Practice Management: Billing, Coding and Collections. Provided by Coverys Risk Management

Transcription

1 Practice Management: Billing, Cding and Cllectins Prvided by Cverys Risk Management

2 Practice Management: Billing, Cding and Cllectins What s the Risk? Overly aggressive cllectin techniques can alienate a patient t the pint f triggering a lawsuit. Particularly, if the patient is billed after a cmplicatin resulting frm a physician s actins r if a patient has a legitimate claim f unsatisfactry care. Cnversely, waiving fees related t treatment can result in a vilatin f fraud and abuse laws. Delaying sending recrds r test results t the patient r anther physician because f an unpaid bill can create the ptential fr a delay in treatment, which may be the basis f a claim. Juries tend t care very little abut the financial aspect f healthcare delivery. If an injury results frm a delay in apprpriate treatment, and the delay is tied t an unpaid bill, the jury will likely be very sympathetic t the patient. When Is This Risk an Issue? Little can threaten the prfessinal relatinship as quickly and as ttally as when a patient perceives billing practices t be unfair. Anger may be smldering under the surface abut a number f unspken issues: the lengthy wait t be seen, the difficulty reaching the practitiner by phne, the perceptin f being t casually dismissed by a member f the staff. These and similar issues may all cme t the fre because f a prblem with billing. Billing, cding and cllectin are thus nt simply business prcedures that rest apart frm the prfessinal fcus f the ffice. They must be cnsidered central t the ttal care f the patient and may ften, but nt always, require the invlvement and ccasinally the interventin f the practitiner. An effective cllectins prcess and a cmpliance prgram are integral t the verall risk management strategy f the practice. Cllectins While sme patients wh d nt pay bills may simply be lax, sme patients wh d nt pay bills are dissatisfied with care and acting ut in anger. If practitiners fail t review patient files befre they g t a cllectin agency, it is pssible fr a patient wh suffered a cmplicatin r had an issue with quality f care t have his/her billing sent fr cllectin. Further, sme patients wh are nt current n bills may have suffered a persnal prblem, fr example, lss f a jb, which makes timely payment impssible. Regardless f the reasn, persnal attentin and the practitiner s cncern fr the underlying prblem can g far tward preventing an escalatin f the prblem. Althugh practitiners are nt expected t give free care except by prir agreement, a practitiner may nt ethically r legally withhld needed treatment because a patient is derelict in paying a bill. A patient with an utstanding bill wh makes appintments fr additinal ffice This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 1

3 Practice Management: Billing, Cding and Cllectins visits withut ever mentining the pen balance may need t either be scheduled fr a visit t discuss payment ptins r be terminated frm the practice. Fr specific recmmendatins n hw t terminate a relatinship with a patient, see the chapter titled Terminating the Prvider-Patient Relatinship. Cmpliance The purpse f a cmpliance prgram is t ensure that claims are prperly cded and submitted accrding t regulatins, guidelines, Current Prcedural Terminlgy (CPT) cdes, Internatinal Statistical Classificatin f Diseases (ICD) cde sets and payer plicies. Inapprpriate billing practices include, but are nt limited t, upcding, billing patients fr prducts received by the physician fr free, imprper billing fr the technical prtin f a service, billing fr services that were nt prvided during an in-persn physician encunter, and accepting inapprpriate gifts fr patient referrals. In additin, the practice is respnsible fr billing errrs made by a third-party billing service, even if the practice was unaware f the errr. Errrs can accumulate quickly and may result in significant fines r ther penalties. The Office f the Inspectr General (OIG) and the American Medical Assciatin (AMA) ffer recmmendatins and guidelines fr develping and implementing an effective billing, cmpliance and auditing prcess. Fraud and abuse investigatins, fines, and penalties may be avided when an effective cmpliance prgram is implemented. Hw Can I Reduce Risk? Practices can implement varius strategies t reduce the risks assciated with billing, cding and cllectins. These strategies include: develping a billing plicy, estimating fees, develping a cllectin prcess, submitting timely and accurate claims, implementing a cmpliance prgram, and cntracting with and mnitring third-party billers. The risk management recmmendatins fr each f these strategies fllw belw: Develp a Billing Plicy Outline a plicy Outline the fllwing in a billing plicy: Expectatins with respect t payment. Acceptability f credit cards. Respnsibility fr insurance frms (ffice r patient). Patient respnsibility fr reslutin f insurance disputes ver services, tests, treatments and prcedures nt cvered by the insurance plicy. Billing fr n-shws and cancellatins with less than a specified time f ntice. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 2

4 Practice Management: Billing, Cding and Cllectins Include in welcme brchure Include the billing plicy in the practice welcme brchure. Infrm patients Infrm patients abut billing practices befre their first appintment. Pst plicy Pst the billing plicy in the receptin area s that it is visible t patients. Ntify physician Ensure that billing staff members prmptly ntify the physician upn receipt f any letters, phne calls, legal dcuments, r any ther indicatin that a patient may be unsatisfied regarding a bill r the care received. Estimate Fees Discuss fees Discuss fees up frnt, preferably at the first visit. Cnduct this discussin tactfully. Ensure that patients are adequately infrmed, s that they are nt surprised at the amunt when they receive a billing. Be sure t discuss cstly r unusual ut-f-pcket expenses befre treatment is rendered. Explain payments Estimate fees and explain payment expectatins t patients entering a lng-term relatinship. Fr example, explain bstetrical and psychiatric care r prcedures that are nt cvered by insurance. Establish a written plan Develp a written payment plan fr self-pay patients and make sure that it is signed by bth the practitiner and the patient. File the riginal plan in the medical recrd and prvide a cpy t the patient. Develp a Cllectin Prcess Review files Make certain that the physician reviews each bill and the patient s chart befre a bill is referred fr cllectin. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 3

5 Practice Management: Billing, Cding and Cllectins Call first Ensure that the practice manager calls the patient t determine the reasn fr the unpaid bill befre turning the bill ver t a cllectin agency. This might uncver prblems related t patient dissatisfactin. Ensure letters are plite Ensure that cllectin letters are plite and invite the patient t call t arrange a favrable payment schedule. In the interest f fstering gd patient relatins, cnsider special payment arrangements fr patients with a true financial hardship. Mnitr the agency Select cllectin agencies that d nt emply abusive r threatening practices. Peridically mnitr the cllectin agency s activities. Instruct the cllectin agency t btain written permissin befre filing a suit regarding an uncllected debt. Cntinue t treat Never deny treatment t a current patient because f an unpaid bill. Never delay release f the medical recrds r test results t the patient r anther physician because f an unpaid bill. Submit Timely and Accurate Claims Determine time limits Determine the payer s time limits fr filing a claim and advise all invlved. Prevent errrs Ensure that any billing sftware used is sphisticated enugh t perfrm the edit functin that prevents claims with errrs, such as invalid diagnsis and prcedure cdes, frm being submitted. Understand reprts Educate staff members as necessary, s that they understand payer remittance reprts. Utilize a clearinghuse Utilize an electrnic claims clearinghuse t file claims, if pssible. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 4

6 Practice Management: Billing, Cding and Cllectins Implement a Cmpliance Prgram Identify inapprpriate billing Develp a cmpliance prgram that effectively identifies inapprpriate billing practices and immediately bans prcesses/prcedures that may result in questinable billing prcedures. Audit billing Develp an auditing prcess t mnitr cmpliance with all rules and regulatins pertaining t yur billing practices. Cde accurately Ensure that cding is accurate, cmplete and timely. Cnsider the fllwing with respect t accurate cding: Be cmpliant with HIPAA Transactin and Cde Sets Standard. Avid clustering. D nt cde fr a middle level f services with the expectatin that sme charges will be higher and sme lwer than the ttal billed. Eliminate upcding. Answer any cding questins accurately, rather than simply submitting the next highest cde. Bill fr bundled services. Avid billing separately fr the cmpnent parts f a service prperly encmpassed within ne billing cde. Make sure all bundled services are medically necessary. Bill fr medically necessary services. Substantiate the need fr every service that is billed in medical recrds dcumentatin, particularly services billed t a federal healthcare insurance agency. Ensure that the dcumentatin is specific, accurate and clear t avid misinterpretatin and prvides an accurate clinical picture f care given r needed. Bill nly fr services prvided. Beware f duble billing. Ensure that practitiners and their practices d nt bill fr the same services. Mnitr cding Create checklist that mnitrs fr apprpriate cding, dcumentatin and cmpleteness f claims fr payment f services. The elements f the auditing checklist may include: This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 5

7 Practice Management: Billing, Cding and Cllectins Whether the service was perfrmed. Whether the service was inapprpriately dcumented. Whether the CPT cde is apprpriate fr the prcedure perfrmed. Evaluate data Evaluate the data btained during audits, identify actin plans as necessary, and immediately change practices that may result in inapprpriate billing practices. Screen candidates Screen jb candidates fr fraud and abuse sanctins. D nt hire anyne with a current Medicaid, Medicare, licensure, r fraud and abuse sanctins. Reprt verpayments Reprt any federal verpayments. Train and educate prviders and staff Train physicians and staff members respnsible fr cding upn hire and when new cding sets are implemented. Cnduct audits and mnitr denials t identify when further educatin is needed. Cntract With and Mnitr Third-Party Billers Cntract with billers Cnsider the fllwing when cntracting with a third-party biller: Cntract nly with a firm r grup that prvides a written guarantee that nne f its emplyees have been excluded frm any federal payer prgram. Create written prtcls detailing the third-party biller s cllectin bligatins. D NOT make payments dependent upn percentage f cllectins. Specify in the cntract that the biller has n authrity t change practitiner cdes. Write int the cntract that the practice has the authrity t inspect the biller s recrds at any time. Include a hld harmless clause in the cntract. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 6

8 Practice Management: Billing, Cding and Cllectins Perfrm audits Mnitr activities f a third-party biller and perfrm randm audits. Crrect any cding and billing prblems discvered during the curse f such an audit. This manual is a publicatin f Cverys Risk Management Department. This infrmatin is intended t prvide general guidelines fr risk management. It is nt intended and shuld nt be cnstrued as legal r medical advice. The cntents may be used within yur rganizatin with yur staff members and physicians. These dcuments may nt be reprduced r transmitted in any frm r by any means, utside f yur rganizatin, withut the written permissin f Cverys. 7