Annual Demographics Update Monday, Jan 9 2017 

In an effort to provide an explanation of the various reasons that we update demographics, we are offering this information to try to help reduce frustration for our patients and staff. Many people think completing the demographics form is only for billing purposes; however, we update patient information for both clinical and insurance reasons as well.

First and foremost, our clinical staff relies on the most current patient demographics to reach patients to communicate results of tests and to schedule patients for follow-up appointments. Initially, they make several attempts using all phone numbers provided. We have experienced phones disconnected and voicemail boxes full, which will then result in our attempt to reach a patient by mailing a note asking the patient to call our office. The last option is to try the patient’s emergency contact and explain that we have an important message. We do not divulge any confidential information unless we have a signed Designated Party Authorization.

In addition, we need to provide current information to specialists when we are referring patients, as well as for prior authorizations for prescriptions, procedures, and testing. These are the primary clinical reasons for having the patient update their information on a regular basis.

From an insurance perspective, it is our contractual obligation with insurance companies to maintain accurate records and current patient demographics to provide the best care. We are audited by all health plans several times a year for Quality Measures and frequently are required to show proof of current information on file.

Roughly 25-30 years ago, patients would pay for their medical services and the physician’s office would give them a bill to submit their own insurance for reimbursement. Now, with participation contracts, the healthcare provider extends credit while we wait for the insurance company to process and pay the claim.

To file a claim, and receive the insurance reimbursement, we have to have the patient sign an “Assignment of Benefits” authorizing their insurance company to send the reimbursement to the provider rather than the patient. This Assignment of Benefits is part of our demographic update form.

We, like all businesses, try to keep our expenses down and make every effort to collect for all services rendered. We need current addresses to mail statements for balances due. Phone numbers are required for the collection process as well. Even though we update this information, we still receive returned mail that is unable to be forwarded, which requires our staff to invest time determining the patient’s new address and/or telephone number. Each statement mailed can cost up to $2.00 per envelope. The Billing and Collection process can be even more costly if we are unable to locate the patient and they end up in outside collection because the collection company charges a substantial percentage to collect the balance due.

We dislike the extra workload as much as the patient dislikes completing the form. Please be assured that we have only included the minimum necessary for the patient to update to make it a bit easier. We appreciate our patients’ consideration and effort.

Yelp: When I want to find a good burger…not find a doctor! Friday, May 15 2015 

people-hate-us-on-yelpMy son just finished his first year of college. He is a business major, and I am interested in the viewpoints of his age group of 19 to 20-year-olds. I asked him his perspective on social media and rating sites like “Yelp”, especially in the medical industry. I had to laugh when he responded, “These sites are good for when I want to find a burger, but not trying to find a doctor.” I did have a proud mom moment!

Though I may be a bit bias, I have to say I agree with him. I have never been one to follow the crowd. I would prefer to experience all that life has to offer and make my own mind up based on my experiences. I have found that the vast majority of people who post on these sites are usually malcontents and self-absorbed. As an Administrator of a physician practice, when a patient is trying to “get their way” they typically threaten to go to “Yelp”. It is a threat and a method of intimidation. Before “Yelp”, people would threaten to file a lawsuit or contact their Senator/Congressperson…even the President!

A good portion of patient demands are unreasonable or not in the best interest of patient care. Sometimes, the patient becomes threatening or abusive toward the staff, which results in the patient being fired from the practice. Unfortunately, due to HIPAA, there is no way to defend ourselves against these accusations. Those of us who experience this firsthand know that IF people were to hear the whole story, they would understand our perspective! Would you trust a drug-seeker who is mad because we would not provide opiates since the patient is on marijuana, albeit “legally” with a medical marijuana card? Perhaps the review you are reading is from someone who is upset that they have a high-deductible health plan, and now they owe money to their doctor.

I have discovered that some reviews are in error. I had a review that mentioned a particular physician that was never a member of our practice. The review was regarding a service that we have never provided. It is nearly impossible to redact these erroneous reviews. Why would one want to trust a review that was a mistake?

Then, there is the fact that Yelp will contact the business to “help” them with their business reviews and create more positive responses…for a price. A great article that discusses this can be found at:

Yelp and the Business of Extortion 2.0

Bottomline, leave the reviews to film or restaurant critics…and maybe not even then! Don’t trust strangers with ulterior motives in choosing your physician. Do you want your healthcare in the hands of a trained physician or an unknown person who is trying to lash out because they didn’t get their way?

Rule-Out, Probable, and Possible: Importance in Documentation Guidelines Friday, Dec 19 2014 

Rule outRule out: Term used in medicine, meaning to eliminate or exclude something from consideration. For example, a normal chest x-ray may “rule out” pneumonia.

Many of us in health care have always heard the directive “never code a rule-out, possible, or probable”, which is true for coding the diagnosis! However, when coding for Evaluation & Management, it is extremely helpful to document any illnesses/injuries that the physician is ruling out because that will support the physician’s medical decision making and will guide the non-clinical/administrative personnel in the physician’s thought processes.

In the “Medical Decision Making-Diagnoses or Management Options” section of the Documentation Guidelines, CMS specifically states, “For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible”, “probable”, or “rule out” (R/O) diagnosis.” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf ; page 44)

In addition, CMS states, in the same document (page 43):

C. DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING
The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
the number of possible diagnoses and/or the number of management options that must be considered;”

I highly encourage all physicians and mid-level providers to include their thought processes in their documentation guidelines. Remember, many of the “bean-counters” that decide the appropriateness of your documentation are not clinical!

At Odds With Others: Hang up the gloves and start talking Thursday, Jan 2 2014 

This article appeared in the March/April 2008 issue of CMA Today the monthly magazine published by the American Association of Medical Assistants (AAMA). It was written by Cathy Sivak.

This article is regarding conflict with others in the office environment and is increasingly a challenge for every office.

“Meaningful conflict actually enhances communications by relating the expectation up front between the parties. Communication can be painful, you may have to correct somebody, but in the end you gain more respect from each other,” says Charlene Burgett, MSHCM, CMA (AAMA), CPC, CMSCS

AT ODDS WITH OTHERS Article CMA Today

Boxing Gloves

Getting ready for the Zombie Apocalypse Tuesday, Mar 12 2013 

Zombie Apocalypse Rescue Team

I am a fan of The Walking Dead show and graphic novels! I love all things Zombie!!  So, when I saw that someone created ICD-10 codes for a Zombie Apocalypse, I was absolutely thrilled!  Here’s the link to see what was dreamed up:

http://www.findacode.com/aprilfools/icd-10-cm-chpt-22-draft.pdf

Enjoy!!!

2012 in review Sunday, Dec 30 2012 

The WordPress.com stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 12,000 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 20 years to get that many views.

Click here to see the complete report.

What Insurance Companies Don’t Want You to Know! Friday, Oct 26 2012 

Finally! A long awaited and much anticipated book about ERISA by two well-respected leaders in the health care industry! This book will provide the secrets in getting claims paid, how to fight denials, and halt recoupments using the features within the ERISA regulations.

This is a must buy! Quite frankly, this is important even if you are a layperson covered under your employer’s group health plan! These are the secrets that your insurance company doesn’t want you or your doctor’s office to know!

Book Description

Publication Date: October 15, 2012
New book helps medical practices use the secrets within the ERISA regulations to their benefit to increase practice profitability The Medical Practice Guide to ERISA: Employee Retirement Income Security Act The Federal law ERISA (Employee Retirement Income Security Act) helps the majority of medical practices make carriers pay on claims that are now being denied, delayed and recouped. Only a small percentage of practices understand how ERISA works — yet with this new book, ERISA could possibly become a practice’s best friend! ERISA is complex and most medical practices, “Don’t know what they don’t know when it comes to dealing with ERISA!” Practices are in the dark in understanding how to protect their employer’s rights in collecting the monies owed them. ERISA regulates the practice s health benefits, health benefit payments, EOBs, and most importantly, appeal rights Using this book will allow the reader to not only capture the funds on thousands of dollars that the carriers are now unfairly denying, but will empower the reader to stop the unfair recoupments, illegal timely filing and improper appeal periods that carriers mistakenly quote to physicians and hospital offices. The authors map out the smart but ingeniously simple tactics that practices can use to force insurance carriers to honor their responsibilities on the policies owned by patients — and to convince the carriers to adhere to what the policies actually require them to cover. Providing an overview of the ERISA law, the Self/Verno book provides tips, tools and techniques to leverage ERISA for practice advantage. They take a close look at real-world ERISA situations, violations and outcomes. Armed with this roadmap, physicians and executive staff can better put their resources to work– leveraging ERISA to improve practice profitability. Noteworthy Features Clear Roadmap Written in layman’s terms so practice leaders can immediately begin to implement a strategy of getting claims paid, how to fight denials and halt recoupments. Practical Guidance Includes real world examples and case studies of how medical practices can use the ERISA rules to work for them. Also included is practical information on how to use the ERISA website and answers to the most frequently asked questions about ERISA. Templates to Get You Started Sample letters (describing exact situations and how they can be handled) will get you started and help your practice take control of the process. Selected Table of Contents Healthcare Basics Definitions Laws Employee Benefits Security Administration: Frequently Asked Questions about ERISA Using ERISA Claims Issues Sample Letters – Timely Filing Denial Response, Refund Demand Layperson Response, Unpaid Claims Letter, Incorrectly Paid Claims Letter, Bundling Denial Letter, Down Coding Letter, Payment to Patient Letter Additional Resources – Helpful Websites, Layperson Documents Authorized Representation, Assignment of Benefit Form

You can purchase through Amazon by clicking on this link:

http://www.amazon.com/The-Medical-Practice-Guide-ERISA/dp/0988304007/ref=pd_rhf_cr_p_t_1

OAISYS Call Recording Case Study Tuesday, Oct 2 2012 

A few years ago, I did a video case study for OAISYS on their call recording solutions. I never thought, until now, to include it on my blog…here goes!

http://www.youtube.com/watch?v=R6Ikzy87h5A&feature=plcp

 

 

 

 

ICD-10-CM implementation date is October 1, 2014 Saturday, Sep 1 2012 

The final rule setting the ICD-10-CM implementation date as October 1, 2014 was released by the Centers for Medicare & Medicaid Services (CMS) on August 24, 2012.

Why am I being Charged for my “FREE” physical? Saturday, Sep 1 2012 

Due to the Patient Protection and Affordable Care Act (PPACA), or commonly called “Obamacare”, Health Plans are starting to cover Preventive Medicine services at 100% with no copays, coinsurance or deductible. Unfortunately, insurance companies are not informing patients that dealing with medical issues during these preventive medicine visits will result in an out-of-pocket charge that could result in a co-payment, or a substantial out-of-pocket expense if they have not met their deductible. Insurance companies require all services to be itemized and coded appropriately. One of the primary reasons is to prevent the health plans from paying for services that are not covered. Providers cannot code problem visits as preventive because this would be insurance fraud and could result in the insurance company denying the claim, dropping the physician from their network, and/or, if a government plan, the physician can face imprisonment and fines.

This has resulted in patients becoming angry with their doctor’s offices. Many practices are trying to figure out how to deal with this issue. At my practice, we notify patients before their preventive visit by posting signs on the exam room walls and the medical assistant provides a written notification for the patient to sign that they understand the billing policy. We are also trying to have the physician alert the patient, during the preventive medicine visit, when their concerns become a medical visit and may result in an out-of-pocket expense to the patient. Depending on the severity of the patient’s concern, the physician may be obligated to address the medical issue because, if he didn’t, it could result in a bad outcome for the patient. For example, if the patient states that they have been dizzy and having terrible headaches, this could mean that the patient may have a brain tumor or other significant medical issue. If the physician ignored this complaint, it would harm the patient or could harm others if the patient were driving a vehicle and had an episode. In addition, this would easily become a malpractice lawsuit against the physician.

Some physicians have chosen not to do both a preventive medicine visit and a problem visit on the same day. If the patient is scheduled for a wellness visit and a problem comes up, the physician would either make the decision to change the visit to a problem-oriented visit and reschedule the preventive if the problem is high risk; or have the patient return to deal with the problem issue at a later date if the problem is a low risk. This method keeps the appointments separate and easier for the patient to understand the difference. The downside is that it requires the patient to come back for a second visit, taking additional time off work, to deal with something that could have been handled during one visit.

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