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F R O M T H E F I E L D
Protecting Yourself from Silent PPOs
Have you ever opened the mail and in the midst of all your payments you suddenly realize you seem to be participating with insurance companies you never heard of or don’t have contracts for? When reading the fine print you realize what network paid you. This is what is referred to as a silent PPO and only careful review of your existing contracts can identify how this happened.
Silent PPOs attach themselves to an existing contract that you have with a carrier. The language in your contracts allow carriers to act as a broker reselling your terms with others. If your contract was not well negotiated you are now taking reduced payments from multiple carriers.
You can protect your practice by asking for specific language added to your contract stating that you get final selection of who you contract with and that you must be notified in writing every time a new carrier is added. You should also include the ability to opt out of any plan you choose not to participate with.
By asking for this option you protect yourself proactively instead of always having to react. This also allows for you to make a listing of healthplans you are actually participating with and arms your staff with the knowledge of who you are contracted with so that they know the correct amounts to collect at the time of service.
I N T H E N E W S
Medicare Local Coverage Determinations: My Experience with an LCD – A Valuable Lesson Learned:
by: Sara M. Lamb
In our practice, cardiothoracic anesthesiology, we typically bill for transesophageal echocardiograms (TEEs), which are performed intraoperatively by our anesthesiologists during certain cardiac procedures. For these procedures, the indication for the TEE is typically mitral, aortic, or tricuspid valve regurgitation and/or stenosis. In some cases, such as a pericardial window creation, I usually find pericardial effusion documented as the indication. Some other procedures we perform with TEEs are ventricular assist device implantations or heart transplants. In these cases, cardiomyopathy or heart failure is usually specified as the indication—and that is where the billing gets tricky for Medicare claims.
Due to the Medicare LCD Revision L16446 VA, effective 01/19/2010, TTE and TEE procedures are only covered for the ICD-9-CM codes listed, which they have determined to support medical necessity. (Cardiomyopathy isn’t one of them; neither is heart failure.) It’s a lengthy list of covered diagnoses, but be careful. Some of the diagnosis codes are covered for one part of the TEE, but not the other. One important note here: it clearly states on the LCD that “the medical record must support the ICD-9-CM code reported on the claim. Medical records, including the permanent image, need not be submitted with the claim. However, these records must be furnished to Medicare upon request.” So be absolutely certain the documentation is clear, the record is complete and your coding is accurate.
The difficulty in billing Medicare for TEEs is you have to check the LCD and your documentation thoroughly. If there’s a covered diagnosis and a non-covered diagnosis both clearly documented in the record, I would rather submit the one that’s covered— and get the reimbursement our providers are entitled to. Check any LCD denials you have received as well. We received a denial based on this LCD, and after researching it I found the diagnosis code submitted on the claim was one listed as covered for the procedure. I submitted a redetermination for this particular claim and received subsequent reimbursement.
F E A T U R E D A R T I C L E
Improve Your Surgical Care Cashflow in One Easy Step
by: Kristi Martucci, CPC
ENTAA Care Billing Manager
Glen Burnie, MD
Collecting patient balances after surgery can be tricky. Many patients are out of work for several weeks after surgery and find it hard to keep up with their bills. These delays in patient payments can severely hinder your collections on high paying services. To improve our collections, our practice developed an approach to collect patient balances prior to surgery.
For scheduled surgeries, we verify insurance benefits on all of our cases. We ask that our patients that have co-insurance, copays, or even deductibles pay their portion prior to their surgery.
In order to calculate what the patient may owe for their surgery, we review the allowed rates for the scheduled surgery and total what our anticipated collection will be. We then apply any patient benefits to the allowed rates. For example: If a patient is having a tonsillectomy, primary or secondary; age 12 or older (CPT 42826) in which the insurance allowed rate in Maryland is $283.00, and the patient has a 20% co-insurance, we collect $56.60 from the patient as a deposit prior to surgery to cover their portion of the cost.
To know the allowed rate for surgeries will require you to frequently update your contracted rates on all plans in your software. This is good business practice anyway. To simplify, you may elect to use one fee schedule, such as the Medicare rate, on all patients to calculate a deposit. The amount will not be exact, but it will be close enough to collect most of the balance up front. Don’t forget to apply reductions or increases, such as a 50% reduction for secondary procedures or a 50% increase for bilateral procedures using modifier 50.
Applying this policy has significantly reduced the amount of surgical patients that are sent to collections and keeps our patient receivables down.
FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies or just anecdotes please submit them to us for future edtions.