Physical Therapy Management & Physical Therapy Documentation

Claim – How to Appeal When Denied

by Nitin Chhoda PT, DPT | Nov 9, 2013 | Electronic Medical Records, Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

Each reimbursement claim goes through an adjudication process once it reaches a clearinghouse and eventually, every biller will receive a denial.

Depending upon the reason, healthcare providers can appeal the decision and MIBs will play a major role in the process. In this enlightening article, well known physical therapist, Nitin Chhoda, explains how to resolve disputes without going through an official appeal.

Many claims are denied for oversights and mistakes that can easily be rectified. Winning payment for their clients requires MIBs to develop an appropriate strategy that addresses the cause of the claim denial.

The first step is a written communication that demonstrates exactly why the claim denial was made in error. The following are some important factors to consider when appealing a denied claim:

Active policies
Improper submission
Level of care
Medical necessity
Networking problems
Pre-authorization
Pre-existing conditions
Procedures that are not covered

Proof the Patient’s Policy is Active and In Effect

When new insurance coverage goes into effect, the information may not have been added to the clearinghouse database. Proof must be provided that the patient’s policy was active and in effect at the time of treatment.

This can be accomplished with a copy of the valid insurance card or a letter from the patient’s employer that provides the pertinent information.

Adhering to the Payer’s Reimbursement Submission

Each claim undergoes close scrutinization. Individual insurance companies have their own policies, procedures and protocols for reimbursement submissions.

Not adhering to these will generate a claim denial, but can generally be fixed by correcting any error or making the appropriate revisions and resubmitting the claim.

Required Level of Care

A carrier may decide the level of care exceeded what was required. Supplying supporting documentation for the claim will usually clear up the matter.

Is the Medical Necessary?

It’s the responsibility of the practitioner to prove through appropriate documentation that the treatment or procedure provided was medically necessary. The clinician must provide a written letter that explains any extenuating circumstances.

Network Unavailability

Payer policies may require patients to only see specific practitioners within their network of participating providers for treatment to be covered. Clinicians need to explain if an in-network provider wasn’t available.

Circumstances of Missed Preauthorization

If a preauthorization wasn’t obtained prior to treatment, explain to the payer the circumstances that prevented the request, such as a medical emergency. The clinician should also supply evidence that the authorization would probably have been approved anyway.

Pre-Existing Conditions

Many policies have exclusions for any disease or condition that affected the patient prior to when their policy went into effect.

To eliminate a claim denial, the onus is on the medical provider to demonstrate that treatment wasn’t due to a pre-existing condition.

If available physical therapy documentation doesn’t support this, an appeal is futile.

Procedures Covered or Not Covered

Each insurance policy has specific restrictions, requirements and limitations. MIBs will need to ensure that the claim was coded correctly and the procedure was covered. If the coding was accurate but proof of coverage can’t be assembled, don’t appeal.

An appeal isn’t always indicated when a denial is received. When all the requirements, coding and conditions of the policy has been met and a denial is issued, it’s important for the MIB to provide the needed documentation and evidence to support the reimbursement.

These strategies provide carriers with clear and logical explanations as to why the denial should be removed and funds facilitated to the practice’s account.

Will Obamacare Cause a Shortage of Clinicians?

by Nitin Chhoda PT, DPT | Nov 5, 2013 | Electronic Medical Records, Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

Under the Affordable Care Act known as Obamacare, approximately 30 million new patients will enter the healthcare system. The Association of American Medical Colleges estimates that by 2015, the U.S. will require 60,000 more doctors than it will have at that time.

The group expects the shortage to increase through 2025, as fewer individuals are motivated to pursue medicine as a career under Obamacare legislation.

The potential for a physician shortage was further noted by a Physicians Foundation poll in 2010.

Forty percent of respondents indicated they would retire early, take employment at a hospital, look for a non-clinical job or quit the profession entirely due to Obamacare.

A shortage of practitioners would mean longer waits for appointments and ERs filled with patients who couldn’t wait to see a doctor.

Medicare patients might need to locate a new clinician and travel longer distances to access healthcare.

Highlighting An Existing Problem

According to Dr. Reid Blackwelder, president of the American Academy of Family Physicians, a growing population, along with an aging population that requires more care, is the driving forces behind a physician shortage.

Obamacare is simply accelerating a problem that already exists.

More medical students are choosing to specialize where income potential is greater.

Obamacare places an emphasis on primary care doctors and makes them the lynchpin of many of its initiatives, the exact place where the largest need is and will be in the future.

To address the need, Obamacare allotted $1.5 billion to the National Health Services Corp, which provides support to healthcare professionals in areas with physician shortages. Obamacare anticipated that practitioners in rural areas would be especially impacted where patients have fewer options than those living in more densely populated areas.

ACOs and Reduced Reimbursements

Accountable Care Organizations (ACOs) created under Obamacare are teams of medical professionals that treat patients as a group for coordinated care.

Primary care physicians are the pivot points in these teams, creating an even greater need that could take practitioners away from the pool of available healthcare providers needed in underserved areas.

Much of the cost to implement and support Obamacare is being taken from Medicare funds. Obamacare reduces Medicare reimbursements, providing the potential to limit clinician access to millions of individuals.

Many practitioners have already stated that they won’t continue to see Medicare patients due to payment cuts.

New Opportunities for NPs and PAs

A clinician shortage could be partially alleviated with qualified physician assistants (PAs) and nurse practitioners (NPs). PAs and NPs can examine patients, diagnose, prescribe medication and make referrals if needed.

In many states, they’re required to work under the direct supervision of an M.D.

Some practitioners are reluctant to embrace a model that relies more heavily on PAs and NPs, or that gives expanded responsibility to nurses.

Health and Human Services Secretary, Kathleen Sebelius, said physician assistants and nurse practitioners are key elements in providing services under Obamacare, especially in rural and inner-city neighborhoods.

If physicians do carry through with their plans to exit the medical profession or seek other options, it could very well lead to a severe shortage of primary care clinicians at a time when 30 million new patients enter the system. Those circumstances could lead to less access to healthcare services rather than more.

Medical Team – Your Typical Healthcare Team and How it Works

by Nitin Chhoda PT, DPT | Nov 3, 2013 | Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

A practice that runs smoothly requires a variety of trained and experienced professionals. Medical insurance billers (MIBs) are an important part of any medical team and in this article, Chhoda familiarizes billers with the individuals they will encounter and how the typical practice functions.

MIBs are individuals of the medical team that are responsible for preparing and transmitting reimbursement claims that enables funds to flow into the practice.

There are many individuals that MIBs will work with to assemble the crucial information needed to file claims, all of whom contribute to the process.

Billers may also be asked to wear multiple hats, depending on the size of the practice.

The following are the common and yet very important members of the medical team:

Physicians
Physician assistant and nurse practitioners
Nurse
Technicians
Medical assistants

Physicians

The managing practitioner in a multi-physician practice is responsible for hiring staff, purchasing equipment and setting salaries, along with awarding promotions, approving vacations and a wealth of other details. They are always the first part in the medical team.

These practitioners diagnose and treat patients for illnesses, injuries and a host of medically related conditions. They refer patients to specialists when needed, prescribe medication and identify any tests that need to be done.

Physician Assistants and Nurse Practitioners

A physician assistant (PA) and nurse practitioner has advanced medical training, a four-year degree, and work under the direct supervision of a physician. Inside the medical team, they perform many of the same services as a licensed physician, from writing prescriptions and ordering tests to conducting examinations and requesting referrals.

Depending on the patient’s complaint, a physician may provide a perfunctory assessment or choose to approve the PA or nurse practitioner’s diagnosis and recommended treatment.

Nurse

The backbone of any private practice or medical team is the nurses. These licensed professionals assess, observe and record patient symptoms and complaints. They’re qualified to assist in medical procedures, provide guidance about a doctor’s diagnosis and dispense medication.

In addition to nurse practitioners, there are licensed practical nurses (LPN) and registered nurses (RN).

Technicians

There are many specialties within the profession of medical technicians. They perform advanced diagnostics, lab tests and treatment procedures that most of the time, are part of the medical team procedures. They’re the individuals that take x-rays, draw blood and operate medical equipment for procedures that include ultrasounds and dialysis.

MIBs may also work with registered health information technicians who are in charge of patient records. They’re charged with maintaining patient medical charts to ensure all information is current and accurate.

They may be responsible for entering the appropriate codes for a patient’s treatment that will be used to reimburse practitioners.

Medical Assistants

The duties of a medical team assistant are many and varied. They may be called upon to schedule appointments and act as a receptionist to greet patients.

Other responsibilities can include gathering insurance information, escorting patients to the examination room and transcribing doctor’s notes.

An efficiently operated medical practice requires the knowledge and skills of many individuals working together toward the same outcome.

The medical team is comprised of professionals in a variety of specialties to maintain patient records, ensure that clients receive the best care available and act as liaisons between patients and other medical staff.

Billers of healthcare practice management are an integral element of the medical team, maintaining the flow of revenues for the benefit and profitability of all concerned.

Every member of the medical team are important. Each of them must always take their responsibilities seriously so that the practice is more effective — giving the best services to clients.

Does Obamacare Promote “Independence at Home” Instead of Skilled Physical Therapy?

by Nitin Chhoda PT, DPT | Oct 25, 2013 | Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

The Affordable Health Care Act, known as Obamacare, is intended to reduce healthcare costs through multiple methods. One way is through a pilot program known as “Independence at Home” that utilizes technology to monitor a variety of health conditions. Known as “e-care”, the program was specifically designed for Medicare patients that traditionally cost the most to treat.

Program Basics

The program was implemented in Jan. 2012. It’s supposed to provide a better level of care, prevent hospital readmissions, achieve a greater level of patient satisfaction, and ultimately, save money.

Medical teams deliver care to Medicare patients in their homes or through a community-based center.

If the team achieves the goals of the Independence at Home program, they’ll receive substantial financial rewards.

E-care can be used to monitor an array of vital signs, providing seniors with convenient, primary care services at home. For the disabled, seniors who find it difficult to leave their homes, and those with chronic illnesses, Independence at Home offers an alternative to expensive long-term care facilities.

Care management teams include practitioners in multiple specialties, from social workers and medical professionals to mental health providers.

Convenience Over Care?

The program opens up new and convenient possibilities for seniors, but all services are no so easily delivered. Those who require extensive physical therapy may not benefit from the pilot program.

The Independence at Home program may have the best of intentions, but it’s confusing for many Medicare recipients who believe they can receive virtually any healthcare service while remaining in their home.

The program could easily encourage seniors to remain in their homes and limit themselves to the available care rather than leave their home to seek services that include physical therapy.

At the other end of the spectrum, patients have expressed concern that the in-home program will promote the use of only basic services and that other options may not be explored in an effort to restrain the cost of care.

Rehabilitation and therapy services will be terminated if the medical team members determine the patient has attained the minimal skills and range of motion needed to conduct daily living activities, or if family members are available to perform those daily activities for them.

The Independence at Home program under Obamacare has the potential to underutilize or limit some treatments in favor of cost savings to a segment of the population that typically has more need and higher healthcare costs.

For physical therapists, it has the potential of providing them with a means of expanding their services into new venues for increased revenues.

How Obamacare Attempts to Tackle Over-Utilization

by Nitin Chhoda PT, DPT | Oct 23, 2013 | Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

It wasn’t that many years ago that few people had healthcare insurance and they only went to the doctor when faced with life-threatening injuries and illnesses. For virtually everything else, they utilized a variety of home remedies and over-the-counter treatments.

Over the years, that changed. The Affordable Health Care Act, known as Obamacare, is on track to curb over-utilization as a means of reducing healthcare costs.

Comfort Over Care

When designing the Act, the views of Dr. Ezekiel Emanuel weighed heavily in developing Obamacare.

A key advisor to the president, he advocated reducing costs through a combination of methods that includes scaling back on “luxury” services, tests and technology.

The Act assumes that patients are self-indulgent and demand amenities that aren’t necessary for their treatment or recovery.

Those demands include expensive hospital rooms, attractively appointed waiting rooms, convenient parking and facilities designed for comfort rather than utility.

Practitioner Protection, Medication And Patient Ignorance

Obamacare works on the theory that clinicians prescribe tests, utilize high-dollar technology and schedule office visits that aren’t needed as a way to earn more money and protect themselves against potential litigation.

Obamacare further cites drug prices that are 10 to 30 percent higher in the U.S. than other countries, marketing costs, and the fee-for-service payment model for rising prices.

Malpractice insurance and consumers’ ignorance of the true cost of their healthcare were also named as factors for skyrocketing prices.

Back To Basics

Obamacare offers a multi-pronged attack that focuses on the cost element of the healthcare equation. Medical professionals and facilities that produce desired patient outcomes are rewarded financially.

The goal is for practitioners to use fewer “unnecessary” tests and technology to determine exact causes and rely more on exams and a patient’s health history to prescribe medications, devise treatments and expedite recoveries.

The cost for using the technology remains the same, but it’s utilized less as a means of lowering costs.

Patient Responsibility

Individuals are tasked with paying more of their healthcare costs and utilizing preventative measures to keep themselves healthy, as defined by their healthcare policy.

Employers and insurers are using financial incentives to promote healthy lifestyles, and encourage people to stop activities or practices that are deemed detrimental, from not getting enough exercise and giving up tobacco to eliminating soft drinks.

Taxes are imposed on people with “Cadillac” policies that Obamacare says encourages over-utilization of services, an outlook that could be an incentive for limited benefit packages in the future.

Those without insurance are penalized for their irresponsibility in not carrying coverage.

Physician Strategies And Struggles

Under Obamacare, practitioners are urged to return patients to a functioning condition as quickly as possible by less expensive means than currently employed. The Act reduces Medicare reimbursements and bundles payments for in-patient hospital stays and post-discharge treatments that were previously billed individually.

Obamacare advocates e-care monitoring at home to avoid hospital admissions, readmissions, and stays in skilled nursing and long-term healthcare facilities.

Independent Payment Advisor Board (IPAB)

Obamacare operates under the theory that access to technology automatically equates with overuse.

IPAB has been charged with finding ways to cut Medicare costs and making recommendations for treatments that automatically go into effect unless Congress moves to block them.

The organization is responsible for determining which treatments and procedures, in the collective opinion of its members, provide the best results/value for the money spent.

The rising costs associated with healthcare are due to a variety of factors associated with a capitalistic society. Obamacare attempts to address those issues with multiple methods that changes the way healthcare is purchased and delivered, combined with an array of taxes on policies and penalties for non-compliance.

Many patients fear that Obamacare signals a return to health coverage that’s only used in the direst situations and losing access to life-saving technology if a governmental panel deems it as too expensive.

Obamacare – The Biggest Change in Healthcare in over 150 Years

by Nitin Chhoda PT, DPT | Oct 13, 2013 | Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

The Affordable Health Care Act, colloquially known as Obamacare, was signed into law on March 23, 2010, legislation that encompassed more than 2,500 pages and destined to be the biggest change in healthcare in more than 150 years.

Many of the Act’s finer points haven’t been finalized or even written.

For instance, the office of Health and Human Services has not created a full set of rules and regulations to ensure the workings of the initiative.

Obamacare marks a milestone in the evolution of healthcare, but to fully appreciate the changes generated by the Act, it’s important to understand the history of healthcare insurance in the U.S.

Other countries typically utilize some form of socialized medicine, while the U.S. combines several methods that includes government subsidized programs, employer-based coverage, and direct sales.

Insurance During World War II

Prior to World War II, health insurance was a commodity that individuals purchased for themselves and was viewed much like the traditional rainy day fund – it was something to be used in an emergency.

As millions of men went to war from 1939-1945, the federal government placed a freeze on wages to prevent inflation. To acquire and retain workers, employers began offering healthcare to workers.

The practice gained widespread popularity with employees as manufacturing processes of the time became more dangerous and the potential for injuries increased. It was a non-taxed benefit that made it doubly attractive.

Policies were much less inclusive than those enjoyed by today’s workers and were primarily used for hospitalization needs.

Inequities For The Self-Insured

Those who had to purchase their own insurance received none of the tax breaks or discounts on premiums available to those who obtained insurance through large employer pools. Obamacare helps narrow that gap with insurance offered through the Marketplace for the approximately 9 percent of the population that purchase their own healthcare.

The self-insured can obtain coverage at rates estimated to be comparable to employer-based policies.

Medicaid And Medicare

To address the needs of the disabled, elderly and poor, the federal government instituted Medicare and Medicaid. Obamacare increases Medicaid income eligibility requirements.

The change allows more people to enter the system, but those living in states that already have generous income requirements may no longer be eligible and will have to purchase coverage through the Marketplace.

Obamacare provides government subsidies to help individuals pay for Marketplace insurance.

Healthcare Through The Years

Healthcare has been an issue in the U.S. since 1854, when it was first proposed for the benefit of the indigent and insane.

The effort to overhaul healthcare in the U.S. gained prominence again in 1933 under President Franklin D. Roosevelt, who managed to enact healthcare as part of Social Security, but not for all citizens.

President Lyndon B. Johnson oversaw the passage of Medicare and Medicaid in 1964, but it took almost 17 years for all states to participate.

President Jimmy Carter and President Bill Clinton proposed sweeping changes in 1977 and 1994, respectively, but both plans failed and were met with significant resistance by the medical community and pharmaceutical companies.

President Obama vowed to fix what he perceived to be a broken healthcare system and in 2010, the Affordable Health Care Act became the law of the land.

It expanded Medicaid coverage, established the Marketplace where the uninsured can buy policies, and established a core of benefits that every policy must offer.

The evolution of U.S. healthcare took a major leap from the accepted norm with Obamacare, legislation that’s inarguably the biggest change in the nation’s healthcare practices in more than 150 years.