Understanding the RAC Audit Process

Understanding the RAC Audit Process

One of the greatest challenges facing practitioners is a potential investigation by a Medicare Recovery Audit Contractor (RAC). Medicare estimates that there is a sixty two percent error rate among reimbursement claims in which documentation doesn’t match the billed expenses.

Private practice marketing expert, Nitin Chhoda, says that when services, fees and documentation don’t match, it increases the possibility of a RAC audit. The good news is that there are concrete steps clinicians can take to reduce the risk. And he shares that information in this article.

RACEven with the best coders and billers, errors can occur and it’s ultimately the responsibility of the practitioner to ensure that records match.

Knowing how the RAC process works allows clinicians to develop measures and install appropriate software systems to minimize risk factors that lead to an audit.

Medicare RAC auditors examine reimbursement claims after payment has been made, using methods similar to those employed by commercial healthcare insurance carriers.

The practice is known as pay and chase among industry officials. They look for inconsistencies in the billable services and submitted documentation.

RAC auditors utilize methods that comply with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.

Determining the Two types of Audits

There are two types of audits – automatic and complex.

  • An automatic audit seeks easily identifiable errors in payments, but doesn’t require human intervention or medical records to determine a problem exists.
  • A complex audit addresses improper payments through a manual evaluation and a request for extensive supporting documentation. Medical providers have strict and definite timelines in which to request an extension, comply with producing the appropriate records, and make appeals.

The process doesn’t stop there. Practitioners singled out for a RAC will be reported to CMS for potential fraud. If the RAC determines the problem is a potential quality issue, they report the provider to the state’s Quality Improvement Organization.

Initiate Self-Audits in order to Minimize RAC Interventions

Conducting self-audits will help minimize RAC interventions, but the best way clinicians have of avoiding an audit is to ensure their flow sheet, plan of care and billed expenses all match. If they don’t, it’s a problem and the responsibility of the practitioner.

Integrated electronic medical record (EMR) software is a critical element and provides the first line of defense toward that goal of avoiding an audit.

RAC auditorsEach EMR differs slightly, but systems such as the In Touch EMR, and In Touch Biller Pro, have capabilities specifically designed to assist coders and billers.

When data is entered, it prompts and advises the user for information and data to ensure all the components match and support each other.

It’s a crucial feature that offers a greater level of compliance and minimizes the probability of an audit.

Knowing how and why a RAC audit is conducted provides clinicians with the necessary information to help them avoid the experience. Confirming that the flow sheet, plan of treatment and documentation are all in agreement is the first step. The second is implementation of an “intelligent” integrated EMR physical therapy software system.

An audit isn’t desirable, but instead of living in dread practitioners should look upon a RAC audit as an additional way to maintain compliance.

Does Obamacare Promote “Independence at Home” Over Physical Therapy?

Does Obamacare Promote “Independence at Home” Over Physical Therapy?

Many physical therapists are concerned that Obamacare promotes its Independence at Home initiative over physical therapy and the answer at this point is yes.

ObamacareThe Independence at Home program uses technology at home (known as e-care) or community centers to identify problems and provide services to save money.

It’s difficult enough to persuade patients they need to visit their clinician’s office, especially the elderly and those with disabilities.

Obamacare’s program could make patients even more reluctant to leave their homes.

When patients can receive services at the local community center, they aren’t going to travel the extra distance to obtain the same treatments at their therapist.

Taking Healthcare To The Patients

The initiative is a new opportunity for clinicians to help patients through providing in-home physical therapy. Patients are less likely to attend sessions at a nearby community center or outpatient facility if the therapist is able to come to them.

The disabled, veterans and seniors will benefit most from in-home services and it provides the means for therapists to use Obamacare to their financial advantage.

Utilizing ACOs To Maximize Returns

One way clinicians can benefit is through becoming part of an accountable care organization (ACO). An ACO is a team of healthcare providers from different specialties that work together to manage patient care.

Obamacare rewards team members financially for good home care management that keeps patients out of hospitals and nursing homes, gets them better quickly, and saves money.

The Return of House Calls with Portable Technology

Many elderly patients have lamented the loss of an era when physicians and nurses made house calls, eliminating the need for them to leave their home.

Obamacare marks a return of those services through the Independence at Home program and with the assistance of the In Touch EMR, therapists can take their services on the road.

The software offers the ability to document patient encounters and treatment with tablet technology anywhere an Internet connection is available.

In Touch Biller PRO can be integrated with EMR technology to create and send reimbursement claims on the go. Both software systems provide practitioners with a new delivery method to increase revenues.

E-Care To Save Money

At-home monitoring is encouraged and it’s the direction in which healthcare is going under Obamacare.

ObamacareClinicians can monitor a number of chronic conditions and symptoms, ranging from blood pressure and heart rates to glucose levels.

Some monitoring devices use the Internet and EMR technology to automatically send data to the practitioner.

Other methods require an actual person to document information collected by a machine.

The Independence at Home initiative in Obamacare promotes therapy in the home or at community centers as a means of reducing overall healthcare expenses.

Therapists will be hit especially hard unless they find ways to utilize Obamacare for themselves. In-home services and ACOs offer clinicians with diversification options, but only if they’re willing to change and expand the way they treat patients.


Coders or Billers: What Does it Take to be One?

Coders or Billers: What Does it Take to be One?

Medical coding and billing aren’t mutually exclusive, but the terms are often used interchangeably. In larger practices, coders collect documentation and insert codes on reimbursement claims, while billers transmit the claims and monitor their progress.

In smaller practices, a single individual fulfills both coding and billing functions. In this article, Nitin Chhoda discusses the important roles and factors to consider when deciding to be a professional biller or coder.

codersCoders don’t have to endure years of training and can enter their profession in fairly short order, but they do undergo intensive education in a variety of specialties.

As they pursue their passion, they will be called upon to perform a variety of duties and will have multiple venues from which to employ their skills.

With mandatory implementation of EMR or electronic medical record technology, the job outlook is excellent for billers and coders.

Acquiring Education

A diploma or associate degree for billers or coders opens the door to a wealth of educational opportunities for entry level positions. Billing or coding diploma and certification programs are available at learning institutions throughout the U.S., along with online education from reputable professional organizations.

Education will cover compliance issues, industry codes and procedures, medical practice management, ICD-9 and CPT coding, technology systems and clearinghouses.

A majority of coding programs require students to be proficient in medical terminology and anatomy, while others include it as part of the program to become a Certified Professional Coder®.

Abbreviated and condensed education plans can be completed in as little as nine months, but the average is from 15 to 18 months. Billers or coders course fees run the gamut, from $600 to $2,000. Add approximately $500 for textbooks or CDs and accompanying materials.

Knowledge in Coding Basics is a Must

Those who pursue to become a coder will be required to know CPT and ICD-9 codes. The alpha-numeric codes provide a description on claims that supports a clinician’s diagnosis and treatment for his/her patient. ICD-9 codes will soon be updated to the ICD-10 standard.

The codes tell insurance companies the services they’re paying for on behalf of their subscriber.

Coders are also fact checkers. They will need an understanding of medical terminology and anatomy to code accurately and ensure practitioners receive the fees they’re due.

Coders will confer with clinicians to clarify any data that appears to be in error or if there’s any uncertainty associated with the available documentation.

The Software to Use

Professional coders will enter coding information into specialized software programs or electronic medical record (EMR) systems. Electronic medical records will soon be the mandated method of communication for healthcare professionals and facilities.

EMR technology has the advantage of functionalities that can assist coders in identifying potential coding difficulties before the claim is transmitted to clearinghouses. Such advantages which can help coders and billers with their EMR system are the following:medical billing and coding

  • Online eligibility verification function
  • Auto patient chart creation
  • Create custom templates
  • Scrub claims
  • Automatic posing of ERAs
  • Generate patient statements and much more…..

Billers and Coders Employment Opportunities

Coders and billers are in high demand and the trend is expected to continue unabated. They may find themselves working in a clinician’s office, hospital or pharmacy. Any medical office or entity that provides patient services will need a coder.

The transition to EMR technology has accelerated the need for coding professionals. In a less than optimal economy and a healthcare climate in which insurance carriers are reluctant to pay even for covered services, coders are on the front lines in the battle to obtain reimbursement for healthcare professionals.

Medical Coders – What are they?

Medical Coders – What are they?

Medical coding is often associated with medical billing, but the two are entirely different career paths. Coders use the information provided by the medical provider for treatment rendered and assign the appropriate codes for billing purposes.

The duties of a biller and coder may be combined in smaller practices and performed by the same individual. Nitin Chhoda shares the main responsibilities of medical coders and the attributes that they must have.

medical codersEducation Always Counts … Of Course!

A thorough knowledge of medical terminology and anatomy is essential for a medical coder. The average medical coder’s course is 15 months long and costs approximately $2,000.

Online training is available from a variety of professional organizations and at multiple colleges throughout the country.

A prerequisite is college-level human anatomy and physiology.

Students will learn how to assemble documentation and interpret guidelines for accurate coding. Courses will address the upcoming transition to ICD-10 codes, along with maintaining compliance and the ethical and professional standards required of a certified coder.

Medical Coders Must Be Familiar with Legalities

Remaining in compliance with government rules, regulations, guidelines and laws will play a major role in a coder’s every day duties.

Medical coders are in contact with confidential information that’s protected through regulations established by the U.S. Office of the Inspector General (OIG).

The OIG rules are designed to prevent fraud and abuse in billing.

Medical coders must also maintain compliance in the usage, dissemination and transmission of patient information as set forth in the Health Insurance Portability and Accountability Act (HIPAA). Known as the Privacy Act, it dictates how to handle sensitive patient data.

Medical Coders Know the Requirements and Compatibilities When Coding the Bill

An extensive array of data is collected during each patient encounter and it’s up to the coder to decipher any clinician notes and gather the documentation necessary to accurately code the reimbursement claim.medical coding

This is where knowledge of anatomy and medical terminology comes into play.

Medical coders are responsible for assigning the appropriate alpha-numerical CPT and ICD codes to reflect the practitioner’s diagnosis and subsequent treatment.

Medical Coders Should Be Familiar with an Integrated Software Technology

All the assembled data must be entered into a specialized medical billing software program or an electronic medical record (EMR) system in preparation for billing.

In practices that employ a single individual who acts as both the coder and biller, he/she will transmit the claim electronically to a clearinghouse for examination before being sent to the payer.

Show Me the Money …

Medical coders who undertake both coding and billing duties will be required to monitor claims to ensure they’re paid, follow up on late or denied claims, and interact with insurance carriers to collect the clinician’s fees.

Certified medical coders also work with patients on their portion of healthcare costs and file appeals with payers when required.

Medical coders hold considerable power within a practice and are professionals in a specialized field. They use their knowledge and ability to keep the flow of funds coming into a practice. They hold the financial keys to enable clinicians to plan, expand and pay the bills.

What are the Medical Billers?

What are the Medical Billers?

Medical insurance billers (MIBs) are the lifeline of a well-funded practice and the connecting link between patients, practitioners and insurance companies.

Billers affect the lives of hundreds of people each week and are an essential link in the reimbursement process. They collect payments for clinicians and ensure that insurance companies pay their portion of the costs for their clients’ healthcare expenses.

medical billerMedical billers perform a variety of functions, from entering the alpha-numeric ICD-9 and CPT codes that tell insurance companies the treatment a practitioner provided to interacting with patients on the balances they owe.

Medical billing staff works with sensitive data each day that requires confidentiality, integrity and ethics.

First Step — Data Collection

An MIB often functions as a coder and a biller, though the jobs can be exclusive of each other. Medical billers gather all the information associated with a patient’s encounter with their healthcare professional.

That information provides the documentation that will be used to support the payment requested from insurance carriers.

They decipher the data to determine the patient’s complaint and the appropriate CPT code to reflect the treatment provided.

Medical Billers Should Have Good Communication Skills

Medical billers spend a considerable amount of time interacting with others as part of the data collection and payment process. Clinicians must be queried to clarify patient encounter information and patients contacted about their payment obligations.

Medical billers also interact with insurance company representatives on reimbursement issues.

MIBs Must Always Verify the Facts

Medical billers are responsible for verifying patient insurance information, the correct billing format for each payer, and assigning the codes and modifiers that result in the practitioner’s payments.

They work with hard facts about patient policies, physician services and insurance company protocols.

Medical billers may also transcribe a doctor’s dictation about the patient encounter. Billers are knowledgeable in medical terminology, which helps them in assigning diagnosis and procedure codes.

Medical Billers Must Have Computers and Integrated Software

Medical billers spend a majority of their time behind a computer screen, ascertaining the facts of each patient encounter. They work with specialized billing software, like In Touch Biller Pro,or electronic medical record (EMR) systems, like In Touch EMR, that assist them in coding correctly, meeting the many submission demands made by payers, and transmitting claims electronically.

Consistent in Following Up Funds

Medical billers track and monitor each claim to determine its position within the reimbursement process. medical billers' software

They submit claims to clearinghouses where they’re examined for mistakes, errors and inconsistencies.

Clean claims are forwarded on to payers for reimbursement.

Medical billers track and monitor each claim to determine its status, ensure payments are made in a timely manner, and deposited in the practitioner’s account.

They work with clearinghouses and carriers if a claim is denied to obtain payment, and interact with patients on co-pays, deductibles and balances owed.

IMPORTANT:  Medical billers ultimate responsibility is to ensure that clinicians collect the maximum amount of money to which they’re entitled.

Medical billers wear many hats in their profession. They’re often one of the first and last individuals with which patients interact on financial obligations, and they comprise the key element in the reimbursement chain.

Medical billers document, code, transmit and follow payments to ensure their client’s financial status remains in the black.

Claims:  Stepping into the 21st Century with Computerization

Claims: Stepping into the 21st Century with Computerization

Computerization is no longer a luxury for a medical insurance biller (MIB). It’s a necessity that enables billers to handle hundreds of reimbursement claims each week and keep revenues flowing to their clients’ accounts.

In this insightful article, Nitin Chhoda outlines the benefits of electronic medical record (EMR) technology for the 21st century billing business.

claimsSimply put, computerization is the process of electronic recording, storing and retrieving of data.

Billing software and integrated EMR systems are available and both offer electronic medical billing and claims management abilities.

The primary difference is that billing software can cost hundreds and even thousands of dollars, while EMR systems can be obtained from reputable vendors for free.

Meeting Mandates

Computerization is necessary under the Affordable Health Care Act to participate in government operated health insurance programs and submit claims to commercial insurance carrier clearinghouses.

EMR systems also provide the mandated security safeguards required by HIPAA for the transmittal of patient information.

Ninety-eight percent of government claims are reimbursed within 30 days with EMR technology and reduces the turnaround time with commercial insurance carriers to as little as 10 days. EMRs encompass a variety of measures to ensure security for authorized personnel, from passwords and time stamps to biometric recognition protocols. Payments can be posted and patient accounts monitored for amounts owed.

Paperless Documentation

Computerization allows MIBs to assemble a complete record of a patient’s diagnosis, treatment and procedures without the use of paper records. Documentation is gathered for every step of the patient encounter and the data is stored electronically where can be accessed whenever needed.

Information data, including claims, can be stored on the computer or in the cloud, and paper reports can be printed when necessary.

An EMR allows users to import written forms and documents into the software program for storage. The software can be utilized with desktop computers, laptops and tablet technology. MIBs can work from any location where a high-speed Internet connection is available, providing billers with the freedom to work from virtually any venue.

No More Excuses

Insurance companies can no longer claim they didn’t receive the necessary documents in an effort to delay payments. Clearinghouse computers automatically send billers notification when claims are received. Billers can use their EMR to track, monitor and manage claims throughout every step of the payment process.

Customization and Coding

claims reimbursement

Custom documents can be created within EMRs to satisfy the individual requirements of each insurance carrier.

Claims reimbursements depend on the proper coding and EMRs are able to handle the transition to updated ICD-10 codes with ease.

EMR technology facilitates the claims process for billers and meets all the requirements for the secure transmittal of patient information.

The technology provides a full level of computerization for every task a biller undertakes. The software systems eliminate paper records and offers portability, enabling billers to expand their repertoire of claims services and open up on-the-go opportunities.