUMBERS DON T WUSS OUT KNOW YOUR WALK-A-WAY POINT WAIT THE INSURERS OUT CONTRACT NEGOTIATIONS DEMONSTRATE HOW WELL YOU TAKE CARE OF YOUR PATIENTS DECREASE ED UTILIZATION DECREASE PHARMA COSTS DECREASE X-RAY USE 2

21 OFFICE EFFECTIVENESS FLU CLINICS WALK-IN HOURS PNP ALSO UTILIZE FOR TEACHING DON T GIVE AWAY FREE CARE IE. CONSULTATIONS OFFICE EFFECTIVENESS REVIEW EOBS EVALUATE FEE STRUCTURES HOW OFTEN? APPEAL DENIALS GROUP SESSIONS OFFICE EFFECTIVENESS COLLECT BALANCE AT TIME OF SERVICE CHECK PATIENT RECORDS AT VISIT LAST WELL VISIT VACCINATION HISTORY 3

22 PROCEDURES IF YOU DON T CODE IT YOU CAN T GET PAID IF YOU DON T DOCUMENT IT YOU WON T GET PAID IF IT IS DENIED AND YOU DON T APPEAL IT YOU DID IT FOR NOTHING PROCEDURES INTEGUMENTARY SYSTEM ACNE SURGERY I&D OF ABSCESS COMPLICATED OR MULTIPLE I&D FOREIGH BODY SUBQ I&D OF HEMATOMA OR FLUID COLLECTION PROCEDURES PARING OF CORN-CALLUS LESIONS MORE THAN REMOVAL OF SKIN TAGS EACH ADDITIONAL SHAVING OF EPIDERMAL OR DERMAL LESIONS-DEPENDENT ON SIZE AND LOCATION 4

23 PROCEDURES DEBRIDEMENT OF NAIL AVULSION OF NAIL PLATE EVACUATION OF SUBUNGUAL HEMATOMA INTRALESIONAL INJECTION 1-7 LESIONS PROCEDURES INITIAL TREATMENT FIRST DEGREE BURN-LOCAL TREATMENT DRESSING AND/OR DEBRIDEMENT WITH/WITHOUT ANESTHESIA SMALL TO LARGE DESTRUCTION(ACTINIC) DESTRUCTION WARTS CHEMICAL CAUTERIZATION PROCEDURES FRACTURE AND/OR DISLOCATION CLOSED TREATMENT OF CLAVICULAR FX WITH MANIPULATION CLOSED TREATMENT OF SHOULDER DISLOCATION CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION-CHILD 5

24 PROCEDURES CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION THUMB WITH MANIPULATION NOT THUMB CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE WITHOUT MANIPULATION PROCEDURES REMOVAL FB FOOT SQ OR 5 CLOSED TREATMENT FX GREAT TOE WITHOUT-WITH MANIPULATION OR 15 OTHER TOES PROCEDURES REMOVAL FB INTRANASAL NEWBORN CIRCUMCISION LYSIS OF PENILE POSTCIRC ADHESIONS FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS 6

25 PROCEDURES SCREENING VISUAL ACUITY VITAL CAPACITY INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION DEMO OR EVALUATION OF PTUSE OF NEBULIZER OR MDI MANIPULATION OF CHEST WALL PROCEDURES SPIROMETRY HYPNOTHERAPY PHARMACOLOGIC PSYCHIATRIC MANAGEMENT INCLUDING PRESCRIPTION, USE, AND MEDICAL REVIEW OF MEDICATION ANYTHING ELSE YOU DO-LOOK IT UP ANCILLARY SERVICES PSYCHOLOGY NUTRITIONAL EDUCATIONAL LACTATION CONSULTANTS DENTAL VARNISH? 7

26 ANCILLARY CHARGES FORM COMPLETION FEE MISSED APPOINTMENT FEE NO CO-PAY FEE LATE PAYMENT FEE-NOT INTEREST NON-COVERED SERVICES CREDIT CARD FEE ANCILLARY CHARGES SURCHARGES RECORD COPYING FEE WAIVERS FOR COVERED ITEMS ANCILLARY CHARGES ADHD PHARMA MANAGEMENT PERIODIC REVISITS PHONE MANAGEMENT? MIN MEDICAL CONF WITH HEALTH TEAM 8

27 EQUIPMENT=MONEY VEP OAE INHALATION THERAPY TYMPANOMETRY PULSE OXYMETRY PULMONARY FUNCTION TEST HCPCS Codes Used to report supplies J Dexamethasone injection, 1 mg J Epinephrine J Ceftriaxone, per 250 mg J Albuterol for inhalation, 1 unit dose 9

28

29 WHAT DO YOU MEAN I OWE YOU MONEY? RICHARD LANDER, MD, FAAP PREVENTING THE MOST FREQUENT MISTAKES IN FOLLOW-UP AND COLLECTION COLLECTION ISSUES? NOT ME WHO THEN? 1

30 MONEY WHO OWES YOU MONEY THE PATIENT THE MANAGED CARE ORGANIZATION BOTH NOBODY COPAYS POST SIGN ABOUT CONTRACTUAL OBLIGATION PHYSICIAN S S TO COLLECT PATIENT S S TO PAY COLLECT BEFORE VISIT IF PATIENT UNSURE SET $ AMOUNT ACCEPT CREDIT CARDS? COPAY SERVICE FEE IF NOT COLLECTED NO CHARGE WITHIN 24 HOURS RESCHEDULE IF TEEN CALL PARENT ATM DIVORCE SITUATION-WHO PAYS 2

31 PATIENT RESPONSIBILITY PATIENT RESPONSIBILITY BECAUSE THE EOB SAYS SO! YOUR STATEMENT SHOULD HAVE CHARGE AND INSURANCE PAYMENT SEND COPY OF EOB IF NEEDED CALL PATIENT IF NO PAYMENT I HAVE INSURANCE PATIENT MUST SHOW CARD TO VERIFY IF NEW COPY CARD, SIGN AND DATE NO INSURANCE-PAY UP FRONT CAPITATED-CHECK CHECK YOUR LIST PATIENT S S RESPONSIBILITY TO KNOW SCOPE OF BENEFITS-NOT NOT YOURS SERVICES OUTSIDE OF INSURANCE HAVE WAIVER SIGNED LABS, SPORTS PHYSICAL INSURANCE PROBLEMS SUBMIT PROPERLY COMPLETED CLAIM FORM PATIENT NAME, DOB, ID#, DOS PROPER ICD AND CPT DOCUMENT TIMELY FILING KNOW STATE LAW FOR CLEAN CLAIM 3

32 INSURANCE PROBLEMS UNDERPAYMENT? 5% LOST REVENUE OVERPAYMENT? DENIAL NOT A COVERED SERVICE-BILL PT INCLUDED IN GLOBAL SERVICE SAYS WHO? INSURANCE PROBLEMS APPEAL REFILE CORRECTED CLAIM PROVIDE DOCUMENTATION CONTACT MEDICAL DIRECTOR FOR PHYSICIAN NOT A SPECIALIST AFTERHOUR CARE CONTACT AAP-PEDIATRIC PEDIATRIC COUNCIL INSURANCE PROBLEMS REMEMBER-YOU TREATED THE PATIENT NOT THE INSURANCE COMPANY PATIENTS NEED TO TAKE RESPONSIBILITY FOR THEIR HEALTH CARE-IT DOESN T T END WITH COPAY 4

33 PATIENT PROBLEMS IF PATIENT ATTEMPTING TO CORRECT INSURANCE ERROR ASK FOR GOOD FAITH PAYMENT IF PATIENT RESPONSIBILITY USE YOUR REGULAR BILLING PROCEDURE LATE FEE IF NOT PAID ON TIME PHONE CONTACT AFTER 90 DAYS DOCTOR PROBLEMS ARE ALL CHARGES CAPTURED? DOCTOR FILLS OUT ENCOUNTER FORM COULD LOSE 10% OF BILLING NURSE TO CHECK NOTES-5% FRONT DESK TO CHECK NOTES AND ENCOUNTER FORM-1-2% DOCTOR PROBLEMS CHECKING THE EOBS FOR ERRORS REASONS FOR DENIALS CHANGES IN PAYMENT 5

34 DOCTOR PROBLEMS DENIALS WHAT IF INCORRECT? APPEAL RE-APPEAL OR EXECUTIVE APPEAL NON-COVERED SERVICE PATIENT PAYS DOCTOR PROBLEMS DENIALS BUNDLING (PART OF ANOTHER SERVICE) ENLIST HELP OF IPA OR AAP DOCTOR PROBLEMS DENIAL OF VISION SCREENING HAS OWN CPT BRIGHT FUTURE GUIDELINES INFORM PT OF MCO POSITION PT TO SIGN WAIVER FOR TESTING SEND PT TO OPHTHALMOGIST AND DOCUMENT SAME IN CHART DECREASES LIABILITY 6

35 DOCTOR PROBLEMS CHECKING THE EOBS- YOU CHARGE X MCO USUALLY PAYS Y TODAY IT PAYS Y-$5 Y WHY? TODAY PAYS X INCREASE YOUR CHARGES HOW MUCH COULD IT BE? CURRENT DAYS GREATER THAN GREATER THAN GREATER THAN GREATER THAN PCC DATA PATIENT PROBLEMS Past due balance contact in office greet and seek cash, check, cc, cdhp-card card monthly statements service fee Don t t accept pt mantra-we paid our co-pay the rest is your problem 7

36 HOW MUCH COULD IT BE? CURRENT 52% AR GREATER THAN 30 DAYS 14.9% GREATER THAN % GREATER THAN % GREATER THAN % PCC DATA PATIENT PROBLEMS 120 DAYS NO PAY 30 DAY TIME LIMIT AND IF NO PAYMENT DISMISSAL FROM PRACTICE GOOD FAITH PAYMENT PERSONAL CALL TO INQUIRE ABOUT FINANCIAL PROBLEMS PAYMENT PLAN-COUPONS PATIENT PROBLEMS BILLING-INOFFICE INOFFICE VS OUTSOURCING COLLECTION AGENCIES VS LAWYER OFFER % TO EMPLOYEE SMALL CLAIMS COURT BANKRUPTCY SETTLE OUT OF COURT? CREDIT COMPANY SETTLEMENTS DO YOU HAVE TO ACCEPT 8

37 COLLECTION BE AGGRESSIVE IN COLLECTING YOU PROVIDED A SERVICE AND NEED TO BE PAID IN A TIMELY FASHION REMEMBER YOU TREATED THE CHILD NOT THE INSURANCE COMPANY 9

38 P.O. Box Kansas City, MO Phone: (816) Fax: (816) An affiliated organization with Children s Mercy Hospital