medical billing transcription supplier information

In the complex and tedious world that is health care billing, those who pay the bulk of the bills--insurance carriers and health plans--have always had their hands full managing bill payment to physicians practices and hospitals of all sizes and types.

But with the latest trend--consumer-driven health care--taking center stage in recent years, managing bill payment is growing more, not less, complex--even as simplifying bill payment continues within the industry.

Consumer-directed plans typically mean more choices of health plans and providers, as well as more financial risk, for employees and health care consumers. Simply stated, health care users, typically employees and their dependents, must pay for medical services for a defined amount with dollars in a flexible spending account, a health savings account or a health reimbursement arrangement.

Health savings accounts, for example, can be used by workers to pay for routine medical expenses, which count toward the deductible of accompanying catastrophic health insurance. Ultimately, consumer-driven plans shift more of the responsibility for health-spending choices onto the patient.

The challenge is that when you create a new way for providers to be paid, as you do with consumer-driven health care, you create more complexity. Some carriers/payors are turning to technology to ease the pain that comes with managing bills in a consumer-driven world.

PreferredOne, a regional health benefits management company serving 550,000 members in Minnesota, needed to meet that growing demand from employers for consumer-driven health products--and solve the technology challenges that go with it. A relatively new entrant in Minnesota's payor market traditionally dominated by several well-established organizations ranging in size from 700,000 to 1.5 million members, PreferredOne needed an edge.

In January 2003, PreferredOne introduced Consumer Advantage, a defined-contribution plan that combines a high-deductible medical plan with both a health reimbursement arrangement and flexible spending account. Quickly, Consumer Advantage became PreFerredOne's fastest growing health plan product, but the product posed an administrative challenge.

With one system housing medical claims data and a second system storing health reimbursement arrangement or health savings account records, each claim had to be processed at least twice, causing bill payment issues. Labor-intensive and error-prone, the process threatened to offset the product's inherent cost benefits. PreferredOne quickly developed a strategy to improve product administration, using software technology from TriZetto Group, a Newport Beach, Calif., technology provider for health plans and carriers.

Using TriZetto's Facets Extended Enterprise application suite, all of PreferredOne's critical data--claims, HRAs, FSAs and more--are held in one central data repository. The claims are processed in one step, quickly and accurately, says John Hofflander, PreferredOne senior vice president and CIO. With both traditional and consumer-driven plan claims now on a single administrative system, PreferredOne has eliminated the expense and risks of integrating disparate software.

"The key to efficient bill management is having the data in one version and in one place," says Hofflander.

Hofflander explains that the new system also automatically updates information related to health reimbursement arrangement or flexible savings account balances, deductibles, and copayments.

"One of the biggest challenges of administering health reimbursement arrangements and flexible savings accounts is that schedules and criteria for rolling over unused balances vary tremendously by employer," he says. "The upgraded system handles this entire process automatically across all employer groups, eliminating hours of work for PreferredOne employees."

Consumer-directed plans may provide health plans and carriers with tremendous opportunities, but, as was the ease with PreferredOne, it also may involve some real IT challenges, mainly the strain of increasingly complex administration.

Kim LaFontana, director of Collector Services and Payor Relations at Athenahealth, a Waltham, Mass., technology provider that tries to smooth electronic billing and collections between doctors' offices and insurers and health plans, says that the consumer-driven health care movement is indeed making things more complex for both payors and providers. Mainly, the carriers need to know when the consumer or employee has met the deductible, which is the point when the insurance carrier or health care plan needs to make payments to doctors or hospitals.

"Insurers need to know and track it, so they know when it kicks in," says LaFontana.

To help small medical groups, those with five to 10 physicians, ensure payment, Ahenahealth provides an application services provider delivery model, which means all the doctors need is a high-speed Internet connection and a browser.

# posted by Medical Information : 2:47 AM  0 Comments

Established in 2000, the PATIENT FRIENDLY BILLING[SM] project began as a way to help hospital and health system leaders create a more patient-focused-and friendly--healthcare billing and collection process. The PATIENT FRIENDLY BILLING project was initiated by HFMA with the American Hospital Association as a catalyst for change, starting with providers and extending to all entities that touch the billing and revenue-cycle process.

Purpose

The purpose of the project is to create a healthcare billing and collection process that results in financial communication that is clear, concise, correct, and patient friendly.

Clear. The bill should be easy to understand and written in clear language. The general type of service provided to the patient should be documented. Patient and payer responsibilities should be clearly stated, necessary actions described, and a source of additional help and information provided. Instructions on how patients can get more details on their bill should be specific and accurate.

Patient friendly, In addition to being easy to read and comprehend, the bill should be easily matched with the payer's explanation of benefits. It should be consistent with everyone's understanding of the insurance benefits and the episode of care. Information about other providers who may also bill the patient should be included. Finally, helpful information should be readily available from the hospital's patient representative or from various publications and Internet sources.

The initial project activities resulted in a report developed by HFMA with the AHA and several leading provider and consulting organizations. The report was designed to help hospitals and health systems create action steps for billing and other financial communications that achieve the patient friendly philosophy. That report was distributed to CFOs and CEOs among HFMA and AHA's membership.

Medical Groups

The project's reach has extended since inception. In June 2002, HFMA and the Medical Group Management Association (MGMA) collaborated to extend PA TIENT FRIENDLY BILLING project resources to medical group management professionals. As a part of this initiative, HFMA and MOMA have issued a report for medical group management professionals offering guidance on actions they can take to improve patient billing. The report, which can be found on the project's web site at www.patientfriendlybilling.org (in the news section), explains how to make physicians' billing statements less confusing and how the effort to make billing statements clearer and more accurate can help improve a medical practice's revenue cycle, MGMA has also adapted the project's support materials, originally developed for hospitals and health systems, and additional information, tools, and case studies to help in the crusade to make the billing process more effective from the patient's perspective.

Insights from Patients

Because meeting the needs of the patient-the consumer-is the project's top priority, the PATIENT FRIENDLY BILLING Task Force commissioned a series of focus groups to obtain feedback from patients, caregivers, and family members about how billing can be improved. Seventy-five people from diverse backgrounds participated in this research, which resulted in a strong, uniform message: consumers are frustrated and distrustful of the current system of financial communication regarding their medical care and want a simplified billing process.

Technology Issues

Most recently, the PATIENT FRIENDLY BILLING project has focused on examining the current patient accounting systems and investigating associated vendors that produce and distribute hospital financial communications in order to reach the project's main objective: to create clear, correct, concise, and patient-friendly bills. As a part of these initiatives, the PATIENT FRIENDLY BILLING Vendor Task Force is striving to unite the patient accounting systems, bill-producing vendors, and any other related dealer to produce comprehensible bills, as well as to provide funding for this ongoing effort. The Vendor Task Force includes representatives from companies that design and install information systems for patient accounting systems and other financial communications.

"Information system vendors play an integral role in patient financial communications," says HFMA President and CEO Richard L. Clarke, FHFMA, "and can make a significant contribution to simplifying and standardizing this process. They have a deep knowledge of the processes in question, because they work with clients with diverse needs and conditions."

The Vendor Task Force will develop guidelines to help healthcare providers improve their billing and revenue-cycle processes. This will likely take the form of reengineered billing processes to improve accuracy and reduce redundancy. The task force may also address the effective use of information technology for revenue cycle automation and standardization. The task force's overarching principle is to make the patient the priority. The task force is using consumer research from the first phase of the project to help determine patient priorities. While researching and debating recommendations, the task force asks, "What does the patient see? What's best for the patient? What does the patient want? What are we trying to communicate to the patient? What do we want the patient to do with the communication we send?

# posted by Medical Information : 2:46 AM  0 Comments

Like a brass band, technology has marched into the therapy arena trumpeting a change in the tempo of therapy. Gone are the hours of repetitive paperwork and errors in record keeping. The new tune has the snappy, key-clicking rhythm of the computer. It frees therapists for more hands-on treatment time, speeds billing, ensures accuracy, and provides a wealth of aggregate data for reports on residents and trends.

What does this technology mean to the nursing home? "Most facilities shop for therapy on the basis of price and service," says Jeff Boland, a consultant with KPMG Senior Living Services. "Technology factors into that because the more sophisticated a therapy company is in terms of how it collects data and transmits them to the billing staff, the more time it can save the client."

Long-term care has traditionally been a bit timid in climbing aboard the silver streak of technology. "Many times a facility will say, 'Oh, it's some sort of whiz-bang technology thing that I don't understand, and I can't imagine it has value for me,'" says Sandro Grima, vice-president of information technology at Aegis Therapies. "But once they see the results technology can deliver, they become very enthusiastic."

Here is a brief tour of what a therapy company's technology should deliver and why evaluating technologic capabilities is important in choosing a therapy company.

Managing the Paper Trail

It's the end of the month and the therapist is adding up units and minutes of treatment for her residents, endlessly writing the resident's name, Medicare number, and all the other resident information on each form. She makes an error and has to turn the 9 into a 7, hoping it will be legible. Although she is a skilled therapist, much of her time is spent on paperwork--and that paperwork is subject to human error.

"Anyone who has had to review handwritten documentation--especially copies of copies of faxes--knows that what those reviewers at Medicare have to look at is just scary," says Bill Goulding, director of outcomes and appeals management for Aegis Therapies. "It's a wonder that they go to the trouble to decipher what the therapist writes."

From the moment the resident is admitted, technology should become the therapist's partner, storing information in a Web-based system and delivering it at the click of a key from any computer with the proper security passwords. Need to fill in resident information, medical information, and payer information on a form? That information, along with CPT codes and care plans, should automatically appear every time the resident's file is opened. The therapist need only enter treatment quantity and time. "The system actually prevents therapists from keying information if it doesn't fit the regulations," says Grima. "That's a huge safety factor for denials." Added benefit: The computer delivers a crisply printed, totally legible log.

"Technology makes clinical care better, easier, and more accurate," says Deb Neil, district manager for Aegis. "We used to have to sit down and fill out two logs for every resident every day. Now the computer actually creates the second log. It allows the manager to track resident care time on a daily, weekly, or monthly basis. We can compare numbers of residents in a time frame and calculate our utilization percentages."

An "e-signature," created when the therapist logs onto the file and certifies the information is correct, protects the integrity of the resident's file. "The system will not allow those records to be changed," says Grima. "That e-signature is as good as the day it was put in."

Once therapists become acquainted with the system, it takes less time to capture their treatment data electronically than it did on paper, which means they can dedicate their time to what they do best--treating residents.

Delivering Oh-so-Accurate E-billing

After using technology to create the resident record, the next step is to transmit it electronically to the facility. Robert Campion, executive director at Heritage Square Healthcare Center in Greendale, Wisconsin, remembers when billing for therapy meant delivering the therapists' handwritten billing logs to a receptionist who would work on them at night. "In between answering the phone and greeting people as they came in the door, she was logging in Medicare billing," he recalls. "Obviously, there were issues of accuracy."

With 21st-century technology, such scenarios have gone the way of the woolly mammoth. No longer must human hands labor to transfer information from one computer to another. A computer interface makes it possible to send electronic files that download directly into the receiving computer. "The ability of the therapy company to feed directly into the facility's billing system without human intervention has really helped our compliance," says Campion. "If there are errors in terms of entering, they are easy to correct, and the system leaves a trail easy to track. From a compliance standpoint, that's huge."

# posted by Medical Information : 2:45 AM  0 Comments

The saying, "If you want something done right, do it yourself," doesn't apply when it comes to ensuring clean claims.

One person-even one department-is hard pressed to take on this challenge in today's environment, where the task of coding and billing claims gets more difficult every quarter, possibly every month. That's how often payers update the rules that govern coding and compliance.

To keep up with ever-changing regulations, patient financial services departments are reaching out to other departments and experts within the hospital to ensure claims are sent correctly the first time. Today, each functional department along the revenue cycle is sharing in the responsibility for reducing the number of days a claim remains in accounts receivable-a difficult task, to say the least.

Reducing Back-End Fixes and Rework

To come up with new ways to reduce the number of claim denials and the amount of time that staff spend fixing claims after the fact, PFS professionals are looking not only at the benefits of front-end medical necessity compliance, but also the value of improving processes before bills hit a claims scrubber.

To drop a clean claim, PFS departments often must undertake the time-consuming process of consulting with multiple departments in order to confirm that the appropriate documentation exists to support adding modifiers or changing current procedural terminology or Healthcare Common Procedure Coding System codes. Worse yet, if the claim scrubber triggers an edit, a decision may be made to simply write off the charge assuming that its value is not worth the trouble of rework to fix the problem. Or the claim will be submitted knowing that it will be denied and will need to be corrected later by denials management staff.

Back-end fixes and rework require that billing or coding staff:

> Manage a worklist of unresolved edits

> Pull charts

> Compare diagnosis and procedure code pairs manually against local fiscal intermediary rules

> Communicate with physicians or departments to check for additional documentation

> Ensure the appropriate use of modifiers

> Relay their findings and fixes back through the abstracting process, returning the claim to the billing department to rescrub

The end result may be cleaner claims, but back-end fixes and rework require a significant investment of time and labor, resulting in lost productivity and increased accounts receivable days.

An alternative approach would be to create a proactive integrated team made up of representatives from PFS, medical records coding, patient access, ancillary and clinical staff, and compliance, with responsibility for:

> Performing retrospective review of claim errors that occur throughout the revenue cycle

> Assigning responsibility for fixing the source of the identified problems

> Determining accountability for error resolution

> Reviewing new and upcoming regulations to determine financial impact and implementation implications

> Approving new services to be added to the chargemaster

This team of experts would review all hard- and soft-coded CPTs, revenue codes, and ambulatory payment classifications for editing, making it possible to track errors and pinpoint problems that occur repeatedly. After defining the impact of various problems, the task force could then address issues that have a significant financial impact or compliance exposure, as well as those that are simply easy to fix.

Although this approach involves a substantial process change for most facilities, it can have far-reaching benefits. Staff resources would be used more efficiently as PFS, ancillary, and coding staff members become more knowledgeable about each other's area of expertise and how they can best work together to effect change.

Taking the Detective Work Out of Coding

There are numerous variables that can have an impact on coding compliance. The Centers for Medicare and Medicaid Services has issued national coverage determinations that affect countless procedures. Local carriers contribute to the maze of information with their own local medical review policies (now known as local coverage determinations). Correct coding edits that regulate which pairs of codes can and cannot be billed together are added and modified frequently. Often the detective work involved in discovering potential problems and avoiding coding errors is overwhelming.

New software and web-based technologies are making this task more manageable. Many electronic or online solutions are designed to quickly and automatically identify specific edits that will derail a claim, thus allowing coders to incorporate this information early in the initial coding session. For example, technology can immediately identify situations in which application of modifier-CA would be appropriate. This modifier, indicating that a procedure payable only in the inpatient setting was performed in the emergency department on an outpatient who died prior to admission, allows the hospital to be paid for the encounter. Without the modifier, the entire claim would be denied.

# posted by Medical Information : 2:35 AM  0 Comments

Physicians at Harmony Ambulatory Surgery Center in Fort Collins, Colo., opted for efficiency when they first opened their doors in 2000. They bypassed traditional dictation and transcription options for the clinical documentation that follows gastroenterology procedures, and instead selected ProVation MD with its GI module. Right out of the gate, they chose IT, time savings, cost savings and a one-and-done approach to documenting the surgical experience.

Harmony's Administrator Rebecca Craig, R.N., says, "Our physicians had vision. They knew that all aspects of clinical documentation are moving in an electronic direction. Even though we didn't have an EMR in 2000, the physicians still wanted a procedural documentation system that could download to one." Turns out, it was the right decision.

Harmony Ambulatory Surgery Center is affiliated with Poudre Valley Hospital and is a 27,000 square foot, multispecialty ambulatory surgery center (ASC) offering general, orthopedic, plastic, GYN, urology, ENT and ophthalmology surgery, and GI and pain management services, with the availability of six overnight beds for those who need more care than a same-day discharge affords. Accredited by JCAHO, the center includes four operating rooms, two gastroenterology endoscopy rooms and a pain management room, plus separate admission and recovery areas. The original five GI physicians have increased their numbers to eight GI physicians, and the ASC handles more than 700 cases per month.

Originally hired as the organization's clinical director, Craig says the software works so well that Harmony added ProVation's pain management module in 2003. In fact, the ASC hasn't yet identified an EMR product that physicians like well enough to purchase and has suggested to ProVation that the vendor consider developing an EMR product as well.

Software at Work

Immediately after completing a procedure, Harmony physicians sit at a workstation and complete their clinical documentation via ProVation MD. In large part, documentation is completed by a series of pull-down screens and menus in which doctors make choices and click, although the system does permit physicians to key in free text as an additional component of their post-operative documentation. As they pull down, point, click and select, the software suggests appropriate ICD-9 and CPT codes for the coding and billing tasks to follow. The physician can accept the suggested codes or change them, if he wishes. The entire package was designed to offer physicians a robust menu of automated options for post-procedure orders, patient instructions, letters to patients with physician impressions and recommendations, recall functions and pathology results tracking, while still allowing and encouraging individual input from physicians who want to generate it.

The physician can also verbally dictate into the system, see his words as text on the monitor and self-edit the text for greater clarity. Craig says most physicians maximize their use of the system's menu-based suggestion and selection features, although several physicians are comfortable keying in free text, and at least one or two regularly use the voice recognition and self-edit features.

When the physician is satisfied with his report, he signs it electronically. The physicians' signatures have been scanned into the system, and each physician has his own password that only he knows, so that only he can sign his own reports. Once a report is signed, the physician pushes another button to print, and the information is not only printed but also pushed forward to multiple next-step users.

One copy of the report automatically goes to the physician's office, whether he is located on-campus or off-campus. Another copy is sent to the coder/biller of Harmony Ambulatory Surgery Center. Another copy is sent directly to the nurses' station. The nurse has the operative report, along with any subsequent orders, discharge instructions and aftercare recommendations for patients heading home, which expedites the discharge process.

Craig says that for physicians who primarily use the system's pull-down menu and selection options, a typical operative report might take five minutes. For physicians who want to key in free text or use the dictation and text-editing functions, the time requirement might expand to seven to 10 minutes. She adds that the nature of pain management treatment also might require documentation time beyond the typical five minutes.

One and Done

"Our physicians don't enjoy having to come back to functions again and again to complete them," says Craig. "After the procedure is done, they want to complete their documentation, and this system allows them to do that. We have no extraneous phone calls, no moving of files or pulling of charts, and we have no three- or four-day turnaround times between the procedure's completion and a physician's signature on the op report. The physicians appreciate us helping them to be more efficient with their time which, in turn, allows them to spend more time with their patients or to see additional patients."

# posted by Medical Information : 2:34 AM  0 Comments

Twenty years ago, Neil Notaroberto was an accomplished and well-paid computer programmer. He liked his work and he enjoyed information technology, but sitting in an office all day was, at best, not his proverbial cup of tea.

Then, through a project affiliation with the Oregon Health & Sciences University, he gained the opportunity to spend substantially more time with physicians, a career choice he had considered earlier in life, but one that lost out to computer science. One neurosurgeon in particular impressed him, and Notaroberto thought, "This guy is making a difference in the world. I need to do that."

Today, Neil F. Notaroberto, M.D., is a solo practitioner and ophthalmologist. His EyeCare 20/20 practice enjoys two practice locations in Slidell and Harahan, La. Immediately after the Oregon experience, Notaroberto left computer programming, returned to graduate school and then proceeded through medical school. He considers himself fortunate to have had two dramatically different and rewarding careers, and the first career has dutifully provided him with a strong business foundation for his second career.

The Business of Medicine

In some ways, Notaroberto is like thousands of other U.S. physicians, working in a solo practice or a small practice of two or three doctors. But in one major way--his IT training and work experience--he is unlike most other physicians.

In 2004, he decided to search out a new practice management (PM) system that would allow him to outsource CPU load to free up processing space, reduce his total cost of IT ownership and support his desire for off-site data management as part of a disaster prevention plan. After considering several server-based and Web-based systems, he selected NueMD from Nuesoft Technologies in Marietta, Ga. The product's Java-based interface and low cost were two primary factors that influenced his choice.

Moving to an Internet-based system was a critical decision, complete with positives and negatives. "There is no foolproof way to make such a decision," he says. "With a server-based PM system, the practice is locked into proprietary software and even hardware that must be serviced by the supplier. Significant issues, like cost containment and portability, are outside of your control."

The first obligation of a medical practitioner, says Notaroberto, is to take the best care possible of his patients. After that, he acknowledges that the practicalities of also running a medical practice as a business play a role. "Medicine is a business of data acquisition and data management on behalf of patients. You have to buy the best equipment to take care of both your patients and your business, and you have to watch costs without sacrificing any elements of quality patient care."

Notaroberto admits that even ASPs (application service providers) have a downside: They are broadband dependent. He addresses that with contingency-based planning and redundancy, and with two methods of data access. "If one is down with one provider, we have an alternative. In addition, all our data is redundantly backed up," both with Nuesoft and a second service provider in California.

Back in 2004, expandability and portability were among Notaroberto's top systems concerns, as well as trying to rein in expenses. Today, he uses a laptop that travels with him to the hospital or home, or even to an Internet cafe, with which he can access data. His business has expanded substantially, and he finds the system well able to handle the increased demands.

Smile, You're on EyeCam

NueMD gives EyeCare 20/20 the registration, insurance eligibility and verification, scheduling, claims, billing and reconciliation functionalities that a practice would expect from a PM system. But Notaroberto also used the PM system for deliberate process improvement within the practice's workflow, and he achieved results to write home about.

He set the system to monitor patient flow in the office, using a live Web cam and a medically trained auditor, who is also a C.P.A., at a remote location. NueMD, he says, supports an extremely detailed time analysis. "We looked at everything from the moment the patient arrived, through check-in, through being seen by the physician and right through checkout. We wanted to see exactly how long a patient has been at each stage, and what might slow me up or slow up my nurse. Just examining those four points of data--and we examined more than four--we were able to identify exactly where the bottlenecks occurred."

His auditor was already familiar with the NueMD system, so a learning curve wasn't at issue. But Notaroberto says that even an auditor not trained on the system could be brought up to speed in a day or two. As it happened, EyeCare 20/20's audit was only one day long and, "We didn't even need the Web cam. We knew within the first day what needed to change," he says. The practice made the necessary workflow changes and "we saw results within a week." Essentially, a long wait time--one that could stretch to two hours or possibly beyond--was reduced to the 30- to 40-minute range within one week. That allowed Notaroberto to increase his patient flow by 25 percent almost instantly, a dramatic increase for a solo practitioner.

# posted by Medical Information : 2:33 AM  0 Comments

QA I read your article about home-based business scares ("Schemes on the Home Front," Shopsmart, October 2000) a little too late. I've recently become a victim of a medical billing scheme. I would like to know if l can still get my money back if I've already paid my credit card company?

--Brenda Rosemarie Johnson Morrow, Georgia

According to Holly Anderson, director of communications at the National Consumer League. federal law allows you 60 days from the date of your credit card statement to withhold payment and dispute a charge. By paying the total charge, you give up your legal right. However, Anderson says most credit card companies are willing to help you resolve the issue.

As a first step, send a certified letter including your full name, credit card account number, and the amount in dispute, along with a summary of your complaints or concerns. The credit card firm must acknowledge your correspondence within one month and investigate the matter within 90 days.

During the investigation process, you are not responsible for the amount in dispute. However, any amounts that are not in dispute will still be subject to late fees or interest, so pay on time.

If the credit card company rules in your favor, it will credit your account for the amount in dispute. Alternatively, you will he billed for the amount in dispute should your credit card issuer rule on behalf of the firm.

# posted by Medical Information : 3:17 AM  0 Comments

UCLA's medical billing group has leased 81,000 square feet at 5757 Century Blvd., near LAX, doubling the size of its current offices in the process. Total consideration for the 10-year deal is more than $15 million.

The move will allow the division to expand without substantially increasing its occupancy costs. While its current space at 10920 Wilshire Blvd. is owned by UCLA, David Thurman, vice president at Grubb & Ellis Co., estimated that the space required for expansion near Westwood would cost about twice as much as the new location.

But building owner Decron Properties Corp.'s renovation of the 331,000 square-foot building was also a factor.

In 1999, the building made the Business Journal's list of "5 Local Examples of How Not to Develop a Property." Van Nuys-based Decron, which primarily owns residential property, bought the building the following year and put about $5 million into rehabbing the space.

"It was not even a B building before," said Thurman, who, with Grubb & Ellis' Chris Sin-field and Bill Maher, represented Decron. "It was a C-minus building, and it's been transformed."

The transaction is also a boon to a Century Boulevard corridor market that had a rough 2001. Last year, the submarket put 300,000 square feet back on the market, and its fourth quarter vacancy rate was 29.2 percent, according to Grnbb & Ellis.

# posted by Medical Information : 3:16 AM  0 Comments

Recent testing of home health consolidated billing has revealed that Medicare regional home health intermediaries have a problem with common working file edits. If a home health episode of care is denied, the therapy services for that episode can be resubmitted by the same home health agency on a different type of bill and the claim can be paid.

That is, the edits are not rejecting a claim for home health services not under a plan of care (type of bill 34x) if it falls within a denied home health episode with the same provider number.

With an effective date of October 1, 2000, Medicare systems will reject a claim for home health services not under a home health plan or care that contains services subject to consolidated billing when a denied home health episode is present and the provider number on the incoming home health claim and on the home health episode match. When the date of earliest billing activity and the date of latest billing activity on a home health episode are blank, Medicare systems will reject a 34x claim that contains services subject to consolidated billing when the provider number matches the home health episode, and the service dates fall within the home health episode start and end dates.

# posted by Medical Information : 3:13 AM  2 Comments

Few hospitals enjoy a wide enough profit margin to provide substantial charity care and then simply write off all of their bad debt, without regard for whether patients can actually pay. Yet focused efforts to avoid bad debt can undermine a hospital's image in its community. For example, the policy of asking patients who seek nonemergency care to pay a percentage of their bills before they leave or receive treatment exposes a hospital to criticism for placing an undue financial burden upon low or middle income individuals who elect to forgo health insurance or cannot afford it.

A Double-Edged Sword

The image of hospitals has not been helped by widespread reports of a difference between the amount hospitals charge uninsured patients and what they charge private insurers, Medicare, and Medicaid for medical care. According to these reports, only the uninsured pay the full price. Critics of the hospital industry also observe that, should uninsured patients fail to pay their bills, hospitals initiate abusive debt collection practices. Such perceptions have fueled the filing or at least 40 class action lawsuits against more than 400 not-for-profit hospitals nationwide, challenging the hospitals' charity care policies and billing practices toward uninsured patients.

The industry's defenders argue that these perceptions do not consider the reality that uninsured patients rarely pay the full amounts they are charged, and many hospitals' collection efforts focus on patients who probably could pay but have actively evaded the hospital's good-faith efforts to discuss payment options.

The States Step In

Given all of the publicity surrounding this issue, it's no surprise it has attracted the attention of state legislators, although no legislation has been enacted. Lawmakers in Alabama, California, Georgia, and Illinois, in particular, considered legislation in the 2004 legislative sessions to cap the amount healthcare providers may charge uninsured patients for medical procedures and limit debt collection procedures.

Alabama HB 805 would have prohibited hospitals from charging uninsured individuals more than the amount Medicare would pay for the same service. And Illinois SB 2579 would have required hospitals to develop "assistance to the uninsured" policies and would have set limits on debt collection activities.

California Governor Arnold Schwarzenegger vetoed legislation, SB 379, that would have required hospitals to provide discounted care to low income individuals and prohibited some aggressive collection tactics. In his veto message, Schwarzenegger expressed empathy for uninsured patients who struggle with expensive hospital bills. But he said he preferred to allow the hospital industry's voluntary charity care and collection procedures more time to work before imposing state mandates. The California Healthcare Association pledged to ensure that every hospital in the state would be in compliance with the voluntary guidelines by the end of 2004.

The Georgia General Assembly considered two bills--HB 1533 and HB 1573--that would prohibit hospitals from charging an uninsured patient an amount greater than the average rate charged to managed care plans. In an interview with the Health Policy Tracking Service, Georgia State Representative Austin Scott, sponsor of the bills, cited legislative opposition to state requirements for hospitals as a reason for their defeat.

Hospital officials noted the voluntary discount programs for medical procedures offered to uninsured patients by many hospitals; however, Representative Scott asserted that state action was necessary to ensure that all hospitals do not charge the uninsured inflated prices. In fact, his inspiration for introducing the bill came from a discussion with a member of the hospital industry who voluntarily instituted a discount policy.

Representative Scott acknowledged his legislation would not solve all of the underlying problems of the healthcare system cited by the American Hospital Association, including the growing number of indigent patients seeking care in the emergency department, the record number of Americans lacking insurance, and the failure of Medicaid and Medicare payment to keep pace with hospital costs. Nonetheless, Representative Scott notes that providing equitable care to the uninsured is an important policy objective, and he intends to introduce the legislation in the 2005 legislative session. He also expects a livelier debate due to the lawsuits. Indeed, the prospect of an increasing number of lawsuits may make this issue a top healthcare priority for states nationwide.

# posted by Medical Information : 2:33 AM  0 Comments

In September, Medical software manufacturer Bloodhound, Inc., requested the American Chiropractic Association's assistance in making sure its programs are consistent with the ACA's policies on coding and billing. Representatives of Bloodhound met with members of the ACA Coding Committee to discuss Claims Guard, a billing review product made by Bloodhound and sold to health, automobile and workers' compensation insurers.

Insurance companies have requested coding advice from the ACA in the past, but this marks the first time a medical review organization has sought such counsel. Following the meeting, Bloodhound officials expressed their delight at the depth of ACA's coding and billing policies, as well as its knowledge of the American Medical Association's CPT code process. Bloodhound also assured the ACA that it plans to continue reviewing ACA coding policy to ensure consistency with its own coding edits.

"We are very grateful that Bloodhound came to us to make sure they are on the right track with our doctors," commented ACA President Donald Krippendorf, DC. "It's a very positive step. I sincerely hope they are the first of many insurance medical review companies to come to us."

# posted by Medical Information : 2:32 AM  0 Comments

Hospitals are faced with a dilemma. An estimated 45 million Americans have no health insurance, and millions more have inadequate coverage that leads to difficulties in paying for health services. The burden of providing access to health services for uninsured and underinsured patients has fallen substantially on hospitals, public health departments, and community health centers. Hospitals are committed to their communities and carry out missions that include significant charity services. And all hospitals with emergency departments are required by law to provide certain emergency services to anyone, regardless of ability to pay.

At the same time, hospitals are expected to operate in a financially responsible manner and manage limited resources effectively. Balancing patient needs and stakeholder expectations while operating in a dynamic regulatory and market environment creates major challenges for hospitals. A fundamental challenge for hospitals, given these conflicting demands, is how to best identify patients who are unable to pay and establish payment expectations for those who are able to pay.

To better serve patients, many hospitals are evaluating their discounting and collections policies and practices for services to the uninsured and underinsured. The PATIENT FRIENDLY BILLING[R] project has developed tools and is sharing knowledge and practical ideas to help hospitals and health systems revise their policies and procedures and implement those revisions quickly and effectively.

Hospitals, patients, and policy-makers have struggled with a range of multifaceted and complex issues as a result of the framework of state and federal regulations and third-party contracting in which hospital charges were traditionally set. Discounting and collections policies for uninsured and underinsured patients vary significantly across hospitals in the United States, so, when revising them, hospitals should take into consideration the unique needs of their organizations and communities. Complicating the issue further are environmental factors, such as the nation's lack of a solution to the growing number of uninsured and underinsured patients; regulatory factors, such as regulatory barriers to changing hospital discounting and collections policies; and hospital factors, such as whether hospital policies and practices meet the needs of the organization and the people it serves.

Key Questions to Address When Evaluating Policies

These challenges require hospital leaders to address numerous significant issues when reviewing or changing current policies and practices related to discounting and collections for care provided to uninsured and underinsured patients. Following are some questions hospitals can use as tools to guide this process. By addressing these questions, hospitals can develop responsible, balanced policies and practices that assist uninsured and underinsured patients:

* Who qualifies for discounted or free care?

* What services are discounted?

* What discount levels are offered?

* How are policies communicated?

* How are unpaid patient accounts resolved?

* What structures and systems are in place to implement and administer policies effectively?

* What is the relevant legal and regulatory context?

The Patient Friendly Billing web site (www.patientfriendlybilling.org) contains a convenient checklist that hospitals can use to make sure they have considered the different aspects of each question, evaluate their current status, and help identify appropriate changes.

Lessons Learned by Hospitals That Have Revised Their Policies

Interviewed hospitals that recently have made changes to their policies offer the following advice for other hospitals contemplating policy changes.

Policy characteristics

* The most effective policies are simple, clear, and written with the patient in mind.

* It is helpful if the policies allow some flexibility; for example, recent pay stubs may indicate income slightly over the discount policy guidelines, but the patient says his work hours have recently been reduced.

Involvement of others

* Including the community in the process can lead to success.

* Hospitals that involve eligibility vendors, collection agencies, and others with a role in the process in designing policies and procedures have fewer implementation problems.

Training, implementation, and monitoring

* Implementation plans need to allow sufficient time to develop and test patient education materials (brochures) and to conduct necessary staff training.

* Hospitals that train frontline staff to discuss payment before the patient leaves the hospital (particularly for prescheduled services) can minimize the need for collection activities.

* An extended business office can focus on self-pay accounts, be responsive to uninsured patients' needs, and promote effective policy implementation.

* Hospitals may find it helpful to track and analyze the impact of policy changes; automated solutions can support this process.

# posted by Medical Information : 2:31 AM  0 Comments

Wall Street expects us to produce a reasonable return, while Main Street appears to want us to operate at breakeven or, worse, a loss. And misinformation about what should be expected from a tax-exempt hospital is perpetuated by those whose agenda is other than a sincere interest in the plight of the uninsured.

How can hospitals maintain--or regain--the public's trust? I believe that the following key actions, which are based on work by experts in the field and best practices, are necessary:

Establish or reexamine and adjust your community benefit analysis. Community benefit relates to the broad-based concept of community service that should be included as part of the organization's mission. To survive, all organizations need to produce financial surpluses; a not-for-profit hospital must produce a surplus to further its exempt purpose, as reflected in its mission. Not-for-profit, therefore, refers to not-for-private-profit. Healthcare executives must examine and assess the community benefit they provide and be able to provide a clear rationale of how they define, quantify, and deliver that benefit.

Establish or reexamine and review charging and collecting practices for uninsured or underinsured persons of limited means Hospitals should attempt to better rationalize prices with cost and market considerations. Charity care policies should be formalized and effectively communicated to the public. Employees who implement the policies and procedures should be continually trained on them. These policies should be updated frequently to reflect the mission and financial capability of the organization.

Redefine the role of marketing and public relations to include effective and ongoing community outreach ... and communicate those efforts. Hospitals should be actively engaged in helping to solve community problems that affect health status. Immunization clinics, health screenings, and health education programs are some of the most common approaches. Other approaches include engaging community and business leaders in developing local solutions to health access issues for uninsured and underinsured persons. Hospitals should prominently disclose all the attributes of their community benefits. It is important that government officials, the media, community leaders, and the public understand all the reasons why an organization qualifies for tax-exemption. Put a human face on community benefits. Numbers are important, but they don't tell the whole story.

The ongoing public criticism of tax-exempt, not-for-profit hospitals is not because community benefits do not exist, but because of not transparently addressing these issues. I believe that tax-exempt hospitals have a special role in the healthcare delivery system. It is critical, therefore, that executives in these organizations take the necessary steps to preserve, evaluate, and communicate the unique benefits these organizations provide.

# posted by Medical Information : 2:54 AM  0 Comments

Patients, doctors, hospitals and others spend approximately $425 billion every year on administrative waste and redundant medical care, says Avisena CEO and founder Albert Santalo.

That translates to 25 percent of annual health care spending amounting to $1.7 trillion. Doctors and insurance companies spend an additional $100 billion each year on paperwork, he calculates.

While Santalo does not think all of that money is wasted, he does believe that his company's software can cut those numbers down. Miami-based Avisena makes software that handles the appointment and billing processes, among other things, for doctors' offices, letting staff concentrate on medical work and outsource administrative tasks.

"We founded this company to improve the picture of the health care industry, to help the provider, the doctor, in his or her struggle to get paid," Santalo says. "Our staff goes after what the doctors are owed so they can practice medicine."

Avisena offers comprehensive practice and revenue management services, such as claims submission, payment posting and insurance collections, as part of back-office management. All are accessed through Web-based platforms.

The company also offers Web-based systems for appointment schedulers, front desk management, payment processing and patient registration. It also offers its clients consulting services on provider licensing, managed care contract negotiations and assistance with government program applications.

Avisena works with small and large practices, with a large portion of its clients being specialists. Among them is Cosme Gomez, a Miami urologist, who has been an Avisena client for about seven months.

Avisena's Web-based software platforms helped Gomez and 13 urologists form a practice under one tax ID number as well as streamline their billing.

"To describe them as a billing company would not do them justice," Gomez says. "They provided us with an excellent practice management and billing software. But more importantly, they have been our backbone for business logistics and operations."

Santalo says the company, which was founded in 2001 and has about 90 employees, is growing at a fast clip, with 300 percent to 400 percent revenue growth in its first year, and about 100 percent in growth each year since. He expects to hire more people for the back-office operation as well as customer service.

"We are increasing our accounts on a national scale. We plan to be a big company," Santalo says. "At the end of the day, we want the providers to practice medicine, not be bill collectors."

# posted by Medical Information : 2:53 AM  0 Comments

Q I'm taking a course on medical billing. Is this still a good business?

Name withheld

A We've included medical billing as a "best business" since the first edition of our book The Best Home Businesses for the 90s (J.P.Tarcher) came out, despite the harm done to this field by business opportunities that promised more than they could deliver to prepare people to do medical billing. Experts estimate 30 percent of doctor's offices and other medical providers contract out their billing.

The homebased medical biller needs to think of his or her market as smaller practices and medical providers that seek payment for services to their patients from third patties. These include chiropractors, dentists and psychologists.

A small office often has difficulty keeping and training an employee to do its billing accurately. Thus, independent medical hillers have more expertise than employees with a variety of office duties. Outside medical billets should be able to increase the revenue of their clients while reducing their overhead.

Medical billets must understand the security and privacy standards for handling medical data provided for in the Health Insurance Portability and Accountability Act of 1996. These standards change, so you must be up-to-date.

# posted by Medical Information : 2:49 AM  0 Comments