Reimbursement Rocks

CMS (The Center for Medicare and Medicaid Services) recently released a report stating that Medicare has recovered more than $1 billion through the Recovery Audit Contractor (RAC) program since 2005, with 85 percent of the money having been taken back from hospitals. When the costs of collecting the money were taken into account–along with the small number of refunds made to providers–CMS was able to return $693.6 million to the Medicare trust fund. Not bad we may say…good for us as tax payers! Recoup from the evil hospitals…they didn’t need it anyway. But what about the rest of us?? How will (or did) this affect us?

In its analysis, CMS said that most of the improper payments made to providers occurred due to billing and coding errors, frequently when one procedure was billed repeatedly. Other problems discovered by RACs included incorrect procedure codes and submission of duplicate claims that both got paid. When the RACs challenged Medicare payments, 14 percent of providers appealed, and 4.6 percent of those decisions were overturned.

The first call I made when I read this was to my good buddy, John Davila, DC, a partner and VP at Compliant Services and Solutions. He’s the master blaster of compliance and who I defer to on such issues. (and I recommend that that my clients do too!) “So, John,” said I, “what was the first thing you thought when you read this?”. Inquiring minds want to know, and that certainly included me! I knew he would be all over this! John replied, “The first thing I thought of was..’Wow this is only from three states’ and then I thought, Whoa, the appeals rate is so small!”. What this means is that 86% of the providers didn’t trust that their information was accurate and thought “why bother” rather than to appeal.

Now, John is a brilliant guy, so I take my cues from him on compliance. We banter on about Medicare, Documentation, and other such topics that we both enjoy. But, when he pointed this out to me, it really jumped off the page. Imagine that this means more than 95 percent of providers who tried to appeal, lost–and those were the ones who felt they had a strong enough case to go through the appeals process! Not surprisingly, CMS acting administrator Kerry Weems called the results a success. Of course it is a success, Weems!!!

I look at this from two directions…one of them is that the providers need more confidence in notes and systems and the other, why don’t we appeal more often!?? Back in my ACA days, it was estimated that more than 60% of claims denied on the first submission, were paid by the second appeal. Dr. John pointed out to me that it was because a different review nurse had to look the 2nd time. Now, that same review nurse can look the second time, and so the 1st appeal may go the same way. With the addition of the QIC for 2nd appeals (Qualified Independent Contractors), that appeal number will come more into line again. A different set of eyes looks at the 2nd level of appeal. But, doctors, why are you not appealing?

I think it’s for some of the following reasons: 1) No confidence in your notes and systems; 2) Don’t know how to appeal; 3) Feel like it’s not worth it or “what’s the point” since only 4.5% of the 14% that appealed were overturned. Here’s the truth! Most DC’s don’t appeal Medicare and other carriers because there is no confidence in your notes and systems. But guess what? If everyone appeals, they have to start paying more claims, don’t they!?

Don’t be a part of the problem…be a part of the solution. Here’s my recommendation: 1) Get help up front! If you need to know your notes are bulletproof, get help up front. That’s what Dr. John’s company does as well as others. 2) Get your systems locked in. That’s what many of us do to help doctors get the systems in order that include doing it right up front, and then appealing. Even Dr. John’s war cry of “Appeal to the End” will fall on some deaf ears, if you haven’t gotten the help and systems in place up front.

This RAC program will not go away. Here’s the good news: If you go through your own appeals process and your claim is paid, there is no “double jeopardy”. This means that due to the context of the program, no more review or overturning can happen on that claim. That is a sturdy reason for me to want to appeal every claim, to the end.

So, when you get that inevitable letter asking for notes, don’t brush it off. Know that it’s a warning sign. Then take your temperature…are you cold and clammy? Fearful? Or confident and defiant? If you don’t feel confident and defiant, get some help! Not only will your office benefit, but the profession as a whole! Thoughts?

I got the call on my cell phone as I was running through O’Hare Airport between flights. I could tell by the sound of the voice on the other end that this doctor was in distress. He believed he had just figured out that his insurance CA was embezzling. He felt guilty that he hadn’t been more on top of things and angry at the same time for this horrible breach of trust. We decided that he wanted to work with me and my team to unravel this and to help him hire and train a new person. I just returned last week from conducting the onsite visit, both for analysis and training. I have to say, my heart aches for this doctor. As I was working with some of the accounts known to have had money stolen from, I worked with the new team member in talking to patients about it as they came in. As I looked into their horrified faces as we explained what happened, nearly every patient said, “How could anyone do this to my sweet, kind, loving doctor?”

The truth is, the doctor didn’t just delegate his insurance department to another; he actually abdicated it to her. When team members or patients would ask about balances or other work to be done, this evil doer would say, “Not to worry, I’m on it”. But there was no follow up and no proof that it was done. Mostly, this was because there was no system in place. But it really bothers me when I find doctors that have so much trust in their CA’s that they simply accept their word as gospel truth. It’s embarrasing I’m sure for a doctor to admit they don’t know enough about that department to manage it. Now remember, I was a finanical CA for most of my career. I wanted my doctors to trust me and they certainly could. I treated their money as if it were my own. But, in truth, it’s their money, in their office and they alone should have systems of checks and balances in place.

It’s important to have competent staff; trustworthy staff. But remember, this is your livelihood and your income. Trusting that to a third party who is not your spouse is a tall order. (And, no I don’t advocate that you fire your staff and hire your spouse…that is a whole different can of worms!) It’s my opinion that all doctors should strive to learn all they can about that department. I taught a group of about 180 at a Medicare seminar in Missouri yesterday, and it was a little annoying to me the number of CA’s in the room who were sent by their doctors, while the doctor took the day off. I know some were holding down the fort at the office, but in this case, Medicare is so important, it should not be delegated without some knowledge of the program yourself as the doctor/owner.

So, what’s a PokeyHontas? Well, as we were talking about the unfortunate situation in this office and the person who was arrested and charged with embezzelment they just cringed every time they said this former team member’s name. We tried to come up with something else we could call them. We found out that this person was held in jail over the weekend. And as sad as that seems, it’s justice for the nightmare that was poured down on this doctor and the team. We went through many names: Evil-doer; Pokey Princess; and finally came up with the perfect name: PokeyHontas…. I hope you never have to have the nightmare of a PokeyHontas in your practice. Take control of your finanical department now before it’s too late!!

And gold to me equates to “cash”. Moolah! Bread! Dough! Dinero! Bird in the hand..worth two in the bush! Cash is King!

Why, then, do you think that as a profession, we’re so willing to extend credit to complete strangers (ok, relatively complete strangers) with no collateral and wait to be paid until some distant third-party insurer decides to pay us?

After 25 years in the profession, most of it behind a desk billing and collecting insurance, I’m more convinced than ever that without balance we can’t survive. I’ve watched over these years as doctors with all the eggs in one kind of basket, like Personal Injury, or Managed Care, have seen it dwindle to the point where I get a call saying, “throw me a life preserver!”. It breaks my heart to watch it.

Even though I’m known in the profession as the “coding queen” and “reimbursement goddess” (both titles I’m honored and humbled to hold), I still believe that balance is the name of the game. In this blog, we’ll explore all the options for reimbursement, and look at the various angles and ideas which we need to explore to achieve perfect balance. Insurance can and should be a part of practice. However, building your cash profit centers, like nutrition, pillows, braces, massage, decompression, spinal pelvic stabilizers, and most importantly, wellness care, will help assure that your practice will always have a cash foundation. What if we could call the money we get from insurance “bonus checks”? Strive to meet your monthly overhead with that money collected over the counter. In this blog, we’ll look at all the ways to do that, insurance billing and collection secrets, how documentation figures into the mix, compliance tidbits, staff training and more.

Reimbursement really does rock. Just ask anyone I’ve ever worked for about the Kathy Dance. Remember that obnoxious little dance Pee-Wee Herman did on his Saturday Morning program. Well something like that! When a check I’d been fighting especially hard for made it in the door, I would do the Kathy Dance around the office, and my doctor always knew it was a win.

Stand tall comrades! And visit back here often for fun and frolic in reimbursement land.