MEDICAL BILLING BLOG

Practices and physician's constantly struggle with understanding how well their billing is working. This can be difficult to do because reliable medical billing benchmarks that can be easily applied are difficult to find. A great solution to this is the use of a Theoretical Yield (i.e., the amount you should collect for every dollar billed if your billing is working perfectly).

Understanding the concept of yield is the key behind assessing the billing performance using medical billing benchmarks.  From a medical billing standpoint, yield is the amount of a claim that should actually result in a payment versus a contractual adjustment. In other words, if your yield is 50%, then on a $100 claim you should received $50 in payments and will write-off the rest to contractual adjustments. In the first article in the series on allowables I discussed why you should set your fee schedule higher than your contractual allowables. Having fees higher than allowables is what results in yields that are less than 100%.

Calculating your practice's yield is straightforward. At its simplest level you take the allowable for a CPT and divide by the fee you charge for that CPT. Using the example above, if your fee for a given CPT is $100 and your allowable for that fee is $50, then your yield is $50 (what you should collect)/$100 (what you charge) = 50%.

This is a straightforward calculation. The complication arises because of the various payer contracts for a practice and the fact that the yield for a specific payer often varies by CPT (i.e., with BCBS you may have a yield of 50% for one CPT and 60% for another CPT).

This means that calculating your yield requires you to understand your procedure mix. To get a close estimate of your yield for a specific payer you can:

1. Take your top 20 CPT codes and calculate the yield for each of these codes; and then
2. Calculate a weighted average for the overall yield based upon the frequency of each of your CPTs;

To move from a close estimate to a more precise estimate your repeat the above procedure but instead of only using your top 20 CPT codes, you use as many as is required to cover at least 90% of your charge volume with each payer. Typically, however, the top 20 CPTs provide an accurate answer.

Once you have completed the above exercise for one payer, you need to repeat this for each of your top payers (you should do this for the payers that represent at least 80% of your payment volume). Once you have done this you can then get an overall yield for your practice by creating a weighted average yield for the practice based upon your charge volume (not payment volume) for the practice. The idea of a weighted average yield of the practice works well as long as your procedure mix and payer mix are stable.  If either changes significantly, then you need to recalculate your yields.

With a weighted average practice yield (or Theoretical Yield) in hand you can easily get an initial understanding of how well you medical billing is performing. This medical billing benchmark will provide significant insight into your true performance. If your practice theoretical yield is 50% and your actual performance is 42% - then you are leaving a lot of money uncollected (up to 8% of every dollar billed). There are a number of items that will keep you from achieving your full Theoretical Yield, but you certainly would expect to be within a few percentage points.

Although developing yields can be tedious work, it is critical to know your practice's yield and use this medical billing benchmark to understand if your medical billing is working well.

About ClaimCare, Inc.

ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

Copyright 2009, Carl Mays II and the ClaimCare Medical Billing Company

Guess what day it is? No, it’s not hump day….it is HIPAA Day! Some providers are taken by surprise! Some practices are under the false impression that they are HIPAA Compliant.  Sadly, we are finding more and more that this is not the case.

September 23^rd is the deadline to ensure that your practice is prepared for the finalized MEGA RULE and HI-TECH Regulations. Numerous updates and changes are required of covered entities. Have you updated your manuals,
the NPP (Notice of Privacy Practices), and all BAA’s (Business Associate Agreements)? Are you aware that the rules governing notifications for marketing and fundraising requirements have changed?  Are you ready? Did you know that if you are found to be NON-compliant, there are strict fines and penalties? 

Are you ready to start the requirement for reporting disclosures to HHS? Do you know what limitations have been applied to that ruling? The HIPAA HITECH, Mega Rule comes with more audits, hefty fines and penalties and not only will it impact YOUR practice, but the impact reaches to all of your business associates. Do your providers use mobile devices such as laptops, I-phones, tablets, or other access that is considered remote access? Think about it!  September 23^rd is just around the
corner. So many questions!  Do you have the answers? If you do not feel prepared for the September 23^rd deadline or the new, stricter HIPAA rules, there are many resources available to help you get where you need to be. If you have questions or need assistance, let us know. We have a team that can help get you HIPAA compliant quickly.

About ClaimCare, Inc.

 ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

 

Many significant coding and billing changes have been introduced in 2012 for cardiologists, particularly electrophysiologists (EPs). The ClaimCare Medical Billing Company has created a 30 minute training video to bring cardiologists and cardiology practice staff members up to speed on the key 2012 Cardiology Coding and Billing Changes they need to understand to insure they have no compliance, billing or collection issues as a result of these new rules.

2012 Cardiology Coding and Billing Changes - Part 1 (13 minutes)

2012 Cardiology Coding and Billing Changes - Part 2 (15 minutes)

 

For more insights concerning cardiology billing, please check out the following collection of articles: Cardiology Billing Articles

About ClaimCare, Inc.

ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work its clients' medical billing systems.  For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.

ClaimCare, Inc - June 15, 2010 - According to various media reports from Washington, action will come too late regarding the June 6 Senate announcement that it is ready to initiate a 19-month Medicare "doc fix." This means cash-flow problems will affect doctors across the country. Senator Charles Schumer (D-N.Y.) said at a press conference that the Senate is expected to have 60 votes to pass the bill "early next week (week of June 14)." But even if the votes come then, more than likely it will take several days for the bill to be passed by the House and signed into law by the President.

On Monday, June 14^th Medicare responded to this continued delay by Congress by deciding that it will extend its freeze on processing claims with June dates of service until Friday, June 18^th. It is possible that Congress will reverse the massive Medicare fee reduction by that date. Given, however, the time line outlined by Senator Schumer, it is unlikely the fix will be completed by that time.

So, on Monday, June 21^st, Medicare may well begin processing June 2010 claims using the 21.3% fee reduction that went into effect on June 1. However, it appears highly likely that within two weeks Congress will retroactively reverse the fee cut. This will result in Medicare claims being reprocessed, causing new "make-up payment" problems for providers. It is a situation that leaves providers to ask some important questions - and to make some important medical billing decisions.  

Question/Decision #1:  Should your medical billing department continue submitting your Medicare claims as usual - or should you hold them until Congress eliminates the 21.3% fee reduction?

If you submit your claims as usual, then you will receive payments as usual - but at the reduced fee rate. When Congress does eliminate the fee reduction, you will have a lot of work to do when Medicare reprocesses your claims. This work includes auditing to ensure Medicare has indeed made all of the make-up payments they should. It also includes responding to patients' questions and concerns about receiving two Explanation of Benefits (EOBs) from Medicare regarding their charges. The situation will be exacerbated when Medicare automatically crosses these lower-paid claims to secondary insurance payers. EOBs and payments involving secondary (and possibly tertiary) insurance payers will cause further confusion and complications for your office - and  for your patients.

If you hold your Medicare patient claims and then submit them after Congress passes the "doc fix" bill, you will not get hit with the 21.3% cut - but you will get paid later than usual. You also will have a much simpler time in terms of ensuring all payments are correct from both Medicare and secondary payers. Also, patients will receive only a single EOB for the dates of service during this "waiting" time period.

Question/Decision #2:  Should you collect co-insurance from Medicare patients under the fee schedule that was in place prior to June 1, 2010 - or under the significantly reduced fee schedule?

If you collect patients' 20% Medicare co-insurance under the reduced fee schedule and the reduction is reversed by Congress, then under Medicare rules you will need to bill patients for any extra amount they owe over $5.00. (You are not forced to try and collect balances that will cost more to pursue than will be yielded in revenue). This will lead to additional expense and patient confusion.

On the other hand, if you collect co-insurance amounts in accordance with the pre-June 1 fee schedule and Congress does not reverse the fee reduction, then you will need to reimburse patients any overpayments greater than $5.00. (The same financially reasonable principle applies to patient refunds.) Since it is unlikely that the fee reduction will stand, this is an unlikely outcome.

Question/Decision #3:  Most likely, you have already filed some June 2010 Medicare patient claims. These will start being processed on Tuesday and will generate many of the issues mentioned above. (The decisions you make now regard being able to minimize the complications rather than being able to avoid them completely.)  These already-filed claims force you to ask and decide: Should you bill patients and secondary insurance payers for the June 1 to June 14 dates of service you submitted (and for which Medicare will begin receiving payment over the coming days) or should you wait for these claims to be reprocessed and paid correctly after Congress reverses the 21.3% Medicare fee cut?

The pros and cons outlined for the questions/decisions in #1 and #2 also apply to #3. If you proceed with billing patients (and secondary insurances that do not automatically cross over), you will have confused patients who receive an initial statement from you and then receive a second statement from you for additional money after Congress retroactively reverses the fee cut.   

On the other hand, not billing patients and secondary insurances until after Congress acts will delay your collections - but will lead to much less patient and office confusion.

My Recommendation:  Every practice must make its own decision about these issues, but a decision must indeed be made. If you can handle the temporary cash flow reduction, then my recommendation is:

1. Hold your claims until Congress retroactively reverses the Medicare fee cut;
2. Collect patient co-insurance under the pre-June 2010 fee schedule;
3. Do not bill patients or secondary insurance for the June 1, 2010 to June 18, 2010 dates of service for which you will start receiving payments over the coming days. Instead, bill the patients and secondary insurances after these dates of service are reprocessed when Congress reverses the Medicare fee cut.

This approach will minimize confusion in the practice and among your patients. It will also minimize the chance you are underpaid for your claims.

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Copyright 2010 by Carl Mays II. Carl is President and CEO of ClaimCare Medical Billing Service, one of the largest medical billing companies in the United States.

Until recently physicians believed that they had until January 3, 2011 to comply with Medicare's PECOS enrollment requirement. This is no longer the case. In May Medicare announced that a new mandate from the health system reform law forced the deadline to be moved up by 6 months. Starting July 6, 2010 if the physicians that refer to your practice are not properly enrolled in the Provider Enrollment Chain and Ownership System (PECOS) then your cashflow will be interrupted. If a claim is submitted to Medicare after July 6^th with a referring physician that is not enrolled in PECOS, then Medicare can reject the claim. This means that your practice needs to work with your referring provider base and ensure that your referring providers are enrolled in PECOS. This is a much higher burden than the more typical medical billing situation where a provider only needs to ensure the he or she is enrolled with a payer.

In order to mitigate any risk to your practice's cashflow you need to:

• Generate a report of your top referring providers,
• Call and check the PECOS system to confirm that your practice's key referrers are properly enrolled (you will need basic information about the providers such as name, tax ID or provider ID),
• Contact any referring providers that are not properly enrolled with PECOS and make certain they know: 1) they are not enrolled with PECOS, 2) why it is critical that they enroll with PECOS, and 3) how to quickly enroll with PECOS (to eliminate any delays on their part in finalizing their enrollment), and
• Send thank you notes to all of the providers that are enrolled with PECOS (this is a great way of showing them how much you value their referrals).

With all of the healthcare bills and Medicare cuts taking up mind share and discussion time, it would be easy to miss the critical PECOS medical billing deadline and find that the 21% Medicare fee cut is one of two big reimbursement problems. Take action TODAY to ensure your practice's cashflow.

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Copyright 2010 by Carl Mays II. Carl is President and CEO of ClaimCare Medical Billing Service, one of the largest medical billing companies in the United States.

Physicians continue to see their collections, cashflow and emotions whipped around like a rag doll in the mouth of a rottweiler. Congress failed to act before the June 1, 2010 deadline. Once again physicians are "officially" under a new Medicare fee schedule that has an average reduction of over 21%. In reaction, Medicare will once more hold claims for the first 10 business days of the month (for June dates of service).

Physicians are being told that this 10 business day hold will have a minimal impact on their collections. This is not accurate, however, since Medicare is not holding the payments for 10 business days; rather they are holding the processing of the claims for 10 business days. It makes sense to hold the processing since if Congress negates the 21% pay cut then Medicare would need to reprocess the claims. This approach means, however, that at the end of the ten business day hold, Medicare will drop the full amount of held claims into the processing hopper and then the normal time line will begin (in other words, do not expect a big Medicare check on June 15th - which is the 11th business day of June). The bottom line is that unless Congress acts swiftly and thus Medicare begins to swiftly process claims, most physicians will see a big dip in their Medicare collections in June (since the payments typically seen in the last two weeks of a month are from dates of service in the first part of the month).

Here is the full text of the Medicare announcement (from the Trailblazer Website):

"The Continuing Extension Act of 2010, enacted April 15, 2010, extended the zero percent update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010. CMS believes Congress is working to avert the negative update scheduled to take effect June 1, 2010. To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners and other providers of services paid under the MPFS, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of June. This hold will only affect MPFS claims with dates of service on or after June 1, 2010.   This hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.   Be on the alert for more information about the 2010 MPFS update."

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Copyright 2010 by Carl Mays II. Carl is President and CEO of ClaimCare Medical Billing Service, one of the largest medical billing companies in the United States.