Medicare: The Government – Your Biggest Payer, Part 1

Medicare: The Government – Your Biggest Payer, Part 1

Clinicians will contract with many commercial insurance providers during their careers, but the heavy hitters of reimbursements are government-backed insurance plans.

In this informative two-part series, Nitin Chhoda examines programs operated by the federal government and what practitioners should know about them.

MedicareGovernment-operated healthcare programs encompass Medicare, Medicaid, Workers’ Compensation, CHAMPUS and Tricare.

Of all the government-run insurance plans, Medicare is the largest and is comprised of four types of coverage, Part A, B, C and D.

Participation is mandatory for some portions and voluntary for others, leading to confusion for patients.

Congress dictates how Medicare claims are paid. Reimbursement requests must be submitted within a specified time frame and the agency prefers to pay providers via electronic fund transfer.

It’s critical for practitioners to verify which Medicare elements a client participates in before services are rendered.

Medicare Part A

The first part of Medicare coverage pays for inpatient care in hospitals, skilled nursing facilities, home healthcare and hospice, but an overnight stay in a hospital is no guarantee of payment. Clients must meet specific requirements for Medicare to pay for inpatient services.

Medicare Part B

The B portion of Medicare coverage is designed to pay for services, treatments and procedures that are medically necessary. Included are services by physicians, home health services, durable medical equipment and outpatient visits. Some preventative measures are covered, including vaccines.

Part B is optional, but those who don’t enroll according to government guidelines are penalized. Patients often believe they’re automatically enrolled when they retire and are dismayed to discover they have no coverage. Recipients also have an annual deductible and pay a 20 percent copay for services.

Medicare Part C

Part C, also known as Medicare Advantage, is an insurance replacement plan offered by private companies that have been Medicare approved. Part C is favored by individuals who prefer private insurance coverage. Depending on the provider, plans can require beneficiaries to pay out-of-pocket expenses, obtain referrals, and only see network providers.

Replacement plans can be used to cover Part A and B services, and some plans include medication and vision coverage. To avoid medical billing reimbursement difficulties and appeals, always verify the client’s coverage, restrictions and limitations prior to treatment, along with the plan’s fee schedule to determine if it differs from Medicare standards.

Medicare Part D

The Medicare prescription drug plan is Part D. While Part D coverage doesn’t typically cause a problem for medical professionals, a large number of Part D recipients mistakenly believe they’ve enrolled in a Medicare supplement policy. Practitioners may find they’re spending a significant amount of time explaining the difference to their patients.

Medicare Supplement Plans

Patients can enroll in a Medicare supplement program, also known as Medigap plans, to cover the costs that Medicare doesn’t pay. It provides a source of secondary coverage, but doesn’t include any non-approved Medicare expenses. Always verify secondary coverage prior to any patient encounter.

Medicare coverageMore than 50 million people age 65 or older and younger individuals with disabilities have some type of Medicare coverage.

It represents a large population of patients upon which practitioners can draw that are covered by a reliable payer.

Incentive payments may also be available for clinicians practicing in geographic areas with a demonstrated shortage of medical professionals.

Reimbursement Using EMR System — The Secret to a Low-Delay Claims

Reimbursement Using EMR System — The Secret to a Low-Delay Claims

As insurance companies scrutinize reimbursement submissions more closely, clinicians are enduring longer turnaround times to collect money on claims.

The simple installation of an integrated EMR can transform those extended waits for funds into a low-delay reimbursement system and Nitin Chhoda explains it here, in this article.

reimbursementEMRs enable faster reimbursements and can detect claims with potential problems before they’re submitted, virtually eliminating denials.

The majority of denials and contestations can be traced to simple human errors in data entry and by preventable problems that can be avoided by verifying a client’s insurance coverage before services are rendered.

An integrated electronic medical record submits claims electronically to arrive almost instantaneously at the intended destination and can detect an extensive array of errors and notify practitioners prior to submission.

Human Data Entry Mistakes an EMR Can Help Avoid

Mismatched, incorrect procedure codes and improper patient information that doesn’t reflect the information for the client’s complaint is a common cause of denials. An example would be listing a procedure for a male when the client is female.

Each insurance provider has its own set of rules for reimbursement submissions. That includes specific claim forms. An infraction results in an automatic denial until the correct forms are submitted.

Health insurance providers are requesting prior authorization for an increasing number of treatments and procedures. If the clinic fails to obtain authorization, the insurance company can refuse to pay clinicians anything.

It happens infrequently, but a patient may need to see their healthcare professional twice in the same day to receive the same or similar treatments. Practitioners encounter difficulties when submitting these types of claims. Insurance companies view this as a duplicate reimbursement request and will reject it automatically.

It would seem like common sense, but clinicians who don’t file reimbursement claims in a timely manner will forfeit payment. Practitioners have one year to file their claim and such oversights can cost clinics thousands of dollars.

Check the Facts Before Treatment Begins

In a time of high unemployment and loss of benefits, it’s essential for practices to verify insurance coverage and client information before the patient ever reaches the clinic. An EMR provides the means to accomplish these and other tasks with alacrity, reimbursement claims included.

Insurance coverage that has lapsed, been terminated, wasn’t in force when the patient received services, and clients not eligible for coverage represent a major reimbursement problem for practitioners. All of that information can be ascertained easily prior to the patient’s appointment.

Many healthcare insurance providers are offering basic or minimal services and few patients understand their coverage or limitations. It’s imperative that clinicians determine the type of treatments covered under each insurance plan.

What constitutes a reasonable fee for practitioners and insurance companies varies widely. Each insurer has its own guidelines on the amount that can be reimbursed for specific treatments and reimbursement claims that exceed which will be rejected for unreasonable fees.

reimbursement claimsClinicians and insurers also differ on procedures. Ordering a CT scan instead of a less expensive x-ray can result in a determination of not medically necessary by the insurance company and loss of income for the practitioner.

An EMR represents the best solution for a low-delay reimbursement system. It has the tools to identify an extensive array of human errors that will delay or prevent claim payments.

An integrated EMR is the key to verifying patient information and insurance coverage to ensure practitioners receive the reimbursement to which they’re entitled.

HITECH Act – Economic Stimulus for EMR Adoption

HITECH Act – Economic Stimulus for EMR Adoption

The Health Information Technology for Economic and Clinical Health (HITECH) Act helps physicians to cope with the EMR transition by providing financial assistance.

Nitin Chhoda elaborates on the importance of the HITECH to practices that are just starting to use electronic medical records.

HITECHImplementing electronic medical records system is an expensive undertaking, but assistance is available to defray the cost as part of the American Recovery and Reinvestment Act (ARRA) of 2009.

Federal funds were allocated in the act to help ease the cost of transitioning to an EMR and to facilitate an increase in their usage.

The portion of the act that deals with financial assistance is the Health Information Technology for Economic and Clinical Health Act (HITECH).

HITECH Act

Depending upon the vendor, an EMR can easily cost $45,000 or more, an amount that takes a big bite from the budgets of smaller practices. Through HITECH, physical therapists can apply for financial aid as “meaningful users” of EMR systems.

The act makes provision for $18 billion through Medicaid and Medicare reimbursement systems, $2 billion for necessary infrastructure, and $1 billion for acquiring IT professionals, along with repair and renovation of health centers.

HITECH also sets aside $550 million as an incentive to purchase equipment and services, and $400 million for research on the impact of EMRs. In addition, $300 million has been earmarked towards health information exchange among providers and $40 million to facilitate the submission of disability claims to the Social Security Administration.

EMR Implementation

Implementing an EMR requires training of authorized users and grants are available for training centers for IT staff needed to support necessary infrastructure. Practice owners that can exhibit meaningful use of EMR-certified technology are eligible for a variety of HITECH funding, but many clinicians still aren’t aware the money is available, or that incentives are only being offered until 2015.

Many incentives hinge on the HITECH’s “meaningful use” clause and it’s a term that’s been confusing to many clinic owners. Meaningful use is a three-pronged approach to the incentive program established by the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health IT.

Stage One

Stage one encompasses 25 criteria and consists of 15 core requirements. Of the remaining 10, therapists have the option of choosing five to comply with requirements.

In stage one of HITECH Act, therapists must adopt an EMR by Dec. 2014 that meets government requirements to qualify for federal funding. To qualify for the maximum amount of HITECH incentive money, clinicians have to attain meaningful use standards at least 90 days before the end of Sept. 30, 2012.

Stage Two

HITECH stimulusStage 2 of meaningful HITECH use launches in 2014 and is a continuation of stage one.

It includes increased demands for electronic transactions, the exchange of health information electronically, and online access for patients to their health data.

Stage Three

Stage three activates in 2016.

Therapists must continue to meet the requirements in previous stages and demonstrate that the quality of client care has improved.

With all that clinicians must keep in mind when implementing a qualified EMR, it’s easy to fixate on the cost and lose sight of the federal incentives available.

Therapists must implement an EMR, but they don’t have to shoulder the burden of expense by themselves.

Federal funding is available through the HITECH Act to assist practice owners purchase, equip and implement an EMR, install the needed infrastructure and obtain training for staff members. Deadlines are attached to federal dollars, making it essential that clinic owners begin evaluating their options as soon as possible.

Claim Appeals 101

Claim Appeals 101

Reimbursement claims can be denied at any time and for any number of reasons. Most problems can be remedied easily, but when talking fails to facilitate a desirable outcome it may be necessary to file an appeal. In this revealing article, Nitin Chhoda addresses the basics of filing an appeal.

clearinghouseMost appeals in the billing process, physical therapy billing included. will involve commercial insurance companies.

How a clinician approaches an appeal has a huge impact on how quickly and smoothly the process is concluded.

Unfortunately, the onus is on the practitioner to prove why a claim wasn’t processed properly for payment. That requires knowledge of the payer and the terms of the contract that was signed with the insurance provider.

Provider Relations

Many contracts include a prompt pay clause that can cost the payer fees and interest on late payments if they didn’t file or process the claim according to the terms of the contract. The first point of contact when filing an appeal will usually be provider relations to ascertain if the claim was received and how it was processed.

A phone call can be all that’s needed to quickly remedy the situation. Some payers provide online reconsideration forms that can be submitted, while others require a formal written appeal. It’s critical to maintain complete documentation of all verbal and written communication associated with the appeals process.

Provider Representative

If the claim wasn’t processed due to the contract loading incorrectly in the payer’s software system, the next step is to speak with the provider representative. This individual is charged with ensuring the contract between the medical provider and payer is correct and loaded in the claims processing software system.

Expect to be vetted and answer specific questions about the claim. The provider representative may be able to locate the problem and solve it.

Representatives also have the power to send the claim back to the payer for reprocessing.

Written Appeals

If a phone call fails to resolve the issue, a written appeal must be submitted. It should include all the pertinent information about the claim and clearly state the expected outcome for settlement. Explain why the actions are being sought and further steps that will be taken, such as referring the matter to the practice’s attorney.

Exercise Control

Appealing a claim rejection is time consuming and frustrating. It’s critical to exercise control and professionalism at all times. claim submission

The appeals process relies on facts for resolution and it’s important to clearly state the problem and the payment expected. Refer to specific clauses in the contract to prove points.

A denied or rejected claim delays payment and appealing the decision can require considerable time and effort.

The process is sometimes necessary to collect the fees to which clinicians are entitled and it’s important to keep a cool head throughout the process.

Most disputes with commercial payers can be solved if practitioners approach the situation armed with the facts and the terms of the payer contract.

Insurance: The Rules, Regs and Who Makes the Decisions

Insurance: The Rules, Regs and Who Makes the Decisions

The rules governing healthcare insurance procedures are as varied as the companies that offer policies. Payers may choose to follow the same regulations as government backed insurance plans, while others have developed their own unique set of parameters.

It’s essential for billers to be familiar with them all and electronic medical record expert (EMR), Nitin Chhoda, has released new data on who makes the rules that govern reimbursements.

insuranceWho Controls The Purse Strings?
When it comes to clinicians being reimbursed for the services they render, practitioners should never forget that insurance companies are firmly in control of the entire process.

Each payer has its own set of policies, procedures, manuals and submission requirements. The payer establishes the rules and regulations that medical billers and coders must follow to ensure clinicians are reimbursed.

Practitioners typically contract with commercial insurance companies to reimburse them when one of their covered clients seeks medical attention. Most individuals have insurance through their employer and the payer underwrites the plan, complete with financial caps, treatment limitations and the need for prior authorization and referrals.

Networking Opportunities
Insurance companies control access to providers through the employment of networks. The insurance company maintains a network of medical providers with which it has a contract. The arrangement ensures a steady stream of patients for practitioners.

In return, the clinician agrees to receive specific reimbursements for services to limit outlays by the insurance company.

Contract Specifics
Contracts define time limits for submitting claims, how long the insurance company has to pay the claim, and the type of plans included in the agreement. Fee schedules, procedures that require preauthorization or referrals, and the appeals process are clearly spelled out.

Other payers choose to adhere to the fee schedule set forth by Medicare, modify the fees to pay 110 to 125 percent of what Medicare reimburses, or even pay less. Even though the medical provider may receive less than the Medicare fee, insurance company executives know that patients covered under their plans represent a substantial client base.

The Path to Payment
Most claims result in prompt payment, but the potential always exists for the payer to repudiate a reimbursement. Practitioners must use caution when negotiating contracts with payers, be cognizant of the terms, and long-term implications. Appeals can be filed when necessary.

Much of the reimbursement process relies upon the medical billing and coding specialist entering the correct codes, and ensuring documentation complies with the payer’s submission specifications.

insurance guidelines

Payer-practitioner contracts should be loaded in the practice’s EMR software to facilitate clean claims.

Insurance companies call all the shots when it comes to reimbursements. Clinicians must be vigilant when negotiating contracts with payers to ensure they’re receiving the best return for their services.

A great many payers exist, each with its own set of rules, regulations and requirements, but with a good billing and coding department, participating in a network of insurance providers can be a good investment for the practice.

The Life of a Claim: How You Get Paid

The Life of a Claim: How You Get Paid

The clock starts ticking on the life of an insurance claim the moment a patient makes an appointment and doesn’t end until the practitioner is paid. To better understand the life cycle of an insurance claim, Nitin Chhoda offers a first-hand look at the process.

claimFirst Contact
When clients contact a practice, it sets in motion a process in which it can take up to three months for the clinician to be paid.

Before patient arrives at the office, staff should already have obtained and verified the individual’s healthcare insurance information to ensure the policy is in force, hasn’t lapsed and who is covered, along with any limitations or restrictions.

Insurance benefits can be tricky to navigate. Clinicians must ascertain exactly what’s covered under the patient’s claim insurance, their deductible and co-pay when they make an appointment. It will impact the client’s available treatment options. Some individuals have coverage under more than one insurance provider. Both policies must undergo the same rigorous verification.

Patients will also be required to sign consent forms allowing the practitioner to bill the insurance company and be paid directly, release information for billing, and for the client to pay any amount not covered by insurance claim. A copy of the client’s identification and insurance card is required, along with a complete health and medical history.

Enter the EMR
All the client’s information must be entered in the practice’s EMR for medical billing. Incorrect or incomplete information will delay reimbursements to the clinic, as will failure to obtain an authorization for procedures. Insurance providers will deny a payment if the correct forms aren’t used, information is incomplete and for other breaches of the company’s particular set of rules.

To document the client’s visit, clinicians will create an encounter form that provides pertinent information about the patient’s complaint, exam, diagnosis and procedures performed. Any secondary problems that are observed must be documented and all the information entered into the EMR. Each diagnosis and procedure code must match or the claim will be denied.

Calculating Fees
Clinicians can now enter the cost of the visit utilizing their schedule of fees. Each procedure and all materials must be calculated into the final cost, from the use of the exam room to bandages. It’s also time for the patient to determine how they’ll pay for any portion of the cost for which they’re responsible.

That can take the form of cash, check, debit or credit cards, or a payment plan. Collect at least a portion of the payment before the client leaves the office.

Submitting the Claim
A reimbursement claim must be prepared and sent to the client’s insurance carrier, complete with documentation of the patient’s financial and clinical information from their visit. Each claim should be double checked to ensure that codes and patient information match, and that there are no omissions, or the claim will be delayed.

The claim will examined in extensive detail by the insurance company to ensure the client is covered, any restrictions and limitations were adhered to, accurate coding was included and information is complete. insurance claim

If a problem arises, the clinician will be asked for additional information or to resubmit the claim.

Practitioners can appeal the decision, collect any unpaid amount from the client or write off remaining costs.

It can take a typical claim up to three months to be reimbursed, even without any difficulties. Using an EMR ensures HIPAA compliance, protects against loss, decreases processing time and accelerates the entire process for quicker deposits and better cash flow.