Email not displaying correctly? View it in your browser. Issue #9 — Mar 23, 2011
AAPC BillingInsider e-Newsletter

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F R O M   T H E   F I E L D

Don't Let Missed Appointments Reduce Your Bottom line
By Delly Parham, AS, CPC

Missed appointments, which include no-shows and last minute cancellations, can cost a practice in different ways. First, take the lost revenue from the missed appointment itself, add the cost of employees who spend time scheduling the appointment and making follow-up calls with the patient, and then add the empty time that could have been filled with other patients.

According to studies conducted by the Medical Group Management Association (MGMA), the average no-show rate for medical offices ranges from 5 to 8 percent, which can be higher depending on the size of the office and the number of new patients.

With lost revenue adding up, more practices are beginning to charge for missed appointments, translating the issue into language patients can understand: a financial one.

A missed appointment charge can help a practice recoup some of its lost revenue. Many practices simply hang the threat of a charge out there to get the patients through the door.

The American Medical Association (AMA) Code of Ethics allows physicians to charge patients for missed appointments and/or for appointments cancelled less than 24 hours in advance, so long as patients are properly advised. Medicare's policy allows physicians to charge for missed appointments so long as the charges apply equally to non-Medicare patients. The amount you charge is up to you, but it must be uniform across the board for all patients, both Medicare and non-Medicare. There is no set amount.

Be ready, however, for extra work that no-show fees may generate. They require additional accounts receivable attention, and itís a good idea to get a signature from the patient on a financial responsibility form saying he or she understands missing an appointment may generate a fee.

No-show fee or not, it is always helpful to call the patient a couple of days before the visit as a reminder.

Charges often range from a flat fee of $10 to $25 or half the cost of the scheduled procedure. The primary goal is to cut down on missed appointments rather than generate revenue. It may be helpful to check what the usual and customary charges are for missed appointments in your area.

G O O D   T I P S

How To Write Appeal Letters That Work!
By Navicure

The complexity of federal regulations and insurance plan rules continues to wreak havoc with the physician revenue cycle. Consider the effect on your practice of expanding global periods, bundling edits, Local Coverage Determinations (LCDs), and non-covered procedure lists. Even the savviest medical billing staff must fine-tune the appeals process to prevent it from becoming a lengthy battle. Knowing how to write an effective appeal letter greatly enhances your practice's chance of getting paid for initially-denied or underpaid claims. Use the following list to improve your appeal letters and increase revenue:

1. Understand the content of your EOB/ERA. Ask yourself:

  • Is the denial/underpayment due to bundling edits such as Medicare's Correct Coding Initiative (CCI), an LCD, or a procedure's global period?
  • Did the insurance plan only pay for one procedure when two were included on the claim form?

Why this is important: The language of the appeal letter argument should address the insurance plan's reason for denial or underpayment.

2. Know where to locate the insurance plan's medical health and coverage policies. Find out whether the insurance plan's policies conflict with the accepted policies of the American Medical Association or your practice's specialty association. Check whether your contract with the insurance plan includes exceptions, and if the patient's benefit plan covers the procedure.

Why this is important: Referencing the appropriate policy and regulation language within your appeal letter provides the greatest chance of success. Supply all supporting documentation with your letter so the appeal reviewer has all information at his or her fingertips.

3. Be familiar with the insurance plan's appeal process. Know which forms and time frames are allowed for submission, follow-up, and response. What additional levels of appeal are possible if you're denied?

Why this is important: Treat each appealed claim like a project. Set expected milestones, including the date of appeal and expected response time. As each claim goes through the appeal process, track the level of the process it's in, as well as the deadline for filing. Note: If you have exhausted all avenues with the insurance plan or feel that the insurance plan has unjustifiably denied your claim, file an external review with your state or federal insurance commission or regulatory agency.

4. Make sure the physician's documentation is clear and complete. Simply circling a CPT® or ICD-9-CM code on a superbill does not provide supporting evidence that the procedure was performed—or medically necessary. Make sure your physicians document as much information as possible in the medical record to support any necessary appeal efforts.

5. Include as much information within the appeal letter as possible. Include 1) all patient demographic information; 2) all pertinent insurance information; 3) date of service; 4) place of service; and 5) EOB/ERA denial code and reason toward the top of your appeal letter. Then include 1) Proof of medical necessity of the procedure; 2) research from the insurance plan’s medical policies, your specialty society information, the patient's benefit coverage, etc.; 3) copies of all radiological, lab, and pathology reports; and 4) any other information. Keep the letter professional.

6. Lastly, send the letter via certified mail so that you have record of its receipt by the insurance plan. As many of you know, two of the most common phrases used by insurers are, "We do not have record of that claim on file," and "We never received it!"

F E A T U R E D   S T O R Y

Getting Paid for Deductibles
By Delly Parham, AS, CPC

The high cost of health insurance has contributed to a sharp rise in deductibles, which may range from $1,000-$5,000. For 2011, Medicare Part A deductible increased $1,132 and Medicare Part B for outpatient services increased $162.

High deductibles can decrease your cash flow, especially during the months of January through March. Patients, especially those who are out of work or on a tight budget, usually consider medical bills a low priority on their list of necessities.

However, even if it is legal, collecting deductibles up front may not be a good business practice. It could end up costing a practice more to collect up front and then have to refund them later in view of increased overhead, including clerical and bookkeeping expenses. For example, in processing a refund you will incur costs for:

  • Staff time
  • Checks and associated bank fees
  • Paper and other supplies
  • Postage

These increased costs may exceed the benefit associated with requiring the up front payment of unsatisfied deductibles. When a physician accepts Medicare Part B assignment, Medicare Part B recommends:

"Since it is difficult to predict when deductible/coinsurance amounts will be applicable, it is recommended that providers do not collect the deductible prior to receiving payment from Medicare Part B because over-collection is considered program abuse. In addition, this practice can cause a portion of the provider's check to be issued to the patients on assigned claims."

Consider the following practice tips which may increase cash flow:

  • Wait two or three weeks after the claims are submitted for the explanation of benefits to find out the exact amount of deductible owed by a patient.
  • Don't assume that the amount you determine at the time of service is the patient's outstanding deductible as you may be surprised that the patient may have visited another provider or have some other medical charges submitted and applied to their deductible prior to the filing of your claim.
  • Ask the patient about additional policies. The patient may have a secondary or supplemental insurance that covers the entire amount of deductible.
  • Confirm the status of deductibles yourself. Most patients do not know what is covered under their plan and may give you inaccurate information.
  • Contact the patient in advance and inform him or her of the amount due. If a patient is scheduled for an elective surgery, verify the patient's benefits prior to the surgery. Obtain payment of the deductible balance or work out a financial arrangement for payment of the portion prior to performing the surgery.
  • Make sure if you give discounts and/or write off amounts for financial hardships, that this practice is done across the board on a case-by-case basis. Do not make this a routine practice. Any fee reduction or write-off should be properly documented.
  • Prevent scrutiny. You can be investigated for fraud if you do not bill for the deductible and/or coinsurance of a Medicare patient. You could lose your contractual arrangements with non-Medicare insurance carriers if you do not bill for the portion due from patients under their plans.

Do not bill the patient more than the fees allowed by Medicare or by non-Medicare carriers. There is no law that says how many times you must bill a patient before taking a reduction or write-off. So long as you can document that you have billed the patient, you should be safe in discounting or writing off a fee due to a genuine documented financial hardship.

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 editions.

In This Issue
Missed Appointments
Write Appeal Letters
Get Paid for Deductibles

MEDICAL BILLING COURSE
Don't underestimate the importance of policies and procedures in the billing world.

HEALTH PLAN POLICY SEARCH TOOL
Save time hunting down information for specific payer policies. We've compiled localized data from over 500 health plan's websites into an easy-to-use search tool.

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