Medicare Compliance & Reimbursement

Tip: Differentiate your claims with the right ICD-10 codes.

If COVID-19 has thrown a wrench into your financial management, you’re not alone. With many Medicare providers cutting hours and limiting the number of patients they see, some have reported losing money during the pandemic. This ripple effect is causing practices to work harder than ever to recoup their losses in 2021.

While some regions are lifting restrictions on hours of operation, many practices are still struggling to get back to their normal patient flow numbers. In fact, some providers have been forced to cut back again — or even close because of the most recent COVID-19 surge. In addition, clinicians are having to space patients further apart due to social distancing and cleaning protocols, causing income to drop due to a reduction in number of patients being seen each day, says Patricia Morris, MBA, COE, a healthcare practice management consultant based in New York, New York.

To ensure you’re bringing in as much cash as possible during this slower period, Morris identifies 10 ways that you can optimize reimbursements.

1. Don’t Overlook 99072

When creating your payment strategy during the public health emergency (PHE), don’t forget about 99072 (Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other nonfacility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease), Morris says.

The AMA created this code “in response to the significant additional practice expenses related to activities required to safely provide medical services to patients in person during a PHE over and above those usually included in a medical visit or service,” according to the 2020 Special Edition September Update of CPT^® Assistant.

“Practices need to start using that if they aren’t already,” Morris says. Payers are reimbursing a wide variety of payment amounts for the code, with some insurers paying just $6 or $7 and others paying up to $150, she indicates.

However, you should not bill the patient if the plan denies the code, she adds. This was intended as an office code for when patients are seen in person, and wasn’t designed for ambulatory centers, but check payer policy since there is wide variability.

2. Maximize Telehealth When Possible

Most Medicare providers are using telehealth as much as they can to boost patients’ comfort levels. Morris urges practices to transition from the types of telehealth technology allowable during the PHE and formalize a compliant telehealth strategy.

“We’ve been spoiled in the last few months with the relaxed telehealth rules, but it’s a good time to shore this up and be as HIPAA-compliant as possible and use the right systems,” she notes. “Right now, for instance, you can use FaceTime or other programs like that, but the rules won’t be this relaxed forever, so it’s important for providers to make telehealth a focal point.”

CMS has indicated it will not reimburse telephone-only services with parity to telehealth/office visits after the PHE period ends. Though the PHE was extended for a fourth time to April 20, a recent letter from HHS Acting Secretary Norris Cochran to state governors suggests it will be extended further.

“To assure you of our commitment to the ongoing response, we have determined that the PHE will likely remain in place for the entirety of 2021,” Cochran said in the letter.

3. Review Your Managed Care Contracts

When it comes to your practice’s income, it’s important to review the reimbursement rates in your managed care contracts, and sometimes that means renegotiating those rates, Morris says. Have a panel at your practice, including clinicians and the billing team, review the contracts to determine whether any changes are necessary to boost your reimbursement and keep a calendar of when you can open renegotiation to update rates.

4. Double Check A/R, Fee Schedules

You should review the accounts receivables (A/R) aging monthly and pay close attention to the “over 90-day” column. Instead of just rebilling the claims, follow up by phone and build a rapport with the claim reps. Collect all unmet patient deductibles and copays upfront and the 20 percent or other applicable copay on surgery cases when no secondary insurance exists, and update the practice’s fee schedule regularly.

“Sometimes a practice hasn’t updated their base fees for five years, so they’re leaving money on the table,” Morris stresses. “The insurance company is not going to tell you they pay out more than you are billing. They will continue to pay you your rate while paying other providers 10 percent to 15 percent more for the same code.”

5. Perform Internal Audits

Although you might assume all of your services are being coded, the only way to know for sure is to perform an internal audit, Morris says. This can allow you to catch services that weren’t billed or that were undercoded.

“Practices are trying to go with the flow during this period, but when it comes to your wallet, that’s not always the best strategy,” she says. “We must change our mindset — stop postponing until we ‘return to normal.’ Embrace this as a new normal and adapt.”

6. Follow Up on Denials

“You’ve got to work your denials,” Morris urges. “Yes, things are different now, but if you’re seeing close to the same amount of patients and your reimbursements are much lower than what you’re used to, you need to drill down and find out what’s being denied and why.”

7. Collect at the Time of Service

You should trust — but verify — that your front office staff is collecting at the time of service rather than waiting to send patients a bill after the fact. Remember that sending a statement internally or through a payment management system is also an expense. “Since it’s the new year, a new Medicare deductible of $203 has arrived, so remember to collect that as appropriate. A lot of practices don’t do that for some reason, but that makes a practice cash-poor for the first few months of the year,” Morris warns.

8. Find the Most Accurate ICD-10 Code

Make sure you’re using specific diagnosis codes whenever possible, Morris says. And, if a patient arrives with a complaint and you don’t find a definitive diagnosis, you can report the signs and symptoms with the appropriate code. “The most accurate ICD-10 code is always a clinician’s decision, and under ICD-10 there are so many codes available to us — we have 68,000 codes in ICD-10 — you can find something that will apply to the symptoms the patient says they have until a definitive diagnosis is found,” she counsels.

9. Determine Whether a Time Study Would Benefit Your Practice

Consider performing a time study to ensure that you’re scheduling staff appropriately, Morris recommends. “So many things can impact whether the clinicians end up running on time, including the amount of time that the physicians spend with patients, the components of the workup, how diagnostic testing is handled, patient mobility and mental conditions, how many rooms they have — these can all contribute to running behind.”

The first step in rectifying staff scheduling issues is having an office manager do a time study to uncover the constraints in patient throughput, she says. “Even if you’ve always done it a certain way, that may not be the best way or easiest way, so an analysis is essential. Sometimes you’ll find that it’s space or location that’s causing the backup,” she acknowledges.

Providers also need to evaluate whether the amount of time they spend with patients is appropriate, Morris says. “I have providers who see 70 patients a day from 7:45 in the morning to 5:00 in the afternoon. But then I talk to providers who start and end at the same times who see 35 patients.”

She adds, “Sometimes providers have long-term relationships with patients who have been with them for years, so that visit becomes a social visit. Obviously, that can throw off a whole day.”