Ethel Owen - Administrator Arthritis & Rheumatology Associates of Palm Beach, Inc. West Palm Beach, FL

Transcription

1 Ethel Owen - Administrator Arthritis & Rheumatology Associates of Palm Beach, Inc. West Palm Beach, FL

2 Practice Structure Office Management Physician Encounter Billing Office

3 Physicians & Administrator Clinical Managers And Physician Associates Business Personnel Check in, Checkout, In-Fusion, Lab & X-ray Staff MA s RN s Mid-levels Billing Manager Billing Staff Administrative Staff

4 Policies and Procedure Manual Employee Handbook Review protocols regularly with staff. Staff members require constant supervision, and retraining.

5 Assign responsibility Regularly review staff performance Ensure compliance and regulatory standards Establish and maintain an atmosphere conductive to staff cohesion and cooperation Procedures and conflict resolution

6 Team Effort Continuing Education for staff Staff in-services Physician and front office communication Front office and back office communication

7 SCHEDULING CHECK- IN PHYSICIAN ENCOUNTER BUSINESS OFFICE CHECK - OUT

8 First Impression Professionalism Set the expectations Bring outside records Cancelation policy

9 Smile and greet patient Review Patient Information Form (PIF) Pharmacy information Medical Release Patient Check referral status Office Policies Scan insurance card Collect co-payment Photo Enter Demographics

10 Review Demographics at Each Visit Phone Numbers Home Address Verify Insurance Verify Pharmacy Information Collect Outstanding Balances

11 Physician obtains history Examines the patient Enter data in to EHR Orders diagnostic imaging and laboratory tests Calculates disease activity score Assessment and Plan Implements treatment plan

12 Code Diagnosis to Support Medical Necessity ICD-10 Is more than a method to communicate a patients diagnosis to an insurance carrier to receive payment Diagnosis Codes Support Procedures and Orders Reduces Compliance Risk Proper ICD - 10 documentation enables quality patient management and ensures proper reimbursement

13 Charge Capture Office Visit Level In Office Labs Injections Medications Procedures Imaging

14 Verify physician orders Schedule ancillary service in accordance with orders Track services provided in-office and at referral facility Comply with payer requirements for Ancillary Services

15 Review follow-up care with patient Verify insurance information Provide patient with applicable written/printed instructions Review outside referrals, Imaging, PT, Labs Collect deductibles and coinsurance, Schedule follow up visit

16 Managing documentation within practice is vital

17 Monitor coding and documentation compliance with regularly performed internal reviews Utilize services of coding consultants to perform periodic audits Employ outside consultants through legal council so all findings are attorney-client privilege

18 Third-parties may conduct coding audits Practice Management System provide assistance Develop profiles on each physician, Identify coding patterns Analyze reasons for inter-physician variance Analyze in comparison to benchmarks

19 Office Encounter Tests or Imaging Procedures Labs Outsides Orders

20 Tell the story Support medical necessity Excellent Patient Care Claims Payment Keeping your Money Successful Practice

21 Consequences of Up-Coding and Down-Coding Level 5 Level 4 Level 3 Level 2 After Before Level If documentation and coding protocols were in place and adhered to, proper E&M coding for Level 3 and 4 for these two physicians would have resulted in an increased annual reimbursement commensurate with work done.

22

23 Accounts Receivables (A/R) is money owed for services rendered Sources of Revenue Insurance Companies Foundations/Industry Co-Pay Cards Patients Co-pays Coinsurance Deductibles

24 Define roles Cross train Knowledge of contracts and allowables Updated fee schedules Procedures Up to Date bundling edits Knowledge of managed care policies and procedures Effective communication

25 Office Claims Management Process Every step exists to increase the likelihood that each claim is reimbursed Pre-Encounter Admin. Access Management Eligibility Medical Necessity Patient-Doctor Encounter Concurrent Denial Mgmt./ Length of Stay Mgmt. Back-Office Administration Practice Mgmt. System Billing Rejection/ Denial Mgmt. EDI* Referral Authorization Patient Self Registry Utilization Mgmt. Coding A/R Mgmt. Bad Debt. Mgmt. Benefit Authorization Patient Portals & Kiosks Government/ Regulatory Compliance Contract Mgmt. Claims Editing * EDI Electronic Data Interface

26 Conduct daily billing audits Daily claims submission Document proof of timely submission Maintain current fee schedules Reports Track denials by procedure, by department, by doctor Appeals and review

27 Robust Practice Management System Provide Reports Aged Account Balances Income by Location Income by Doctor Rejected Claims Report By Doctor By Location By Procedure

28 Robust system for preparation and submission of claims Ability to load and maintain payer fee schedules Ability to track claims Knowledge of payment terms by payer Ability to code check Modifiers Diagnosis code and procedure mismatch

29 Practice viability under increasing economic pressure: Operating costs increasing; reimbursement declining Revenue needed to replace equipment, hire trained staff, expand services and locations, etc. Ancillary revenue sources under pressure Consumer-directed health plans on the rise to combat employer health costs - more pressure on price Consolidation among insurers giving payers leverage Under Insured Patients

30 Key Objectives Using the right people, tools and processes to maximize cash flow Collect on every procedure Collecting the contracted amount Time Management Claims Management Maintain Accountability Appropriate work loads

31 Education and training Communication Documentation Front office collections Back office billing and collections Customer Service Physician Involvement

32 Questions?

33 Thank You for Your Participation!