BILLING AND COLLECTIONS

BILLING AND COLLECTIONS

IMPORTANCE OF BILLING It does not matter how many surgeries, critical care or pain patients you treat if you do not get reimbursed for your services Collections is what drives the entire anesthesia department

Anesthesia Reimbursement Medicare pays 51 different medical specialties and anesthesia has the lowest percentage of reimbursement (25.2%) of any of the specialties

Perfect world Pt undergoes an anesthetic Charge slip gets filled out Procedure gets coded Claim gets submitted Insurance company receives it Pay for service in 30 days

Reality Paperwork is cumbersome under the best of circumstances Pts and anesthesia providers have inaccurate perceptions of insurance coverage

Reality Coding systems have gaps Medical records documentation now has payment as well as medical/legal implications

CPC coders whose job besides correctly coding the diagnoses and procedure is to also: Know that therapeutic procedure have a great reimbursement than a diagnostic one so they need to identity when the provider failed to provide the correct procedure so they can request additional documentation in order to increase our reimbursement

The anesthesia staff must also be trained to have an understanding of the billing and collection process along with the legal rules The old rule “junk in junk out” illustrates the importance of a correctly designed charge slip to insure we receive all of the necessary information in order to maximize your legal reimbursement

Anesthesia providers are number 2 on the “hit list” for the FBI and OIG The fines for filing a wrong claim can be $11,000 plus 3 times the incorrect amount

Patients perception of fraud Services that were never provided but billed Billing twice for the same procedure Being billed for a more expensive procedure than the one received

Why anesthesia is number 2 on the hit list Only medical billing specialty that gets paid extra for time thereby controls own “time clock” Anesthesia often gives the patient amnesia so they do not remember meeting the anesthesia provider

Why anesthesia is number 2 on the hit list The hospital supplies charges along with the anesthesia provider’s bill often confuses patients as far as double billing for 1 service

Anesthesia providers historically do not listen to billing personal unless their have clinical background in the past This has to change if we are to maximize our legal collections!

Insurance reimbursement Just like clinical medicine insurance reimbursement is ever changing Requires everyone to build a base of knowledge that must be constantly refined

INSURANCE COMPANY OVERVIEW Think of it as a car dealer in that there are multiple options available according to their premiums Insurance company sole purpose is to make a profit for their shareholders and not as some patients believe to pay out benefits

Commercial Carriers Virtually all medical insurance has both a deductible and coinsurance on covered services No insurance covers “everything” despite what pts think

Commercial and Medicare’s Local Medical Review Policy Written medical policies that each Medicare carrier has established that state what procedures require what diagnoses to justify medical necessity in order to get reimbursed

Medicare Secondary Situations Motor vehicle accidents Liability situations Renal disability Employed Medicare pt with company insurance

Medicare Secondary Situations Spouse family plan has coverage on Medicare pts Workers’ Compensation Program Veteran’s Administration Employed disable individual under 65 yo

Anesthesia Billing Has 19.8% of it’s claims denied which is the highest rate of any of the 51 specialties paid by Medicare Normal rate for physicians' is 6.3%

Monitored Anesthesia Care This is the number one reason why there is such a high denial rate for anesthesia Medicare no longer wants to pay anesthesia providers to be the highest paid baby sitters if they are not clinically needed

NATIONAL INSURANCE REIMBURSEMENT Same payment regardless if the anesthesia technique is MAC, regional or general as long as there are no restrictions on medical necessarily

DEMOGRAPHICS This is one step in the billing process that technology can be of great benefit by having the computer in admitting electronically transmit the information to the billing computer Number one reason for insurance payment denial is typographical errors of patient’s information

DEDUCTIBLE The most difficult part of the bill to collect The insurance company applies the first bill to the deductible The patient remembers the healthcare provider who they had to write the largest check for their services

MEDICAL NECESSITY Each insurance company has there own policy which are usually written by the medical director or medical review board Publishes their policies in newsletter sent to providers

USUAL AND CUSTOMARY CHARGES This charge is whatever the insurance company has decided they want to pay for a procedure There do not have to state how they determine this figure This phase is used to put “political pressure” on the provider to join their network

INCORRECT PAYMENTS Industry estimates are that 8-12% of insurance payments are wrong and there are usually in the favor of the insurance company Large write-offs allow the insurance companies to issue “mispayments”

*INSURANCE COMPANIES* The longer they delay payment to the provider then the higher their profit from having the interest off your money in their bank The longer they delay the more grateful the provider is for just getting at least some payment, even if it is not the usual amount or the fact they had to wait an extra 3 months for the payment

*INSURANCE COMPANIES* If the insurance company does not pay after receiving the first claim 25% of medical practices will write off the charge If the insurance company does not pay after receiving the second claim 33% of medical practices will write off the charge

EXCUSES ON WHY THEY DON’T PAY Never received it Need additional information either demographic, diagnosis or on the procedure Diagnoses doesn’t support the procedure

EXCUSES ON WHY THEY DON’T PAY Policy has expired Policy doesn’t provide coverage for the procedure Patient has another policy which is the primary insurer

EXCUSES ON WHY THEY DON’T PAY The other parent’s (ex-spouse) insurance is responsible This should have been a work comp case This claim is a result of a MVA meaning that someone’s automobile liability insurance is responsible

INSURANCE FOLLOW-UP Some computers automatically refile at a predetermined time factor Success with refiling depends on the reason for their not paying Computers can generate a large number of refunds from receiving 2 payments for the same procedure

INSURANCE FOLLOW-UP One of the most important jobs in the billing office Call the insurance company and find out why they haven’t paid Needs to have the personality and desire to be a problem solver

*INSURANCE FOLLOW-UP* Once you know why they haven’t paid, you must solve the immediate problem with the particular claim but also fix the process so it doesn’t reoccur

“SKIMMING” A term used to describe when a billing department or billing service to collect the “easy” 80% insurance payment and then make a weak attempt at collect the other 20% because of their increase cost

BILLING THE PATIENT After receiving payment from insurance company or notification on why the insurance company will not pay then the patient is sent a bill

*PAYMENTS FROM PATIENT* Can make the difference between a great and good month or good and bad month The 20% not paid by the insurance that is the patient’s responsibility is difficult and time consuming to collect Labor intense because there is no way to automate with use of technology

PRE-COLLECTION PROCESS If patient doesn’t pay send a pre-collection letter not another statement before turning over to collection If your department offers the patient a payment plan then make the amount of minimal payment the same as the hospitals

COLLECTON AGENCY Collection agency usually charges 33-50% of the amount collect Before turn over to collection review patient's name, surgery, surgeon and total amount

National Average Reimbursement Medicare pays $21.43 Medicaid pays $9.99 for MDA and $6.94 for CRNA BCBS pays $50.66

National Anesthesia Numbers National average case is 10 units however hospitals that do not perform more complex cases have an average of 8 units

Bundle Payment A single check pays the hospital and all providers associated with treating the patient for their disease or surgery

Bundled payments Healthcare Billing and Management Association (HBMA) reports 8-12% of claims are underpaid normally and if bundled it could be as high as 20%

Bundled payments A disaster for the hospitals billing department along with billing service Hospital get EOB of 50 pages and they are suppose to find the anesthesia payment?

BILLING AND COLLECTING This is a profession and not a job for the minimum or near minimum wage employee The majority of patients are not high wage earners therefore it is difficult for them to pay even the 20% co-pay not to mention the deductible

BILLING AND COLLECTIONS