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.

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

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.

I’d rather buy a month’s worth of Starbucks than…pay my doctor bill Wednesday, Jul 6 2011 

One of the biggest frustrations we have in the health care industry is due to patients not understanding their own health insurance benefits. Oftentimes, patients think that just because they carry insurance, that means that everything is covered and they don’t have to pay anything. Patients receive health care service and a month later they discover that their insurance doesn’t cover that particular service; however, instead of accepting the responsibility of paying, many patients fight, demand, and threaten the physician’s office staff to make the balance go away.

This phenomenon has gotten worse in the past twenty years or so. I subscribe to the theory that much of this mentality is due to the inception of HMO’s. In the beginning, HMO’s had either zero patient financial responsibility, or an exceptionally low out-of-pocket cost. People have been conditioned in thinking that health care is an entitlement. After about a decade, due to insurance companies (and employer groups) not being able to withstand the expense of higher utilization of “free” health care, they began to make the consumer more responsible by charging higher co-pays and not covering certain services. Unfortunately, most Americans expect the same Cadillac coverage without any additional expense (beyond their insurance premium and co-pay).

A major challenge in physician practices is to help their patient’s understand their insurance company’s reimbursement policies, all the while maintaining good will. Physicians are finding themselves having to develop various financial informed consent forms to assure that the patient understands that they may be responsible for some of the cost. Medicare has required this, in the form of Advanced Beneficiary Notices (ABN), for years.  Even so, we often hear patients state, “I signed it but didn’t read it.”  Or, “I was afraid if I didn’t sign it that I wouldn’t get the service.” Perhaps the days of accountability are long gone.

One of the biggest threats we hear from patients is that they will leave our practice if we don’t write off their balance. Not much that you can do about that. Health care is a business and we cannot pay the bills with altruism. In addition, it is fraud to bill the insurance company for services and write off the patient’s responsibility. Aside from financial hardship cases, routine adjustments of patient responsibility can get a physician excluded and/or fined by the government when it is a government program such as Medicare or Medicaid. Worst case scenario for commercial insurance is the insurance company dropping the physician from their network.

With lower reimbursements, practices really need to devote more energy in collecting all revenues due. The average overhead for a primary care physician practice is reaching 60%. There are no government subsidies for physicians, other than rural health care, community health care centers and native american health centers. More and more physicians are closing their offices, retiring early, selling their practices to hospitals, transitioning to concierge medicine, or going to cash only practices. This is devastating to primary care because of the physician shortage; however, many specialists are also getting hit hard as well.

If it’s not documented… Thursday, Dec 2 2010 

I want to share with you my call recording system in our office. Initially, we had phones that would record, but it was only after someone pushed the record button on the phone and I would never get anything prior to the record button being pushed. In addition, the telephone system’s call recording speaker was very sensitive and if one of my employees sighed, breathed, or there was any other noise on our side of the phone, it would override the speaker and I would only hear our side of the conversation. It was very frustrating!

I have been recording our inbound and outbound telephone calls for over three years now and it is one of the best things I have ever done in my 25 years of practice management! The system I have was developed by OAISYS. They have two products, Tracer and Talkument. Talkument is more basic. I started with Talkument and upraded to Tracer about a year ago!

I did a case study for them because I love their product so much!

http://www.oaisys.com/casestudies/NSFM.aspx

and

http://www.oaisys.com/movies/flash_only/NSFM_Case_Study_flash.html

There is really no Federal Law regarding telephone recordings in this scenario. Each state has their own regulation and can either be “one-party” or “two-party”. One-party states only require one party to know about the telephone call being recorded and that would be the recording party. Two-party states require both parties and that is where you would hear the message that states “all calls are being recorded for quality assurance purposes.”

Arizona is a one-party state. I have my staff and physicians sign a disclaimer that they know that the phones are recorded, just to be on the safe side in my office. I also have a label on all phones reminding people that their conversation is recorded. I am the only person who can access the recordings…the physicians can not even access them!

Here is a website that covers telephone recording laws:

http://www.rcfp.org/taping/.

The OAISYS server is attached to our phone system. It has it’s own IP address, so there is no software to install on your phone system or computer server. I don’t remember how much hard drive space is on the server, but we have not filled the hard drive up yet. I do have another external hard drive attached to the system so when we do fill the drive, it is programmed to have the oldest calls dump into the external hard drive. All phone calls are saved and will be saved permanently, or until we decide to purge. I spoke with our malpractice insurer and they suggested that we retain the calls using the same guidelines as retaining patient medical records.

I am able to log into the server and the calls appear similar to how Outlook is laid out. I can search using various parameters, such as date of call, outside telephone number, office extension, inbound/outbound calls, etc. I can combine those parameters and do a search to drill down even further.

We have had three licensing board complaints and, in all three, I used the voice recordings as evidence…we won all three! All three licensing board complaints were completely dropped! Think about the malpractice savings because these things could have resulted in a malpractice lawsuit as well. This alone has covered the cost of the system over ten-fold!

In addition, I have used the voice recordings to help my staff in understanding that they made a mistake or may have sounded rude on the phone. Oftentimes, I can just let them listen and they discover the problem themselves…makes my job so much easier when they have the buy-in!

I have used it to fight insurance companies. I have used it for the smallest, mundane things, like the front office hanging up without getting a name or phone number of the patient…I go onto Talkument/Tracer and can pull the actual voice recording and re-listen to the person identifying themselves and the phone number shows up on caller ID on the system.

And, how many times, have you had a disgruntled patient who has stated that someone told them something and you know darn well that the person is not sharing the full truth with you? Yes, I have brought patient’s in my office to listen to their own conversation. I have emailed their telephone call to them proving that they made their appointment on a specific date, time and with a specific doctor because they state otherwise.

Bottomline is that I detest being lied to and I hate not knowing who to believe. If it happened on our phone line, I can hear it for myself and make my decisions based on fact! There is no better place to be and that, to me, is priceless.

My physicians and several other key staff, initially, had some trepidation about the system and now they bless the day we got it.  In fact, they wrote recommendation letters themselves sharing their feelings on having this system in our practice:

http://www.oaisys.com/downloads/NSFM_Letters_of_Recommendation.pdf

I seldom put this much passion into another company…OAISYS has won me over from the minute I saw them as a vendor at another conference I attended. I have had many dealings with OAISYS and they are a top notch company…if I ever think of ending this healthcare gig, I would be on their doorstep asking them to hire me! They use a third-party to do the installation, for us it was Sonoran Integrations, and they were excellent as well.

Oh, and another thing that we use it for, that may be of specific interest to those of you in Pediatrics:  Arizona has really strict laws regarding caring for minors and parental consent. As we all know, there are those parents that will drop their toddler off at one end of the block and expect him to get to the office, sign in and make informed medical decisions and pay their copay in Cheerios. Okay, maybe I am embellishing a little bit, but we all know that parents will drop off their teenagers and we cannot see them because we do not have parental consent.  With Talkument, I have the ability to record the parent’s consent and note in the chart that it was given and recorded (a verbal is okay, but I hate to have that “he said/she said” thing in a court of law!).

Why is COBRA insurance so much money? Wednesday, Apr 14 2010 

stethoscope coiled like a cobra snake

Why is COBRA insurance so much money?

It seems that the general public has absolutely no understanding of what COBRA insurance is and why it costs so much.  You can read the “official” information outlining COBRA by visiting this link:

http://www.dol.gov/dol/topic/health-plans/cobra.htm

In “layman’s language”, COBRA is an extension of the insurance that a person had while they were employed.  The employee has group insurance through their employer. Typically, employers pass on some of the insurance premium to the employee while they are employed.  Historically, the vast majority of employers that provided insurance to their employees offset some of the premium as a benefit of employment, so the employee never actually realized the actual premium amount for the insurance coverage that he enjoyed.

Upon separation of employment, an employee is extended COBRA Continuation of Coverage; however, the employer passes the entire cost of the health insurance premium to the employee.  At the very most, the employer (or insurance company handling the COBRA requirements for the employer) can charge a 2% administration fee.

The fact is that health insurance premiums are very expensive.  If an employee only paid a nominal amount for their health benefits while they were employed, that just means that their employer paid a greater portion of the premium.  It’s unfortunate that the vast majority of employees don’t understand this concept, even after they receive their COBRA paperwork stating the total amount due for their health insurance.  Typically, people complain about the cost of COBRA as if they are being offered a completely different insurance that costs more than what they had.

No, folks, you are still enrolled in the very same health plan that you had while you were employed, but now you are responsible for the full premium and not your employer!

New Trick by the Health Insurance Industry Tuesday, Nov 3 2009 

Imagine that you are an independent contractor for a company that pays you a specific rate for a specified amount of work; however, if you do more than the specified amount of work you would receive an additional amount.  Now, if you were to do that additional amount of work separately you would receive 100 dollars.  But, if you do that additional amount of on the same day as your normal work load, you would receive your normal pay for your normal work load and 50 dollars for the additional amount of work.  Would that be acceptable to you?

To illustrate further, I do my work and earn $100.   Tomorrow, I fill in for someone else and do their work and earn $100.  Okay, that seems fair. Tomorrow, I not only do I do my job, but I also completely do someone else’s work.  As an independent contractor, should I receive $100 for my normal work and that’s it?  Should I receive $200 for a double workload?  How about if I only get $150…$100 for my work and $50 for completing someone else’s job?  I think many of us would say that I should receive $200!

Unfortunately, many physicians are experiencing the $150 example from health plans when it comes to providing medical care on the same day as a preventive medicine visit.  According to universal coding principles, it is expected that a physician will code an evaluation and management (Office Visit) for diagnostic (medical) issues when done on the same day as a preventive medicine (complete physical).  One of the primary reasons is so insurance companies do not have to reimburse for services outside their reimbursement policies; for example, if the patient does not have preventive medicine benefits but comes in for a physical, the physical can not be coded as a covered medical benefit just to get  paid.

In physician coding, we are trained to code all services accurately to represent what actually was performed and documented so as to not open the practice up to the risk of fraud and abuse allegations.  In theory, one would think that if there is a universal coding policy, then the service should be reimbursed in a consistent manner; however, this is not the case.  What we are seeing is that the majority of health plans will pay the problem visit at 50% and the physical at 100% (there’s your $150!).  A few others will not reimburse the problem visit at all on the same day as the physical (you only get $100…double the work at the pay of one job!).  Consequently, many physicians are telling patients that they cannot have both services performed on the same day, thus the physician is able to get full reimbursement for each service (aha! that’s where I put my $200!).

It is inconvenient to the patient to make two appointments; but with the increasing expenses that physician’s practices are having to absorb, it is just not possible to throw away all or half of a reimbursement.  In addition, it is inconvenient to other patients who are not able to get in to be seen because of the physician’s full schedules…or doing in two visits that which he can do in one.  Understandably so!  The physician should be reimbursed for all of his services fairly.  This will allow the physician to be able see additional patients who require medical attention and not play insurance games!

Woman charged extra for asking doctor too many questions Saturday, Aug 8 2009 

Woman charged extra for asking doctor too many questions | 3 ON YOUR SIDE |
Arizona | azfamily.com

by Gary Harper/3 On Your Side

August 5, 2009

A Valley woman says she has a billing problem with her doctor’s office.

The billing problem has to do with a “well woman exam,” basically it is an annual physical for women.

The woman you are about to meet says it was supposed to be covered 100% by her insurance carrier, so why does she keep getting billed by the doctor’s office?

Shannon Karal, like a lot of women, knows the importance of having an annual physical. She says, “I do all my preventative visits for dentist, doctor, any of the normal things I try to go as much as they say you should go.”

So Shannon scheduled a well woman exam at a physician’s office called Doctors Goodman and Partridge, an exam she says that is 100% covered by her insurance carrier. Shannon explains, “I just had some questions and concerns about normal things that a young woman like me would have.”

Shannon says the exam was completely paid for by her insurance, however, she keeps getting a bill for $92 from the doctor’s office so, she called to find out why and, according to Shannon, she was told she asked too many questions during her exam.

She admits, “It makes me feel like next time I go to the doctor I shouldn’t share any of my questions or concerns or take any more time out of their day because I might be charged extra for that.”

Shannon maintains the questions she asked during her exam were all normal “female-related” questions and she cannot believe she would be charged. “I would completely understand this extra charge if there was another test done or something they do for my questions. But nothing! It was all verbal.”

The office of Doctors Goodman and Partridge would not talk to 3 On Your Side about Shannon’s case citing privacy issues but after our inquiry, they sent Shannon a letter saying, “The problems evaluated and managed at that visit were above and beyond the scope of a normal well woman exam” but, Shannon says that is nonsense and feels she is being billed for asking too many female-related questions, and taking up too much of the doctor’s time. Shannon tells 3TV, “I feel like there’s a stop watch every time I go to the doctor and they’re gonna be timing me and making sure I don’t go over that time and if I do then ‘Oh, there might be an additional charge for this.'”

Helped Patient Battle Health Plan and Won! Sunday, Jul 5 2009 

Just about a week ago, I received a call from a patient who was extremely upset that she was being billed $1,400.00 by the imaging facility for a CT scan after we told her that she did not need a prior authorization from her insurance company.  Typically, this is one of those things that it’s our word against the insurance company and, historically, the insurance company seems to always win.  I guess the axiom “he who holds the money has the power” applies in this kind of situation.  The insurance company insisted that they did not have a record of our phone call to them and that they would never have told us that this patient did not need a prior authorization for the CT scan.  The patient was irate and understandably so…especially with the economy the way it is.  As a goodwill gesture and to keep peace with the patient, I would have accepted the responsibility and paid for the scan and our office would be out the money.

But…we voice record all our incoming and outgoing telephone calls using a system called Talkument.  I have all of the staff and physicians trained on what information is helpful to me when I need to investigate a telephone conversation.  In this case, I pulled the patient’s chart and the medical assistant wrote a note stating that she called the health plan on 5/23/09 at 3:13 pm and found out that no prior authorization was needed and that she talked with Ann.  I knew my medical assistant’s extension and searched based on the information that I had, and viola, I found the four minute telephone conversation between my medical assistant and the health plan representative, Ann, who said that the patient did not need a prior authorization for the CT scan!

I had a three way conference call between the patient, myself and the health plan where I played the recording for them.  The patient was ecstatic!  I had to play this information a couple of levels up the ladder and was still told that someone would have to get back to me (quite frankly, I don’t think they were ready to address the fact that the doctor’s office actually had recorded them!  Uh oh!  They were caught!)

About a week later, the health plan representative called me and stated that they would cover the cost of this CT scan “this one time”.  She still did not want to take responsibility for her company giving inaccurate information.  She made it sound like we doctored up the recording…even though we have caller ID that had the health plan’s toll-free number and the first two minutes of the recording was the automated system that announces the health plan name.  I was even told by the rep that the person with whom my medical assistant had talked with, Ann, was not an employee of this health plan.  I love the lack of accountability!

Defensive medicine is taking on a new definition.  Besides the Internet, the next best resource I have in my office is the voice documentation system for phone call recording!  The system has aided me with staffing issues, patient issues and now insurance issues.  It has definitely paid for itself in protecting my physicians and our office from lying and deceit.