medical billing transcription supplier information

In 1993 about 6 billion medical claims were processed, burying physicians and health care providers under a deluge of paperwork This forced many medical professionals to outsource their billings and collections to companies capable of wading through numerous insurance codes and government regulations. Electronic medical billing services has proved to be a viable business opportunity for companies with experience in accounting, provider billing and computer systems.

Electronic medical billing services read patient claim forms, inputs the data according to complex coding systems and then submits the forms via computer to major clearinghouses. The clearinghouses then bill the patients or the insurance companies, who, in turn, pay the physicians.

Armed with 14 years, experience in hospital medical billings and a $5,000 investment, Vanessa Best began Precision Health Care Consultants in Jamaica Estates, New York, in 1995. A physician at the hospital where she was employed was leaving for private practice and Best persuaded him to retain her medical billing services - for $1,200 a month. Best's business now earns $38,000 annually. In addition, she was recently employed as a consultant to help launch the medical billing division of the Fidelity Group, a $8.5 million African American-owned insurance, benefits and medical management company in Great Neck, New York.

For new entrants to the industry, home-based medical billing businesses generally net $30,000-$100,000 a year. Most billing services receive $3 per claim processed; of this, a claims clearinghouse generally takes a fee. After a claim is processed, it takes about two to three weeks for a physician to receive his or her money, and depending on the payment terms, another 30 days before the client pays the billing service.

To get started in the business, you'll need a computer, fax machine and a medical-billing software package that meets claim requirements for Medicaid and Medicare. Generally, you can start with as little as $5,000. After a couple of years in the field, you may want to become certified. Certification, which is provided through groups like the National Association of Claims Assistance Professionals (NACAP), is voluntary in most states.

If you're interested in attracting physicians to your service, "you can't be trite or cute," says Norma Border, national director of NACAP. A small business owner, she emphasizes, must demonstrate professional slickness - from the physical presentation to marketing materials. "You have to be aggressive, meticulous, detail-oriented and willing to keep abreast of the constant changes in the health care industry.

Each year, about 15%-20% of small businesses providing medical billing services drop out of the industry, Border estimates. Many of them don't understand the degree to which clients will rely on them for accounting, consulting and analysis. In addition to filing, medical billing services also provide scheduling activities, special reports and profiling - helping physicians determine which services are performed most often.

Medical billing services is a growing industry that can provide you with significant financial rewards. But be warned that it's extremely competitive, and requires aggressive marketing. If you're trying to break into the field, Best suggests seeking out new physicians who are looking to set up private practices and placing ads in local newspapers. "And if your clients are pleased," she says,"they'll refer you by word-of-mouth."

# posted by Medical Information : 3:19 AM  0 Comments

The Billing Method Principles are Verifiability: A medical transcription billing method should be subject to verification with such verification being available to parties to the transaction. Definability: A medical transcription billing method should accurately define all measurements and be free from definitional ambiguity. Measurability: A medical transcription billing method should allow for complete understanding of the formulas used in its calculation and result in a clear and concise invoice. Integrity: A medical transcription billing method should be fair and honest, resulting in invoices that accurately reflect and charge for services rendered. Consistency: A medical transcription billing method should be generally reliable and consistent in its application.

Companies competing for the Beacon Awards were scored on their description of the BMP approach, i.e., their marketing, sales and support activities, operational components, technical components, business components, case studies, and references. Based on these criteria, a distinguished panel of judges from AAMT, AHIMA, and MGMA scored Cymed, Inc. as the overall winner of the 2005 Beacon Award.

"MTIA's Beacon Awards demonstrate their (MTIA's) commitment to a standard of integrity in the relationship between transcription service and client." Sandy Fuller, Executive Vice President and COO of AHIMA, and a member of the panel of judges.

The Beacon Award should not be interpreted to recognize or offer any opinion on the winner's competency, integrity or service capability--it is solely an evaluation of their description of their BMP approach and their client reference comments.

MTIA congratulates the companies who were chosen as finalists: Acusis 2nd Runner Up, Webmedx 3rd Runner Up, and DRC 4th Runner Up.

# posted by Medical Information : 3:18 AM  0 Comments

Lack of funding can stonewall healthcare providers' efforts to implement electronic medical records (or electronic health records) at their facilities, according to the fifth annual Survey of EHR Trends and Usage from the Medical Records Institute.

Nearly two-thirds--64 percent--of survey respondents cited the "lack of adequate funding or resources" as their most significant challenge to EMR implementation. Some 37 percent said lack of support from medical staff was another major hurdle. The survey examined results collected from 759 provider groups, including large hospitals, small practices and integrated health delivery organizations.

Other major barriers cited include respondents' inability to find an EMR solution or components at an affordable cost (32 percent); difficulty in finding a solution that is not fragmented among vendors or IT platforms (30 percent); difficulty in creating a migration plan from paper to electronic health records (29 percent); inability to find an EMR solution that meets the individual provider's application or technical requirements (27 percent); and inadequate or incomplete healthcare information standards or code sets (23 percent).

In spite of the obstacles, a strong majority of respondents--nearly 83 percent--acknowledge that EMR systems can help improve workflow. Another 78 percent said such systems can help improve clinical documentation to support appropriate billing service levels, and 77 percent said EMRs will help to improve patient safety.

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

The 7.6-magnitude earthquake has resulted in the death of at least 30,000 people in Pakistan, with nearly 600 deaths in India. According to the United Nations, more than 2.5 million people were left homeless after Saturday's disaster and death tolls are expected to rise as rescue workers reach severely affected areas.

Immediate relief is needed for families who have lost homes and loved ones and continued support will be required in the coming weeks to help restore power and services as well as rebuild homes and shattered lives. MTBC's board of directors has made a $10,000 contribution to the relief efforts.

MTBC has responded to this disaster by rushing urgently needed relief to the victims. David Rosenblum, President of MTBC, explained, "MTBC has prepared a convoy to travel to the affected areas with supplies of food, tents, mattresses, and medicine, and we encourage anyone who can help to do so."

More help is needed as roads begin to open, enabling supplies to reach remote villages. If you would like to help in the relief effort, we invite you to direct your browsers to www.unicef.org.

About MTBC

MTBC currently offers 4% medical billing, free electronic medical records software, online access to billing and scheduling information, as well as real-time eligibility verification. With practice management tools, financial reporting capabilities, online scheduling and office forms, MTBC's services are unmatched in the industry.

# posted by Medical Information : 3:55 AM  0 Comments

Pat Palmer analyzes medical bills from all over the country and prides herself on her ability to crack codes.

Medical bills, typically composed of complex multi-page lists of codes, could seem confusing and intimidating to a consumer. Many hospitals, however, are making bills more patient-friendly and less burdensome to interpret.

Palmer makes a living as a medical bill reviewer. One particular code she cracked was for a cost-support device. Palmer discovered that a cost-support device translated into a teddy bear in Virginia - or a heart-shaped pillow in California.

As the founder of the Medical Billing Advocates of America, Palmer serves as a consultant for insurance companies and individuals to uncover medical billing errors. Since the association was established in 1994, Palmer has seen an increased number of corporations contracting medical bill reviewers.

More and more companies are starting to look into the large amount of money going out in medical expenses, said Palmer. They make sure the providers are paying correctly and aren't billing for things they shouldn't.

The Medical Billing Advocates of America, headquartered in Salem, Va., has 30 members in 18 states and Washington. The group is pressing for national reform to standardize medical bills and make certain charges fraudulent and abusive.

Under current law, hospitals can be prosecuted if they don't report Medicare billing errors to the federal government. The statute in the Social Security Act has a 10-year statute of limitations and includes penalties for billing for services not provided and upcoding. The law, however, only applies to misuse of federal money, and does not include provisions for individuals or companies.

Under the government, these charges are considered fraudulent and abusive, said Palmer. Why does that not stand for everyone, not just Medicare?

In Maryland, the Health Cost Services Review Commission regulates approved charges. The items must be used for a patient's care, with the exception of billing for patient convenience charges such as use of a television or telephone.

I'm not familiar with anything like that [the teddy bear], said Tony Morris, assistant vice president of financial operations for Greater Baltimore Medical Center. But disposable supplies could be part of a patient's care treatment and on the bill.

Detecting errors

GBMC has been making progress in detecting medical errors before they occur and performing self audits to target weaknesses in the billing system.

We have a compliance program that takes a more proactive approach, said Stacey McGreevy, compliance officer with GBMC. We identify errors that can occur, train people and respond quicker to other potential errors that are out there.

Two years ago, GBMC received approximately $60,000 per month in denials from insurance companies which found charges for tests that were not medically necessary. The hospital has since dropped that amount to $16,000 per month.

It was a hot area - hospitals billing for things that weren't medically necessary - such as seeing a gynecologist and him ordering a cholesterol test, said McGreevy.

The hospital now recovers approximately 85 percent of all charges because of the systems in place to prevent errors.

Morris said many of the hospital's errors are the result of human mistakes and include incorrect room charges, keystroke errors and charges for services that were never performed.

Occasionally we will see complaints for services never rendered, said Morris. Sometimes the description is confusing and the charge was correct.

Lack of training and education typically leads to errors, according to Morris.

Hospitals need to continue training, said Morris. When they put people in positions, they need to have a series of quality checks to make sure they're doing their job.

The Maryland Hospital Association also is increasing its awareness of billing errors.

We're seeing progress, said Nancy Fiedler, spokeswoman for MHA. There's an acknowledgment that because bills are complex, errors do occur.

Use it, pay for it

Palmer said patients from across the country have been billed for many ridiculous items, including gloves, sheets, drapes, gowns, flowers, towels, soap and cotton swabs. One client was billed for a fog reduction device that was nothing more than a towel to wipe the lens on a scope.

There is no explanation of what we're being charged for, said Palmer Patients assume they're important items used for their care.

GBMC said that if an item is used for the care of the patient, they will be billed for it-including cotton swabs.

If there is an error, the patient needs to go to the hospital, said Morris. If we have charged something [inappropriately], we'll take it off.

Many medical bill reviewers charge patients based on the amount of money saved. Some larger companies are charged a flat fee or on an hourly basis.

Accu-Rate, an El Paso based medical bill review company, estimates that more than 90 percent of all hospital and doctors' bills have errors and 70 percent of those errors are overcharges.

# posted by Medical Information : 3:53 AM  0 Comments

Physicians in the Loyola Medical Practice Plan in Maywood, Ill., use a point-of-service billing system to help increase collections and third-party payments.

The plan, affiliated with Loyola Medical Center in Maywood, includes nearly 500 physicians.

The point-of-service system is made up of a mainframe computer network, with work stations placed in various hospital departments to provide patients with bins when they leave the hospital or a physician's office following treatment, according to Mark Plumley, systems analyst for the physician group and installer of the system. Patients receive a bill showing the amount their insurers will pay and the amount they must contribute.

SYSTEM GROWS. The system, implemented in the summer of 1989, began with eight stations. Four more stations were recently added.

Stations are located in various departments, including pediatrics, obstetrics and gynecology, orthopedics, medicine sub-specialties, psychiatry, general medicine, pediatric neonatology, and neurology/ ear, nose, and throat.

Through its pediatric billing station alone, the physician group estimates that it saves 1,700 per day, based on before and after comparisons of collections, Plumley said. He added that the group's daily savings will total more than $10,000 with all stations running.

The group spent more than $70,000 on dot matrix printers, protocol converters, and other computer hardware, which allowed the system's personal computers to be linked with the physician group mainframe.

"The physicians wanted small, quiet printers," Plumley said. "They wouldn't allow mainframe printers because they were too big and noisy. Laser jet printers were too big for the small work areas."

He estimated that the plan saved almost $100,000 by using smaller hardware and converters instead of buying larger printers connected directly to the mainframe system.

Initially, the system was used for physician office visit charges and certain outpatient pediatric, obstetrical, and gynecological procedures, Plumley said. Hospital charges for other outpatient procedures and inpatient stays in the neurology and pediatric neonatal units were added this fall.

"These [departments] are self-contained units, so point-of-service billing can be used," Plumley said. "Use for inpatient stays is much further down the road. Too much information would have to be scanned into the system and it wouldn't be a time-saver for [inpatient hospitalizations]."

PROMPT PAYMENT. Point-of-billing systems offer two advantages over normal collection procedures, Plumley said. First, patients are aware of how much their insurer or third-party payer will cover and how much they must pay out-of-pocket. Billing representatives also are available to answer patients' questions about their bills.

Bills are immediately sent to third-party payers instead of being forwarded first to health plan administrators and then to insurers.

The system eliminates the negative aspects of billing, such as "telephone tag" between physicians and patients, delayed payments, and other slow-downs, Plumley said. "This has increased collections. More people are paying on the spot," he said.

# posted by Medical Information : 3:52 AM  0 Comments

Nuesoft Technologies has introduced a program that offers medical billing schools free use of its NueMD(TM) medical practice management software system. The Billing Education Software Training (BEST) program gives instructors a hands-on training tool for students studying collections, billing, submissions, electronic data interface (EDI) posting, and other billing-related functions.

"Our physician client base has expressed the need to have access to qualified staff candidates who are up to speed on the newest billing technologies," said Nuesoft Technologies President and CEO Massoud Alibakhsh. "And, billing professionals need to be aware of tools that will help them effectively handle insurance reimbursement and third-party billing. Nuesoft created the BEST program to address both of those needs."

NueMD's practice management solution is delivered over the Internet using a high speed connection. Because of this delivery method, NueMD is platform independent, and can be used by multiple users in multiple locations. This format is conducive to an educational facility that might have several locations, use varying operating systems, or require students to work on billing projects outside of the classroom environment.

Great Oaks Institute of Technology and Career Development in Cincinnati is one of the first participants in the BEST program.

"We are excited to be using NueMD for our training facilities," said Certified Professional Coder Cheryl Carrier, who is an adult education instructor at Great Oaks. "It is very important for students to use a billing software program in a classroom setting so that they can get the practical experience that they will need to prepare them for their careers. And NueMD's ease of use makes it a perfect fit for our needs."

# posted by Medical Information : 2:58 AM  0 Comments

Question

I am board certified both as an internist and as a different specialty. Am I allowed to refer patients to myself for consultation so that I may bill for an initial consult code when addressing the other specialty problems?

No. A consultation is a request for an opinion from one healthcare provider to another healthcare provider. The claim would never be approved because block 17 on the claim must show the name and Unique Provider Identifier Number of the requesting physician when a consult code (99241-99255) is billed. That name and number cannot be the same as the provider who is billing for the service.

Question

I made a home visit to a Medicare patient and received a denial for the claim I submitted because I was not the "hospice" physician. How can I be paid for the home visit?

You need to use modifier "GV" as the visit code on the claim. Modifier GV indicates "attending physician is not employed or paid under agreement by the patient's hospice provider."

Question

As internists, we perform ventilator management when seeing in-patients at the hospital. When we bill the vent management codes 94656 and 94657 in addition to daily care hospital codes 99231 to 99233, we receive denials for ventilator management from Medicare, saying they are "bundled." How can we be paid for both, and how can we learn about bundling?

You cannot be paid for both on the same day because the ventilator management codes are bundled into the E&M (daily care) codes by Medicare and many private carriers.

Visit the Centers for Medicare and Medicaid Services web site (http://www.cms.hhs.gov/medlearn/ncci.asp) to view the Correct Coding Initiative, which lists all of Medicare's "bundles."

Question

I found an old Medicare check that I have not cashed. It says that it's void after 60 days. Will they issue a new check to me?

Yes. Call Medicare and they will issue a new check.

Question

We use a patient-activated cardiac event monitor. We hook up the patient, run a baseline, and bill code 93270 for the service. We've been told by a company that we cannot bill for this code since we have the patients remove the monitor from themselves and mail the monitor back to the company. How can we bill for the hook-up and the time the nurse spends transmitting a baseline to the receiving station?

You've been given some incorrect information. There is absolutely no requirement in the CPT code book or Medicare Carrier Manual that says you have to be the one to disconnect the leads from the patient in order to bill for the hook-up code 93270.

For complete billing instructions on cardiac event monitors, visit my web site at www.donself.com.

Question

The 1995 and 1997 Evaluation and Management documentation guidelines do not say if I can use a check-off template for my progress notes. Is this legal?

It is legal, and most consultants recommend it. The template is beneficial by allowing you to document the higher levels of services in less time. You'll find that this simplifies the process of documentation.

Also, if you check the "abnormal" box on the form, be sure you specify what is abnormal.

Don Self is an expert in Medicare coding and has been educating health professionals for 14 years through consultations and seminars. . All questions will receive a personal answer, and some will be published. No fee is charged for single questions; a consultation fee may be charged for multiple questions.

# posted by Medical Information : 2:57 AM  0 Comments

Accurate and up-to-date medical information is critical to the successful operation of a well-managed camp, and today's computer technology is prepared to handle the job with flying colors. Although medical modules have only recently become a standard part of camp management systems, they can be a thorough, convenient, and time-saving tool for the camp health center.

Medical modules must provide reliable information about medication disbursement and record treatment processes and make data available for compensating the camp through filing insurance claims or billing parents. Furthermore, medical modules must be intuitive for the health professional, easy to use, and closely integrated with other camper information in order to minimize data entry by the health center. Above all, a medical system must be designed to provide high levels of security--not only to safeguard the integrity of the data but also to provide utmost confidentiality for the patient.

Proper medical record keeping is not only a hallmark of sound management, it is also a first line of protection in the event of legal complications resulting from a health-related incident at camp. As with most medical record keeping, a good medical module will not permit users to alter historical information. Each record will be stamped with the user name and date and time of entry and will provide an accurate and thorough audit of health center activity throughout the camp season.

An accurate medical information database provides reporting opportunities that increase the cooperation between the health center and nonmedical staff. For example, division leaders can be kept informed of the special medical needs of their campers--such as missed medications, activity restrictions, or special health center appointments. A printed report reduces the confusion often caused by relaying such information verbally or through the camper. In addition, the printed report is positive evidence that the information was transferred accurately and on time.

A well-designed medical module will help users provide enough information for a sound audit. While somewhat arbitrary, there are certain essential data elements that are easily identified and can be provided for by the medical module. Most systems will provide sufficient flexibility to expand on these elements according to the requirements of the user. We can examine some of the features of the medical module more closely to see how they are organized.

General Camper Information

Emergency contact information should be immediately available on a camper's record. It will include the name of the person to contact and one or more telephone numbers and, if the camper has insurance, the insurer name and policy. For camps that issue medical or insurance forms as part of enrollment, there should be some indication that these forms have been received so that missing forms can be obtained prior to the camp season.

Some medical modules provide space for indicating special conditions that can be very important--if not life saving--in the event of an emergency. Typical entries might show an allergic reaction to penicillin or sulfa, or conditions such as diabetes or asthma.

Medications

Unfortunately, children are arriving at camp with more and more medications. A medical module will provide a record for each medication, showing the time of day for dispensing and the correct dosage. This record will also show the start and end dates for the medication and, perhaps, the name and phone number of the prescribing physician. With this information at hand, the system can print a medication list for a particular time of day, labels for medication envelopes, and other reports to organize dispensing and to provide a record of this activity. Some systems will keep an inventory of medications, flag the user if supplies are running low, and keep a record of camp-supplied medications that need to be billed to the family.

Treatment

The medical module will record treatments with the following:

* date and time of treatment

* attending staff member

* presenting condition and circumstances surrounding it (such as where it happened and whether or not the camper was supervised at the time)

* treatment offered

* where treatment was performed (at the health center or somewhere off-camp)

* disposition of the patient (was she retained, returned to normal, or restricted from activities?)

* whether or not her guardians were notified

In addition, some provision may be made for reporting the treatment to an insurer or for billing the guardian for special health center services.

Once a treatment has been completed, the medical module may include provision for scheduling follow-up visits by the camper following treatment. This schedule will show the camper's name, the reason for the follow-up visit, and the time and staff person to see. Follow-up schedules help medical staff plan their day and, through reporting, provide information that will help division supervisors make the necessary changes in the camper's daily schedule.

# posted by Medical Information : 2:56 AM  0 Comments

Are you leaving money on the insurance reimbursement table? Find out how to get the most out of medical billing.

The expansion of optometric practice into medical eye care has been exciting. Aside from being challenging, fun and necessary for the growth of our profession, medical eye care can be quite profitable. Optometric continuing education is replete with wonderful courses explaining the clinical side of eye care. What sometimes is missing is the final step - how to get paid. I'll use this article to help you with some of the fundamentals of medical billing and coding.

Noticing recurring themes

After presenting several medical coding seminars, a few things have become apparent.

* Doctors and their staffs are interested in learning proper medical billing and coding.

* Many doctors feel that they're leaving a ton of money on the reimbursement table.

* Many doctors feel intimidated by the process of medical billing and coding and therefore tend to under-bill for their work.

The following sections of this article will address these issues in greater depth.

O.D.s want to know

If you have any influence on your state association's continuing education agenda, then please consider yearly coverage of billing and coding topics.

A good role model for billing and coding information is the American Academy of Ophthalmology (AAO). Besides publishing a regular newsletter and sponsoring an Internet chat room devoted to billing issues, the AAO coordinates a yearly national lecture tour called CodeQuest, which is a full day packed with essential information on medical billing issues. Yes, they discuss what is new for the season, but they also review the basics every year because new staff and returning staff need to hear some things regularly. The AAO has responded to their members' needs for regular billing and coding information.

Revealing a common fear

From what I've heard, many doctors around the country are afraid that they're leaving money on the insurance reimbursement table. And after hearing samples of their fee schedules, I'm afraid they're correct. For example, let's say that you're a Medicare provider and that your fee for 92004 (new comprehensive exam) is $65. The average maximum Medicare payment for 92004 is $123.60. Therefore, each time you bill Medicare for 92004, you're leaving $58.60 on the insurance table.

Insurances put together what's called the insurance maximum allowable payment schedule. The maximum allowables are what insurance has determined to be a fair and reasonable payment for medical procedures.

When giving a billing and coding talk, I show attendees their local insurance maximum allowables. The typical reaction is surprise and concern over the huge disparity between their fees and the insurance maximum allowables. Not that optometric physicians are overcharging - they're actually undercharging terribly. Think of it this way: Insurances put the amount of money that they think your services are worth onto the reimbursement table. But all too often we say, "Oh, no, I'm not worth nearly that much." Ideally we should say, "Thanks for the payment, but I'm worth more than that and will look forward to a raise next year."

In at least two instances of which I'm aware, the medical plan has actually decreased its payment schedule after receiving billings that were significantly lower than what it calculated. Understandably, why would an insurance continue to offer more money than what most doctors want? To avoid the risk of insurances lowering their payment schedule, charge at least what they offer to pay.

Take the suggestion from the folks at AAO's CodeQuest: If you're being paid what you're billing, then you're not billing enough.

Learn the trade secrets

Hopefully by now you realize that it's in your best interest to:

* learn the insurance maximum allowable payment schedule

* charge at least as much as the insurance offers.

What if our fees are higher than the maximum allowables? Then great! That means that you'll be sure to collect 100% of whatever the insurance is offering. According to your insurance contract, you must write off any amount over the maximum allowable. Further, your patients won't be aware of your change in fees because their co-pay remains the same no matter what the fee. Yes, some insurances have the patient co-pay a percentage of the total allowable, yet a change of that small of a percentage typically goes unnoticed.

Now we have to find out what the insurance maximum allowables are for medical eye procedures. We also need a clear understanding of how Medicare calculates payments.

Meet the RBRVS system

Resource-Based Relative Value Scale(s) (RBRVS) is the foundation of medical insurance payment. With the help of the Harvard School of Public Health, the federal government created the RBRVS in the late 1980s, in part to apply a scientific methodology to calculating Medicare payments to physicians. Most insurances (e.x., Blue Cross-Blue Shield, Aetna, Medicaid [in most states], state workmen's insurance, etc.) have adopted the RBRVS to calculate physician payment.

# posted by Medical Information : 2:42 AM  0 Comments

United States ex rel. Barbera, v. Tenet Healthcare Corp., U.S. Dist. Ct., S.D. Fla., No. 97-6590-CIV-Jordan/Brown, Mar. 25, 2004.

Barbera was the CEO of Tenet Physician Services and was responsible for managing Tenet's physician practices in Florida. He reported to his superiors that he felt one of Tenet's hospitals had improperly entered into statutorily prohibited financial relationships with several physicians and had overbilled Medicare for referrals from these doctors in order to induce the doctors to refer patients to the hospital. After reporting the alleged violations to his employer, Barbera was terminated. He is now a vice president of another health care company, overseeing operations at some of its hospitals.

Barbera sued Tenet under the Federal False Claims Act, 31 U.S.C. §§ 3729 to 3733, which provides that a whistleblower who reasonably believes fraud has been committed may tell the government and file suit against the offender on behalf of the government. The government then investigated and intervened in the case. Suit also alleged violations of the Stark law, 42 U.S.C. § 1395nn-which prohibits physicians from referring Medicare patients to medical facilities with which they have a financial relationship-and the Anti-Kickback Act, 41 U.S.C. §§51 et seq., which prohibits payments or remuneration to any person in return for the referral of patients covered under a federal health care program.

Defendant contended that the compensation agreements were acceptable given the competition to acquire physician practices in the geographic area and its desire to establish an integrated delivery system to compete for managed care business. Defendant argued that this competition is what caused the compensation to doctors to increase.

The parties settled before trial for $22.5 million, including about $5.18 million, plus attorney fees and costs, to Barbera as allowed by the whistleblower protection provisions of the False Claims Act.

# posted by Medical Information : 2:40 AM  0 Comments

Hospitals can best understand the fall range of factors that can affect their outpatient revenue by comparing billing patterns among peer hospitals. To identify missed charges, regardless of cause, this comparison must consider both primary and secondary services appearing on the claims.

Focus 1: Practice Patterns

The analysis of differences in practice patterns, should begin with a comparison of the actual services performed. Simply looking at a charge description master (CDM) alone would not provide evidence of such differences. A hospital in a major Midwestern metropolitan area, for example, compared primary and secondary services delivered in association with echocardiograms with such services delivered by peer hospitals in its market. The peer hospitals had different practice patterns in the type and volume of services. Upon analyzing secondary services, the hospital found that its peers perform a number of additional examinations for a small percentage of patients that it typically does not perform or performs at a much lower rate. For example, the peer hospitals perform cardiovascular stress tests and nuclear medicine exams of the heart in conjunction with echocardiograms 1 to 4 percent of the time, whereas the hospital generally did not perform these exams. The analysis raised the question of whether all hospit als should be performing these studies, and alerted the hospital to a practice pattern that might need to be reviewed.

Focus 2: Internal Procedures

Comparing billing patterns of two or more hospitals also can allow a hospital to identify missed charges caused by deficient internal procedures. For example, upon comparing its MRI services with those of its peers, a large urban hospital found that it was not reporting MRIs in conjunction with emergency department services, whereas its peers were routinely reporting such MRIs. When hospital managers investigated this finding, they discovered that patients' charge tickets were not being updated following MRIs. As a result, billing information for the MRI was not being captured. A CDM review would not have identified this operational problem.

# posted by Medical Information : 2:39 AM  0 Comments

Medical bills.

We dread seeing them, we often complain about them and we really don't want to pay them out of our own pocket.

For years, we counted on insurance paying our medical bills. But with changes in health care coverage today, we often pay a greater share of our medical bills, and we're paying closer attention to them.

"Insurance coverage is the No. 1 concern, more than the medical bill itself," said Colette Lasack, director of patient business services at Gundersen Lutheran Medical Center, which has 1.4 million patient clinic visits and 75,000 hospital registrations each year.

Lasack said medical problems are a stressful time for patients. "They want a great cure, but they don't want to pay for it," she said.

And medical bills can be confusing, but officials at both LaCrosse medical centers say they are making strides to improve the billing process and the actual bills - to make it easier for patients.

The billing process is a medical maze itself Bills are generated as soon as a patient walks in the door for medical care. Most of the information often is sent electronically to the patient's insurance company.

"We then wait for payment from the insurance company, and no bill is sent out (to a patient) until we hear from your insurance company," said Richard Bernard, director of patient financial services at Franciscan Skemp.

New rules under the Health Insurance Portability and Accountability Act of 1996, otherwise known as HIPAA, require that insurance companies have a uniform code system for patient accounting and a standard way to accept claims, Lasack said.

At Franciscan Skemp, patients receive separate bills for clinic, or physician services, and hospital services, Gundersen Lutheran patients receive one bill for clinic, hospital, laboratory and other services.

Gundersen Lutheran sends bills and letters to about 68,000 patients a month. Franciscan Skemp bills about 32,000 patients a month, Bernard said.

Lasack said Gundersen Lutheran's first communication with a patient is an itemized statement - not a bill - sent within 15 to 30 days of medical care.

"We've debated whether to send these out or not, but it tells patients what the actual cost is," Lasack said. "We get a lot of calls because people think it is a bill, but this statement is a courtesy."

Once a patient is billed, if no payment is made on a bill within 120 to 130 days, Franciscan Skemp officials review the account, then send a final notice to the patient before turning the bill over to a collection agency, Bernard said.

"There are lots of opportunities to pay the bill before it gets to collection," Bernard said. "We don't send to collection those who can't afford it, only those who won't pay.

"Once it hits the collection agency, we have nothing to do with the bill," he added.

Lasack said Gundersen Lutheran has a formal financial counseling program to help patients receive Medical Assistance and get loans. "The vast majority want to pay their bills," Lasack said.

Bernard said the number of people unable to pay their medical bills on time has grown because of a slow economy, increasing medical costs and changes in insurance benefits including higher premiums, copayments and deductibles.

"A lot of people struggle, and as long as they contact us and not ignore the bill, most of the time we make arrangements for payments," he said.

Gundersen Lutheran has social workers who work from the start with patients, such as those with cancer, who might have larger medical bills, Lasack said. "We're not going to deny care on the basis that they can't pay their bills," she said.

"But patients need to contact us so we can work something out."

Franciscan Skemp has 3 percent to 5 percent of its patients on a payment plan, Bernard said. Gundersen Lutheran has about 2 percent of self-pay patients on payment plans.

Bernard said technology will continue to change and improve the billing system.

"It makes sense to improve the time the bill gets to the patient and reduce that lag time. That is our challenge."

Lasack said new systems also will improve the readability of bills.

"I'd like to see at an appointment where you get a statement of your charges today,'' Lasack said. "That would help with the expectations of the patients.

"Patients come here for great care, and the last impression they have of this place is their medical bill, so we want to do everything to work with them," she said.

# posted by Medical Information : 5:54 AM  0 Comments

To succeed in healthcare, new technology must prove itself not only to users, but also to those who pay for it.

"A new technology cannot displace an established technology--with its installed base of plants, equipment, training, personnel, and satisfied customers--unless the innovation is about ten times more cost-effective than its predecessor."

One new technology that shows potential for cost effectiveness in healthcare billing is natural language processing (NLP).

NLP software extracts facts, such as ICD-9 codes, from narrative text that is typically created by transcriptionists working from physician dictation. The results of several formative studies suggest that NLP can improve medical record coding productivity and consistency without sacrificing quality. In fact, commercial NLP products for radiology and emergency medicine are now being sold. But whether the technology works as promised is only part of what is required for commercial success in a mainstream market.

Other factors that will play a role in the rate of adoption and the staying power of NLP include:

* How does NLP affect workflow?

* What mode of clinical data capture (unstructured text or structured/coded) will emerge as most desired by clinicians?

* Are other supporting technologies required for mainstream adoption?

* Can NLP fit into existing healthcare information technology legacy environments without requiring significant human re-engineering and/or costs?

* Is there a natural buyer?

* Will NLP increase revenue or reduce cost? By how much?

* Does NLP address healthcare executives' high priorities?

Three vendors--A-Life Medical, CodeRyte and Paradigm--have made significant investments in NLP software designed to automate various aspects of medical record coding from narrative text. A-Life began in 1996 with an ICD-9 and CPT-4 coding product for emergency medicine and in 2000 expanded its scope to radiology. CodeRyte started in mid-1999, aggressively built an autocoding ICD-9 and CPT-4 product for radiology and has already expanded into cardiology. Paradigm's NLP software, built over a number of years, identifies ICD-9 diagnosis and procedure codes from dictated/transcribed inpatient charts.

NLP and workflow

Since NLP products for radiology and emergency medicine are now emerging in the early adopter market, NLP's end-to-end impact on workflow and workload will soon be apparent. 3M sponsored studies of products from three NLP companies conducted in "laboratory" settings that have demonstrated 30 percent to 50 percent improvement in coder-productivity, reduction in workload reflected in the number of charts that can be coded without human intervention (40 percent to 65 percent), and improved inter-coder consistency with no reduction in coding accuracy. However, what these "laboratory" studies do not tell us is what the environmental, workflow and integration affects of NLP will be in a variety of healthcare settings, factors that will influence the rate of the adoption.

NLP radiology clients of A-Life Medical and CodeRyte are beginning to realize significant workload reductions through NLP batch processing. NLP customers electronically ship their dictated/transcribed ASCII records to the remote service centers where their charts are coded overnight and returned ready to be shipped to third-party payors. Charts that can't be "autocoded" by NLP software are flagged by the system for human review.

Clinical Data Capture

Among those who study the potential of NLP as an autocoding or coding-assist tool for billing, debate exists over the size of the market opportunity, in light of the variation in prerequisite use of dictation/ transcription.

In acute care markets, transcription services may actually be on the rise with transcribed documents representing a small but important percent of the total patient chart. Physician dictation and transcription services are heavily used in many hospitals for pathology, operative, history and physical exam reports as well as discharge summaries. Radiology and emergency medicine are also heavy transcription users.

But in other areas of medicine such as physician offices and clinic settings, handwritten notes are still the norm. In an October 1999 Harris poll, physicians were found to document in the following ways (frequencies):

* Handwritten notes (54.2 percent)

* Dictation/transcription (31.1 percent)

* Speech systems (4.4 percent)

* Computer keyboard (4.3 percent)

* Handheld devices, like PalmPilot (0.2 percent)

* Mixture of other (5.8 percent)

A major assumption made by those investing in NLP is that, in spite of the high cost of transcription services, "free text" or ASCII is not going away and may be on the rise.

Supporting Technologies

Automated transcription of continuous speech has yet to deliver on its promise, but may eventually be a big market driver for NLP by eliminating transcription costs. Without automated speech recognition, NLP vendors will be pinning their hopes on physician preference to talk versus type and that the demand for that preference will outweigh the cost of transcription services (about $10,000 per year per physician at many hospitals). For institutions already absorbing the cost of transcription, NLP software costs may seem relatively small compared to the benefit. Yet the sales process for NLP vendors to institutions accustomed to either handwritten or template-based clinical documentation will likely be more difficult.

# posted by Medical Information : 5:53 AM  0 Comments

Q.

Due to the flu vaccine shortage, we have decided to vaccinate our regular patients. We would like non-established Medicare patients to pay the regular fee for vaccines rather than Medicare's fee. Is this allowed if non-patients sign a private agreement?

A.

No, this is definitely not permitted. If you see a patient with Medicare Part B coverage, you have to accept assignment on the vaccine and administration. This is not negotiable as the injections must be filed with Medicare and private agreements with the patient do not change the requirement.

Q.

The Emergency Department summoned me for a consult for a critically ill patient. During the consult, I treated the patient with several procedures (insert CV catheter and arterial catheter). The patient expired during my visit. I documented "Critical care time 1 hour, 40 minutes; total time 2 hours, 40 minutes," so that I can bill the out-patient consult (99245) and critical care (NEED CODE HERE). My staff says I cannot bill for both. Who is right?

A.

Your staff is doing you more than one favor by saying you cannot bill for both codes during the same encounter. Not only are they informing you of the correct coding, but they may be making you money. It appears that the entire time you were working on the patient, the patient was critical. If this is the case, you should properly bill one charge of 99291 (30-74 minutes) and then two charges of 99291 for the additional 30 minutes each.

Q.

We do not provide primary care in our geriatric consult service, which includes an outpatient clinic, inpatient consult service, and several geriatric rehab units. Patients come for an initial consultation, which lasts 2 to 3 hours. After that visit the team (physician, social worker, and nurse practitioner) discusses the patient. Within 4 weeks, the patient returns for an hour-long visit to review any findings and to receive recommendations. Both visits are recorded; results are forwarded to the physician who initiated the consult. Is the second visit considered a follow-up consult or an established patient follow-up? If the patient needs a medication change, are our physicians allowed to make the change, or do they have to recommend it to the PCP?

A.

The second visit, in which the patient receives the team's results, cannot qualify as a follow-up consult, because such consults are in-patient, and this appears to be an out-patient service. Therefore, the second visit will be an established patient office visit (99211- 99215).

Yes, your physician can write a prescription, order medications, initiate treatment, etc. In fact, your physician can conduct any of these procedures on the first visit, since initiation of treatment does not negate the consult.

Q.

What are the guidelines for billing a new patient if a provider was previously employed by a provider group and services were billed under the group's tax and billing ID numbers, but now the provider is solo and wishes to bill patients previously seen (within 3 years) as new patients, under his own tax and billing ID, since he has to make new patient charts.

A.

Medicare considers those patients established, since the physician has provided professional care, in any setting, to those patients within the previous 3 years. The need for creating a new chart is not a factor in reimbursement.

Don Self is an expert in Medicare coding and has been educating health professionals for 14 years through consultations and seminars. Send Medicare-related questions to Don Self c/o Geriatrics, 7500 Old Oak Blvd., Cleveland, OH 44130 (toll-free fax 800-788-7188, e-mail donself@donself.com). All questions will receive a personal answer, and some will be published. No fee is charged for single questions; a consultation fee may be charged for multiple questions. Access to related information is available on the web at: http://www.donself.com. The information in this column is designed to be authoritative. The publisher is not engaged in rendering medical or legal advice.

# posted by Medical Information : 5:52 AM  0 Comments