It’s always a fantastic feeling when other people speak on behalf on your products or services, so we were thrilled to see a very nice comment on a recent article at Physician’s Practice “Patient Balances: Get Them or Get Ready to Close Your Practice.” The article details the importance of collecting patient balances as quickly and effectively as possible as doctors face declining reimbursements and increasing overhead and regulation. We have long championed the Credit Card on File system – where patients leave a credit card securely on file with the practice’s gateway and the card is charged after insurance is billed for any patient balances under $100. Balances above $100 (or whatever limit a practice may set) are either placed into a payment program, or paid in full after contacting the patient. One of our very successful clients whose practice has implemented such a program commented on the article about her own experience.
We started a year ago with a Credit Card on File program, on the advice of Mary Pat Whaley. After 1 year, our patient balances are very small, and for practically every balance over 90 days old, the patient is on a payment plan, but since our overall patient A/R is very small, it doesn’t represent a lot of outstanding income. We have over 2000 credit cards on file. Patients are not allowed to see the doctor without leaving a card on file, and they agree to this over the phone when they make an appointment. I’ve found it very challenging to understand and charge patient balances upfront, so we’ve opted for Credit Card on File instead. We charge the copay, file the claim, then charge any remaining balance to the card, once the EOB is received. We charge the card if the balance is under $100 (with an email receipt), and if over $100 we call the patient to determine if they want to pay in full or in installments. Most pay in full, and most appreciate the call. We do not send out paper statements. It takes about 1/4 FTE to manage the credit card collections, but I have an excellent receptionist who handles this very nicely with the patients. There are some issues when the card declines, but we follow up with a weekly phone call, and if necessary, a paper statement (not often). There will always be a few that will never pay, but you can’t escape that in this business. We are proud of our credit card collections, which is why I’ve detailed it here so you can consider it for your practice.
Marian @ Tue, 2013-07-23 11:12
Why, thank you very much, Marian!
If you’d like to learn how to start a Credit Card on File program in your own practice like Marian did, then you’ll want to join us next Thursday, August 8th at 3pm EST for “How to Start a Credit Card on File Program in Your Practice” our popular 60-minute webinar and Action Pack that will give you the tools and plan you need to implement the policies.
Spending one hour of your time and $59.95 now can mean all the difference in your bottom line tomorrow.
One of the (many) things that separates the business of medicine from so many other industries is the complexity of healthcare reimbursement. The healthcare reform process in the United States is shining an unrelenting spotlight on the price variances between identical services and the inscrutable way that providers set their fees. Since a large portion of the services rendered are negotiated and paid for by a third party, medical managers deal with a different set of challenges and require a specialized understanding of how payment mechanisms operate.
As we are all patients, we can all benefit from a basic understanding of the most popular types of insurance plana, and how they work for subscribers. Understanding health insurance is critical to understanding medical management as well as how healthcare is changing under reform.
Indemnity plans (often called 80/20 plans)
These plans typically have a deductible – the amount the patient pays before the insurance company begins paying benefits. After the patient’s covered expenses exceed the deductible amount, benefits are paid as a percentage of actual provider charges, often 80 percent. These plans usually provide the most flexibility in choosing where and from whom to get healthcare.
Preferred Provider Organization (PPO) plans (also called a network plan)
In these plans the insurance company enters into contracts with selected hospitals and physicians to furnish services at a discounted rate. Patients may see a provider within the network without a referral. Patients with this plan may be able to seek care from a doctor or hospital that is not a preferred provider (considered “out-of-network’ providers) but the patient will have to pay a higher deductible or co-payment. Exceptions exist if covered medical services are not available inside the network.
Exclusive Provider Organizations (EPOs)
Very similar to HMOs, EPOs may limit coverage to providers inside their networks, however EPOs do not generally require referrals to see in-network specialists. EPOs are often the insurance plan of choice for self-insured hospitals and large medical systems.
Health Maintenance Organization (HMO) plans (also called gatekeeper plans)
These plans have patients choose a primary care physician (PCP) from a list of HMO providers. The PCP is responsible for coordinating all healthcare for their HMO patients. If patients need care from any network provider other than the PCP, the PCP usually must provide a referral. Only care provided by a participating HMO provider will be paid. Treatment received outside the network is usually not covered, or is covered at a significantly reduced level. HMO plans often have the lowest premiums, deductibles and co-pays, but can be restrictive on when and where patients can get care.
Point of Service (POS) plans
These plans are a hybrid of the PPO and HMO models. They are more flexible than HMOs, but do require patients to select a primary care physician (PCP.) Like a PPO, patients can go to an out-of-network provider and pay more of the cost. However, if the PCP refers you to an out-of-network doctor, the health plan will pay the cost.
Catastrophic Health Insurance Plan
A catastrophic health insurance plan covers essential health benefits but has a very high deductible. This means it provides a kind of “safety net” coverage in case patients have an accident or serious illness. Catastrophic plans usually do not provide coverage for services like prescription drugs or shots. Premiums for catastrophic plans may be lower than traditional health insurance plans, but deductibles are usually much higher. This means patients must pay thousands of dollars out-of-pocket before full coverage kicks in.
Some patients are combining catastrophic health insurance plans with Direct Primary Care (DPC), where for a monthly fee, a primary care physician provides office visits and some additional care such as lab tests and flu shots.
Consumer-Driven Health Plans (CDHP)
CDHP describes a wide range of approaches to give patients more incentive to control the cost of either their health benefits or health care. Patients have greater freedom in spending health care dollars up to a designated amount, and they receive full coverage for in-network preventive care. In return, they assume significantly higher cost sharing expenses after having used up the designated amount.
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of Consumer-Driven Health Plans. They may be referred to by the health plan under a different name, such as Personal Care Account. They are also available to enrollees in High Deductible Health Plans who are ineligible for an HSA. HRAs are similar to HSAs except an enrollee cannot make deposits into an HRA, a health plan may impose a ceiling on the value of an HRA, interest is not earned on an HRA, and the amount in an HRA is not transferable if the enrollee leaves the health plan.
Health Savings Account (HSA)
A Health Savings Account allows individuals to pay for current health expenses and save for future qualified medical expenses on a pretax basis. Funds deposited into an HSA are not taxed, the balance in the HSA grows tax-free, and that amount is available on a tax-free basis to pay medical costs. To open an HSA, you must be covered under a High Deductible Health Plan and cannot be eligible for Medicare or covered by another plan that is not a High Deductible Health Plan or a general purpose Health Care Flexible Spending Account (HCFSA) or be dependent on another person’s tax return. HSAs are subject to a number of rules and limitations established by the Department of Treasury.
High Deductible Health Plan (HDHP)
A High Deductible Health Plan is a health insurance plan in which the enrollee pays a deductible of at least $1,250 for individual coverage or at least $2,500 for family coverage. The annual out-of-pocket amount (including deductibles and co-payments) the enrollee pays cannot exceed $6,250 for individual coverage or $12,500 for family coverage. These dollar amounts are for 2013.
A colleague of mine has been part of a well-known PM/EMR company’s software support team for 10 years. She often tries to steer people to me when she cannot solve a client’s problems with a software solution. Even though she was once a practice administrator herself, she is a software support person now and the problems she sends to me cannot be solved with software. “Mary Pat,” she asks me, “Why do they think I can solve their practice management issues? All I am empowered to do is to help them use the software.”
Earlier in my career (before EMR) I heard someone call “Practice Management” software “Billing” software and I remember being offended for some reason. I thought “Billing” was such a narrow description of what PM software did – but they were right. That software is meant to deal with everything billing. It all comes down to billing – whether it is the actual billing/claims management itself, running reports to diagnose billing problems, or capturing recalls so patients get reminded to come in for a service and…get billed. Before you unload on me in the comments let me be clear that I am not saying that healthcare is all about billing, I am only saying that Practice Management software was developed to handle the financial side of the house.
Practice Management software cannot “do” practice management. It cannot figure out your workflow so you capture data in the most efficient way, and it cannot analyze your reports and tell you what to change to increase efficiency or decrease overhead. It certainly cannot tell you the best way to schedule, or how much to charge your self-pay patients. It is only a billing tool.
I have worked in healthcare long enough to have helped practices go from manual billing (you typed or hand-wrote claim information on a 1500 form and mailed it in) to their first practice management system. I did a lot of practice management consulting even though that’s not what I was there to do. I had to get them in shape on paper so they could handle the software. I had to get their workflow optimized so the software would make things better – not worse.
An implementation of Practice Management software is not intended to do anything but set-up the system and train you to use it. Sometimes that perfectly rosy future the salesperson paints is nothing like the painful first steps (and cash flow jam) of a new system. An implementation will not fix the issues that are existing in your practice that have nothing to do with the functionality of your billing system.
Your Practice Management Software can:
Automate your registration process so patients can register and check-in online, or at a kiosk in the practice.
But your Practice Management Software cannot:
Train staff to greet patients and make them welcome in the practice.
Your Practice Management Software can:
Check the patient’s eligibility for active insurance coverage.
But your Practice Management Software cannot:
Automatically choose the correct insurance company/payer to attach to each patient account (one of the biggest problems I hear about in the field!)
Your Practice Management Software can:
Calculate the days since the patient’s last physical, the days left in a global period or visits left in annual cap.
But your Practice Management Software cannot:
Help the patient understand their benefit plans and understand their financial responsibility.
Good practice management has a lot to do with attracting, training, coaching and retaining the right staff, as well as providing them with the tools to do the job you hired them to do. Getting the software right is a must, but don’t expect your software trainers to be able to solve any of your staffing, communication, workflow or cultural problems. That’s up to you, the Practice Manager!
Medicare recently started denying an increased number of claims because documentation submitted for diagnostic tests does not include signed test orders or evidence of intent (MD progress notes listing tests needed) and evidence of medical necessity (description of clinical conditions and treatment showing the need for the testing.)
Most of us who have gone through the implementation of a EMR realize that electronic medical records (EMRs) do not always “tell the story” of a visit in the way that paper records used to. Encounters are documented without the glue that allows an auditor to understand what went on during the visit. Here are three ways to make sure that your documentation meets requirement for Medicare and other payers.
Establish Medical Necessity: Make sure the test is attached to the right diagnosis
Some providers attach all diagnoses assigned to a visit to any/every test ordered and performed. This is incorrect. All diagnoses can be attached to the Evaluation & Management (E/M) code, since all were addressed during the visit. Don’t list any diagnoses from previous visits that were not addressed at the current visit unless you note their impact on your decisions for care at the current visit.
Remember that screening tests and diagnostic tests are two different things. A screening test is ordered when you are looking for something with no provocation. Wikipedia states that a screening test “may be performed to monitor disease prevalence, manage epidemiology, aid in prevention, or strictly for statistical purposes.”
A diagnostic test is ordered when there is a sign or symptom that prompts the provider to look for the cause. Wikipedia defines a diagnostic test as “a procedure performed to confirm, or determine the presence of disease in an individual suspected of having the disease, usually following the report of symptoms, or based on the results of other medical tests.”
According to Medscape, the 5 main reasons for any test are as follows:
Screening: Screen for disease in asymptomatic patients. For example, a prostate-specific antigen (PSA) test in men older than 50 years.
Screening: A test may be performed to confirm that a person is free from a disease or condition. For example, a pregnancy test to exclude the diagnosis of ectopic pregnancy.
Diagnostic: Establish a diagnosis in symptomatic patients. For example, an ECG to diagnose ST-elevation myocardial infarction (STEMI) in patients with chest pain.
Diagnostic: Provide prognostic information in patients with established disease. For example, a CD4 count in patients with HIV.
Diagnostic: Monitor therapy by either benefits or side effects. For example, measuring the international normalized ratio (INR) in patients taking warfarin.
Reveal your decision making in the record
Need add’l tests to est. xxxxxx. Plan to…
Return in 3 wks and repeat test to establish…
DM worsening – will….
Consider d/c xxxxxx medication if fatigue persists.
Hypothyroidism vs. anemia?
Fatigue most likely sec. to HTN meds – r/o electrolyte abn.
DM stable, continue current regimen, recheck in 3 months.
Don’t forget the signatures!
A signature log can be as simple as entries on a document such as:
Provider Name (printed): ______________________
Full signature (written by provider): ______________
Initials (written by provider): ___________________
Dr. Maria Todd has been in healthcare since 1979 and has been the nation’s leading managed care trainer and consultant since 1989. She’s trained more than 70,000 healthcare professionals via more than 2500 road show seminars presented through McGraw Hill Healthcare Education Group, HFMA, MGMA, Heritage Professional Education and Business Network. Her iconicManaged Care Contracting Handbook sold more copies than any other managed care professional handbook in history, and is now in 2nd edition. No other industry professional has contributed more to the art of managed care contracting and managed care professional skills education than Dr. Todd. Manage My Practice recently sat down with her to learn more about “the new age of contracting.”
Mary Pat: Maria, you are teaching attendees at your contracting course what is new about payer contracting. What’s different in the current environment?
Maria: The managed care contracting scene is radically different under healthcare reform and the PPACA. Anyone who hasn’t revisited their contracts in the past few years because they conveniently “rolled over” year to year may find that they could be shut out of renegotiation, certain networks and other strategic updating that should have been done vigilantly since 2009.
Mary Pat: Do managers still need all the previous skills related to contracting with payers?
Maria: They need even more! For example, they will need to be able to safely configure bundled case rates without overlooking costly inclusions due to vague or ambiguous descriptions and accurately calculate the business opportunities and risks under capitated models.
Mary Pat: Contracting carries a lot of risk. How do you teach people about contract risk?
Maria: By showing them the ambiguities in every day contract language that doesn’t look like legalese but can create loopholes for payment bundling, denials, foreclose appeals, and force the physician to refrain from billing.
Mary Pat: Many physicians have told me that there is no real negotiability in payer contracts anymore. I don’t believe that is true – what do you think?
Maria: I have always been able to negotiate some changes, perhaps not all that I’d like to. The fact of the matter is that if there is nothing to negotiate, the contract is considered “adhesive” and unfair and the courts can toss it out. Language can also be construed in interpretation against the drafter, if it is ambiguous. Also, the courts are not there to be paternalistic. If you negotiate some and leave others the courts put the onus on the physician or his/her manager for not finishing the job. You are not entitled to a fair contract unless you negotiate one. The class teaches participants how to spot problems and mitigate them, and provides more insight to defend a reason to say “no thanks, I’ve had enough!”
Mary Pat: You say “Price is not the driver anymore.” What is?
Maria: New trends in contracting level the pricing field. That means that quality and service accountability, as well as adherence to evidence-based care protocols and guidelines will be measured, prescribing habits and patient engagement…only now, they will be contracted performance elements. The whole new ball game of pay for performance is now driven on different metrics. If one doesn’t perform at a base level, one will have to find another ball field.
Mary Pat: Do managers and physicians need the help or review of a lawyer before they sign a payer contract?
Maria: Yes.. but for the right reasons. Too many attorneys are asked to assist on operational reviews. For most attorneys, those without practical experience in health administration and operations, (late entrants into law school after a career in healthcare, for example) the doctors and managers you mention are asking the attorneys to work outside their scope. Attorneys should, for the most part, review for enforceability and compliance, not fee schedules, operational practicability, and procedural matters that are purely at the discretion of the contracting parties to agree.
Mary Pat: In your course you discuss contracting with ACOs. Can you talk about what practices will need to learn to be able to contract appropriately with ACOs?
Maria: Which ones to align with, first. Second, how to get out if they make a bad decision, and third, what to look for and watch out for along the way. No one wants to miss the ACO with the successful management and operations and shared savings outcomes, and be left with the ACO that doesn’t function well, isn’t aligned and doesn’t make any shared savings bonus at the end of the year.
Mary Pat: Many managers do not know how to handle ERISA (self-funded insurance plans where the employer acts as its own payer) claims. Do you teach skills to deal with ERISA claims?
Maria: I teach 3 ways to deal effectively with this problem. We know practices hear “We’re ERISA and we don’t have to pay timely or accurately.” We teach practices how to get paid faster and more accurately from ERISA payers and teach them exactly what to say to the “ERISA Excuse.”
Mary Pat: Do you talk about out-of-network strategies in your course?
Maria: Yes, because there will be times when the right strategy is to say no. Even them physicians and other healthcare providers may be able to attract market share in other ways, some that may even cost less in overhead and hassle factor – like, cash, for instance.
Mary Pat: What is the single most important thing (without giving away any trade secrets from your course!) that you wish managers and physicians would know about contracting?
Maria: How 150 words and phrases we use in everyday language like “shall” and other words like appropriate, adequate, reasonable, material, use best efforts, use reasonable commercial efforts, best, other, indemnify and hold harmless, can make life so miserable for physicians and their managers and collections staff because they didn’t realize the implications.
Maria has very graciously agreed to give Manage My Practice readers a 20% discount (code MMP2013) on her 3-day managed care contracting workshop which will be offered on August 14, 15 & 16, in Denver, Colorado. The Healthcare Business Institute, a new non-profit training and professional skills development institute in Denver, Colorado will host this hands-on workshop at the Grand Hyatt Denver Downtown. For more information and registration, call 800-209-7263 or register online here.
Recently we covered the issue of marketing your medical practice to Millenials, the biggest generation group in human history. That got us thinking – what about the other generation groups? We know that they have vastly different needs and wants, but healthcare services are a must for pretty much everyone.
How does medical marketing differ from one group to the next, and what can you do to make your services appeal specifically to each group? Let’s consider the Baby Boomers, for example, which is the group currently reaching retirement age.
Most Medicare patients believe that Medicare pays for everything they need or want at their physician’s office, but there are services that either:
Are only covered by Medicare for a specific medical need (for instance, performing a diagnostic EKG when the patient has no related symptoms)
Are only covered by Medicare at specific intervals (for instance, performing a Pap smear more often than every 24 months for low-risk women)
Are never covered by Medicare (for instance, an annual physical)
In any of the above cases, because Medicare may not or will not pay, medical practices will give the patient an Advance Beneficiary Notice (ABN) that explains what Medicare may not pay for, why Medicare may not pay for it, and what they (the patient) will be responsible for paying IF they elect to receive the service and sign the ABN stating so.
The ABN must be supplied before the service is rendered, or the practice may not bill the patient.
The practice cannot give out “blanket” ABNs that state “whatever Medicare won’t cover.”
Once the patient signs the ABN and agrees to pay for the service, the practice must give a copy to the patient, keep the original on file and use a modifier on the claim to indicate that a signed ABN is on file and available for inspection.
The signed ABN is a requirement for charging and collecting from a patient for any services the patient asks for but Medicare may/will not cover. For the same circumstances for non-Medicare patients, a non-Medicare ABN may be used.
The millennial generation is already the biggest cohort in the history of humanity. Fact– Depending on the source you use, there are presently between 78 million and 80 million millennials in the U.S. For your practice to include millennial patients in the future, you need to target them specifically in your strategy, and “one-size-fits-all” healthcare marketing strategies simply won’t work. Here are some vital facts to help you identify how to approach them.
Fact #1: Millenials are Educated and Privileged
Born roughly between 1980 and 2000, they are widely considered the most privileged and best-educated group ever to have inhabited the earth – so far, anyway. Millennials have had access to health care since birth, many have never known poverty or hardship and most are literate, with a whopping 70% expected to attain a college degree. They are also more knowledgeable about their health, having grown up in a time when their education included sex education and open debate on issues such as smoking and abortion.
Fact #2: Millenials are Weight- and Health-Conscious
Our clients and readers are constantly asking “What do I need to do to be ready for all of this change in healthcare?”There is so much to digest, plan for and keep track of that our industry is constantly seeking new skills to confront new challenges. Professional development is a critical part of career plans in most industries – but the speed at which healthcare administration is changing is pressing the issue even further. But when can already-swamped managers find the time (let alone the money!) to stay sharp and expand their skill sets?
In the past five years a solution has emerged from the Internet. The MOOC, or “Massive Open Online Course” is a model that has the potential to revolutionize how we educate people on a large scale – not to mention give busy managers a chance to get high-quality education at little or no cost on a flexible schedule. After several universities put free, open-coursework courses online to great success, several sites developed to expand the scale of the model. Now sites like Udacity, Courseraand edX offer free courses with video lectures, materials, and examinations to anyone who can access their site. The New York Times dubbed 2012 “The Year of the MOOC”, but it might be 2013.
If you are a manger looking to stay sharp, check out some of the Coursera offerings for summer and fall of 2013 below!
On June 17, 2013, the National Uniform Claim Committee (NUCC ) announced the approval of Version 02/12 1500 Health Insurance Claim Form (1500 Claim Form) that accommodates reporting needs for ICD-10. The Office of Management and Budget (OMB) has approved the 1500 Claim Form under OMB Number 0938-1197.
During its work, the NUCC was made aware by the health care industry of two priorities that were included in the revisionsto the 1500 Claim Form. The first was the addition of an indicator in Item Number 21 to identify the version of the diagnosis code set being report, i.e., ICD-9 or ICD-10.
The need to identify which version of the code set is being reported will be important during the implementation period of ICD-10.
The second priority was to expand the number of diagnosis codes that can be reported in Item Number 21, which was increased from 4 to 12. Additional revisions will improve the accuracy of the data reported, such as being able to identify the role of the provider reported in Item Number 17 and the specific dates reported in Item Number 14.