Healthcare Practice Management

Common Myths About the Medicare 8 Minute Rule

by Nitin Chhoda PT, DPT | Feb 6, 2014 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Software

There’s a lot of confusion about the Medicare 8 Minute Rule and how many units to bill. Calculating the correct number of units can be confusing without the proper training and understanding.

Many clinicians are unknowingly under billing and cheating their practice out of legitimate reimbursements.

The 8 Minute Rule is being used by Medicare and an increasing number of insurance companies.

Those that don’t follow the Medicare guideline typically bill in 15 minute increments.

For insurance companies that do follow the Medicare rule, each billable unit must be between eight and 22 minutes in duration, but it only applies to timed CPT codes.

The Total Is What Counts

Problems arise when an uneven number of minutes are dedicated to different tasks.

To bill accurately and ensure that they’re adequately reimbursed, clinicians must total all the minutes in the session for the maximum number of billable units.

To be included, only face-to-face time spent with the patient counts toward billable units.

The 8 Minute Rule applies as follows:

1 unit is 6-22 minutes
2 units is 23 to 37 minutes
3 units is 38 to 52 minutes
4 units is 53 to 67 minutes
5 units is 68 to 82 minutes
6 units is 83 to 98 minutes

Understanding Is Essential

Billing becomes more difficult when multiple procedures or services are provided.

When an uneven number of minutes occur, therapists should choose the code that best represents the majority of the treatment time.

To understand the 8 Minute Rule, therapists should talk with a professional biller. Without a full understanding of how the rule works, therapists will encounter errors and reimbursement denials.

Automatic Calculations

The In Touch EMR® automatically calculates the time for each CPT code.

The system knows if it’s a timed or untimed procedure and assigns the appropriate number of units.

Clinicians have full control and can change the claim before it’s sent.

Demonstrations can be scheduled to learn how the software works. It takes the guesswork out of calculations, increases efficiency, and ensures therapists are getting paid the full amount to which they’re entitled.

Billers Ethical Issues in Medical Billing and How to Avoid Them

by Nitin Chhoda PT, DPT | Jan 23, 2014 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Professional medical insurance billers have access to patient information that’s protected by law. A career in the profession requires an individual with honesty, integrity and a highly developed sense of ethics.

Nitin Chhoda says that the professional life of an MIB contains multiple ways in which they can run afoul of ethical issues. An honest mistake can be corrected, but an ethical issue, either by commission or omission, can land a biller in trouble with the law. He explains further using the following factors which MIBs should be concerned about.

Breaking Confidentiality – The First Thing that Billers Should Avoid

Patient confidentiality is ensured by law. Violations by either word or deed will find clinicians and billers in trouble for a breach of HIPAA security regulations.

There are strict rules governing the sharing, release and transmission of health-related data and identity theft is a real concern.

The Blame Game

It takes only moments to obtain clarification for coding questions. Billers that submit inaccurate codes and try to shift the blame to others when the error comes to light won’t be employed for long and will earn the ire of their co-workers.

The billers’ job is to maintain the revenue stream by coding accurately and honestly.

They Should Not Ignore Errors

Billers are only human and an error is inevitable. However, when an error is uncovered, it’s imperative to bring it to the practitioner’s attention, correct it and submit a corrected claim immediately.

Failure to do so can result in a payment deficit, or an over payment that can have adverse financial ramifications for the clinician. The same ethics apply if an insurance carrier handles a claim incorrectly and inadvertently over or under pays the practitioner.

No More and No Less

Ambiguous information calls for clarification. Not every act performed by the clinician is billable. Eligibility for an increased level of payment requires additional skill or work by the practitioner.

IMPORTANT: Code and bill only according to what the documentation indicates.

To Bundle or Not Unbundle: A Biller’s Concern Too

Each code is designed to include multiple actions within the treatment process. They’re billed as a whole rather than individually. There are times that billers should know when unbundling is appropriate, but the technique must be used with extreme caution.

Billers must also know that some codes aren’t compatible with others and documentation must support that extra time or expertise was required.

They Must Protect Patients

Many payers require patients to receive treatment from their network of physicians. Seeing an out-of-network provider may not be covered or the patient may have to pay additional out-of-pocket expenses.

Billers should endeavor to protect patients from this and explain the practice’s protocols for handling these types of situations.

To reiterate, the billers must always consider the following factors during the process of medical billing:

Confidentiality of patients’ information
Avoid blaming others for errors they committed
Minimize errors as much as possible
Provide just coding – no more, no less
Awareness of bundling and unbundling codes

Protecting the patient includes verifying their coverage, obtaining a pre-authorization when needed and making referrals within the patient’s network.

Failure to do so can result in the patient being hit with an enormous bill they can’t afford. Following the dictates of the patient’s insurance also protects the clinician from non-payment.

Ethical issues for medical insurance billers can come in many guises and MIBs must be vigilant. They must code accurately, act honorably and perform ethically. Doing so will demonstrate their honesty, integrity and professionalism, while ensuring the best reimbursements for practitioners.

Flow Sheet and EMRs Increase Reimbursements

by Nitin Chhoda PT, DPT | Jan 19, 2014 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Flow sheet helps clinicians track what they did for a patient on previous and current visits, but they’re much more than a means of patient management. They hold the key to obtaining reimbursements.

Claim denials and delays result in fiscal hardships for practices and in a time of shrinking healthcare payments, and in this article, Nitin Chhoda explains how the flow sheet is a critical element in the reimbursement process.

Flow Sheet and its Important Role to Claim Reimbursements

The flow sheet has to justify the billing amount and should be designed to reflect the CPT code in the reimbursement claim.

It forms the basis of the billing, streamlines the reimbursement process and supports medical necessity.

A properly designed flow sheet provides all the information needed for billing and supports each prior step.

The flow sheet provides a permanent record of care, supplies and products dispensed that are eligible for reimbursement. They’re essential for patient care and management, reimbursements, and can be used for research and quality improvement.

A flow sheet offers a birds-eye view and summary of changing factors that includes vital signs, diseases, treatments, medications and test results.

It’s used to document findings for each patient encounter, allowing practitioners to tell at a glance if the patient is being seen for a new condition or something that has occurred in the past.

No matter what type of practice is being operated, the flow sheet is one of the greatest assets available to determine when patients are due for check-ups and tests, and facilitates moving patients through the office in a timely manner.

–> Clinicians don’t have to start from scratch when working with established patients.

The Value of an EMR in Creating Flow Sheet

Maintaining flow sheets to expedite reimbursements is much easier with an electronic medical record (EMR) system.

The In Touch EMR, which is also integrated with billing software called, In Touch Biller Pro, is an example of an “intelligent” EMR that advises and prompts users when information is entered to ensure each element of the reimbursement claim matches and all the necessary components support each other.

EMRs offer portability to help clinicians provide a superior level of care, while allowing practitioners to see more patients within the day.

Clinicians can move easily through the office without the need to find and retrieve paper records before patients can be seen. They also support the creation of custom forms and templates.

The systems encompass built in calendars, calculators and treatment reminders. Clinicians can pull up photos, videos and print information for patients to take with them.

It ensures patients have data from a reputable source instead of letting them surf the web and obtain erroneous information.

An EMR can be implemented on tablet technology, allowing practitioners to diversify the practices services. The systems can be updated by multiple healthcare professionals and utilizes electronic communication to save time, money and resources.

Data can be retrieved whenever needed, for printed reimbursement claims, RAC audits or litigation. Errors due to illegible handwriting are eliminated.

To file reimbursement claims that are paid quickly, the flow sheet must reflect the CPT codes used and all the documentation must support the billable expenses. EMRs are an essential component of the process, with prompts to ensure each step supports the next, for clean claims that are paid quickly.

Claim — How to Appeal and Handle When Denied

by Nitin Chhoda PT, DPT | Jan 17, 2014 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

When a reimbursement denial is received, medical insurance billers (MIBs) may need to initiate an appeal process to collect disputed funds for practitioners. In this informative article, Nitin Chhoda reveals the most common reasons for denials and the best strategies for handling claim disputes.

Each claim goes through an adjudication process at a clearinghouse to check the data for errors before forwarding it to the appropriate insurance carrier.

A claim examiner conducts another exploration of the claim and renders a decision. The examiner can choose to pay the billed expenses, reimburse at a reduced rate, or deny the claim.

Insurance carriers usually deny payment for one of seven typical reasons. Some of the factors are the following:

Carrier’s procedures
Medical necessity
Inactive policies
Out-of-network
Level of care
Pre-existing conditions
Pre-authorization

Unknown Carrier’s Procedures

MIBs should be aware of each payer’s procedures and policies for handling claims. Each insurance company has its own hierarchy and protocols for reviewing a claim. MIBs should also check the contract between the clinician and the insurance company to determine that all conditions have been met.

Medical Documentation is Necessary

When a claim is denied on this basis, it’s up to the MIB to provide documentation that the appropriate diagnosis and procedural codes were employed. Sometimes a coding change and resubmitting the claim will result in a satisfactory resolution.

If the codes are accurate, a letter must be provided that clearly states why the treatment was necessary, along with any extenuating circumstances.

Patient’s Insurance Policy is Now Inactive

It’s essential that the MIB has proof that the patient has an active insurance policy at the time treatment was provided. This can be accomplished through a copy of the individual’s medical card, a letter from their employer, or a statement from the insurer.

Out-of-Companies-Network of Physicians

Some carriers require patients to only see practitioners within the company’s network of physicians, but situations arise when an in-network clinician isn’t available.

A simple letter explaining, in detail, why the patient didn’t have access to the carrier’s network of clinicians can easily turn a denial into a payment.

Having Too Much Level of Care

Claim examiners may determine the level of treatment that was billed exceeded the usual care for a particular ailment. The culprit in these situations is usually a lack of physical therapy documentation that fully explains why additional treatment or procedures were required. Providing supporting documentation usually takes care of the problem.

The Most Common – Having Pre-Existing Conditions

Most insurance policies won’t cover treatment for conditions and diseases that patients were afflicted with prior to when their policy became active.

If treatment can be linked to any prior health problem, the need for an appeal is negated.

If it wasn’t related to a previous health issue, MIBs should provide a written explanation as to why the ailment wasn’t related to a pre-existing condition.

Unable to Meet Pre-Authorization

A wide variety of treatments require pre-authorization for reimbursements. MIBs can reverse a denial if they provide proof the treatment would have been approved, as in the case of an emergency. A convincing argument can result in full payment and waiving of penalties for not obtaining the pre-authorization.

A denial doesn’t always result in an appeal. Providing documentation and a convincing argument as to why the denial was in error is essential when disputing reimbursement rejections. Clear and concise communications are critical elements of strategies to obtain payment for denied claims.

Services Rendered: The Options to Offer as a Medical Insurance Billers

by Nitin Chhoda PT, DPT | Jan 13, 2014 | Electronic Medical Records, Medical Billing, Physical Therapy Billing

The future of medical billing is as bright and busy as billers want to make it. As various portions of the Affordable Health Care Act take effect, professionals and health care facilities will be serving an influx of new patients, requiring a variety of billing related services.

In this informative article, physical therapist and electronic medical record (EMR) specialist, Nitin Chhoda, examines services offered by medical insurance billers (MIB).

Certified medical insurance billers provide a variety of services, from coding and transmitting reimbursement claims to accounting and tracking accounts, along with full practice management services.

Much depends upon the work environment. Those who work in medical practices and facilities may be tasked with simply coding and transmitting claims electronically.

Medical insurance billers working from home may choose to offer a la carte services to meet the specific needs of the client. Tracking accounts receivable and payable, and pursuing unpaid amounts owed by insurance companies and individuals are also part of a biller’s duties.

Who Are The Clients?

Most medical insurance billers think exclusively of medical practices when offering services, but any healthcare provider or facility is a potential client, from small clinics to practices with multiple clinicians. Hospitals, nursing homes and mental health professionals offer other options. Often overlooked sources of clients include dentists, pharmacies and social workers. Services can be adapted to meet individual requirements.

Customized Services and Specialties

Certified medical insurance billers always seek to bill accurately and quickly to increase the cash flow for their clients. They may also take on a multitude of other duties, including making referrals and recommendations within the field. Some medical insurance billers have taken their prior experience in marketing and other professions and applied it to billing to assist practitioners promote their products and services.

Medical insurance billers have their finger on the financial pulse of practices. They can determine when a client’s finances are faltering and offer consulting services. Some medical insurance billers specialize in services to physicians just starting out who can’t afford an in-house biller, as well as medical professionals who are closing out their practice.

Others have found their niche by working with rural providers who don’t have access to medical billing services or by handling non-insured patients.

EMRs and Portability

EMRs are an essential element for medical insurance billers, allowing them to perform their tasks quickly and efficiently, with clean claims that approved the first time. Built-in functionalities meet HIPAA security standards and EMRs provide alerts if claims contain potential problems or if a security issue is present.

An EMR also provides medical insurance billers with portability, allowing them to offer services from multiple locations and take the job to the client.

The software systems are capable of producing graphs, reports and charts to keep practitioners informed of how they fare financially.

Multiple opportunities exist for medical insurance billers and those who are willing to offer specialized, customized services are indispensable. Billers who offer the little “extras” are in high demand, but medical insurance billers should never lose sight of their most important goal – quick and accurate billing that produces a steady monetary flow for clients.

Medical Billing Basics, Rules, and Regulations

by Nitin Chhoda PT, DPT | Jan 5, 2014 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

A medical insurance billing (MIB) specialist is one of the most trusted individuals in a practice. Clinicians trust billers with the personal information of their patients, to obtain the largest revenues to which they’re entitled and to do so in a manner that’s accurate and legal. Nitin Chhoda discusses why integrity is one of the greatest assets a medical billing staff must have and why it should never be compromised.

Certified MIBs are specialists in their field and must conform to accepted coding practices and standards.

They have a moral, ethical and legal responsibility to code each reimbursement claim accurately, and deal fairly with patients, providers and payers.

Medical billing people are legally accountable for maintaining compliance and confidentiality, even if encouraged by unscrupulous individuals to “bend” the rules.

Ignorance is Never an Excuse

Coding regulations and requirements for submitting claims can change quickly. The onus is on the medical billing staff to remain informed and current, whether it’s a coding change or the manner in which clearinghouses accept reimbursement claims.

Always Keep it Private

Many billers are required to sign a confidentiality agreement and it’s becoming standard procedure in many practices. Confidentiality is more than a suggestion. It’s the law as outlined by HIPAA.

IMPORTANT: Patient information is to be protected at all times and there are stiff criminal penalties for those guilty of violations by word or deed.

Mistakes Cannot be Avoided But Should Never Be a Habit

No one is perfect and mistakes will occasionally be made. If there’s doubt about data contained in any portion of the patient encounter, obtain clarification from the practitioner before coding. When a medical billing staff makes a mistake, they’re obligated to report it to the payer and correct it.

No to Fraudulent Billing

There are many ways in which medical billing may be considered fraud. Over billing or unbundling to obtain more money, and under billing to get claims approved quicker, hurts the financial well-being of the practice and is illegal.

Routinely forgiving patient balances or failing to collect co-pays may run the practice afoul of anti-kickback statutes.

Insurance carriers are always seeking ways to avoid paying claims. Double billing and claiming for unnecessary procedures are red flags for payers, who have the option of initiating an investigation into the clinic and its medical billing practices.

Maintaining complete documentation that supports each medical billing reimbursement is critical.

Being Compliant is a Must

Medical billing staff must work within the dictates of the National Correct Coding Initiative edits to provide ethical, accurate and honest cost accountings to which practitioners are entitled.

To maintain compliance, MIBs are charged with providing documentation that supports a diagnosis or procedure, and to explain costs that exceed the expected norm.

Compliance also extends to the methods by which patient information and reimbursement claims are transmitted.

The Affordable Health Care Act has mandated that billers and any entity or facility that transmits a patient’s personal data must do so through electronic medical record (EMR) technology that provides the appropriate security and safeguards.

As certified medical insurance billers, medical billing staff must have an ethical and legal responsibility to code correctly and accurately. They must maintain compliance within the confines of state and federal law, and be cognizant of the numerous requirements of insurance carriers.

Doing so will increase the number of clean claims that are paid promptly and ensure that the medical billing staff and practitioner’s reputations remain above reproach.