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Get Paid Now!

Maximizing Practice Revenues in the Face of Reform &Transition

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Agenda• Healthcare Trends & Impacts– ICD-10 & ACA– Tech Tools

• Collect from Insurer’s– Denial Management – Effective Appeals

• Collect from Patients– Easy Pay Policy– Scripting

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Major Changes

• The healthcare industry is undergoing extraordinary transformation in the face of the Affordable Care Act and the transition to ICD-10.

• Healthcare providers, practice managers and billing-collections staff should expect to see, and prepare for, dramatic impacts to revenue and collection.

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ICD-10

• Do an assessment of your current clinical documentation

• Identify and assess ICD-10 transition impacts on other areas of the practice

• Make a list of your vendors• Post implementation

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Narrow Networks

• The insurance companies created "narrow networks" within their full network of providers; only a subset of physicians within any given insurance company's network "qualify" for participation in the exchange plans.

• A physician could be participating with an HMO and a PPO-type product, but be excluded from the exchange product.

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Narrow Networks

• Know whether you are participating with an exchange plan.

• Determine your fee schedule. • Communicate clearly with patients that are

not in the exchange plans• Don’t put all your eggs in one basket!

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The ‘90 Day Grace Period’

• Patients with exchange plans can actually use the plan for 90 days without paying any premium – this is the grace period.

• Practices are at risk financially for the cost of any services provided to patients with exchange plans during the first 90 days of the plan. Convert to an electronic Credit Card on File (CCOF) program, in order to have the ability to control the timing of the payment of patient-responsible balances, and can protect themselves financially.

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Preventative vs. Diagnostic

• Under the Affordable Care Act, insurance plans now cover preventative care without patient cost sharing, i.e., without co-pays, co-insurance, or deductibles.

• Services that are not classified as preventative care are still subject to cost sharing. It is important for physicians and their staff to be able to differentiate between the two in order to avoid blindsiding patients and avoid experiencing a revenue loss.

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Preventative vs. Diagnostic

Preventative services:• If an abnormal finding on a preventative mammography

screening is later found to be normal, then the future mammography screening is considered preventative.

Diagnostic services:• If an abnormal finding on a preventative mammography

screening is later confirmed to be abnormal, then the future mammography screening is considered diagnostic, and any deductible, co-pay, or co-insurance is applied.

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Preventative vs. Diagnostic Services

• If coders know the difference between the two, and can code correctly with supporting documents as a backup, they can effectively maximize physician reimbursement. • Provide a disclaimer to your patients making

them aware of the different types of care and what their potential out of pocket costs might be:

“I do (or do not) want to receive diagnostic services not covered under my preventative

benefits.”

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Technology Tools

• EZ PayDR. patients pay their bills online • OAISYS. Provides secure, reliable and affordable call

recording and quality monitoring solutions• Wellero. allows your patients to connect with your

practice, make payments and verify insurance coverage using their smart phone

• Kiosks. Let your patients check-in and make their copayment at a kiosk in your reception area.

• CareCredit. Doctors offer CareCredit payment options as an alternative to consumer credit cards, cash or checks

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Collect from Insurance Companies

• Insurance companies are trying to spread risk and keep as much money in their organization for as long as possible as they “adjudicate a claim.”

• They use auditing software, often called “claim review programs” (Denial Engines) to sift through millions of submitted claims.

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Claim Denial Rate

• According to the American Medical Association claims denied by insurers on the first submission ranges between 1.38 percent and 5.07 percent.

• The Medical Group Management Association reports

(2012 Performance and Practices of Successful Medical Groups) that the best-performing medical practices experience a denial rate of 5%. In worst cases, practices are seeing claims being denied at a rate of 10% to 30%!

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Claim Denial RatePayer Total Value of

ClaimsValue of Denied

ClaimsDenial Rate

Aetna $379,000 $36,000 9.5%

United $256,000 $17,000 6.6%

Total $635,000 $53,000 *8.0 %

The Average Claim Denial Rate for this practice is 8%.Remember, your goal should be 5% or less!

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Appeals Solutions“THE SQUEAKY WHEEL GETS THE GREASE!”

United Healthcare Ordered to Pay Civil Fines Insurance Director, Christina Urias, orders United HealthCare of Arizona to pay

a civil penalty of $243,250 and United HealthCare Insurance Company to pay a civil penalty of $121,250, for violations of Arizona’s insurance laws.

The combined fine of $364,750 is the largest the Insurance Department has

ever assessed for such unlawful practices and both companies have agreed to take corrective action to prevent future violations.

In particular, the Department found that both companies had violated state

laws governing: (a) member appeals of denied services and claims; (b) timely payments to providers; (c) provider grievances; and, (d) record keeping and documentation requirements.

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State & Federal Law

• Each state has very specific rules regarding timely payment of claims (30-90 days). Claims must be paid or denied within a reasonable amount of time and comply with the states unfair claims settlement practices.

• ERISA/Self Insured’s & Union Plans: Title 29 of the United States Code of Federal Regulations.(B) Post-service claims.

• Medicare: Current law also mandates a minimum of 14 days to pay claims that have been submitted electronically

• Medicaid (pray)

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Claims Department

Adjuster Adjuster Adjuster Adjuster

Supervisor Lead

Claims Manage CS Manager

Unit ManagerAdjuster Adjuster Adjuster Adjuster

Adjuster Adjuster Adjuster Adjuster

Claims with written formal complaints get routed to the claims manager, the lead or customer service supervisor.

These claims are typically sorted for priority adjudication!

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Actions Steps Get the Patient Involved!

To: The Insurance Commissioner or Regulatory Board From: The patient Dear Insurance Commissioner, On (date) a claim was submitted on my behalf by (name of provider) to (name of insurer). As of (date), my claim

has not been responded to. According to (statutory code) this claim must either be paid or denied in (number of) days.

My provider has informed me, that all necessary claim information was filed in an appropriate and timely

manner. In addition, my provider has supplied me with all other documentation I might need to pursue a formal complaint against (name of insurer).

My doctor and I have operated in good faith with (name of insurer). This letter shall serve as a written formal

complaint with your office.Thank you for your time and attention. Sincerely,(Name of patient) CC. Claims Manager

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Action StepsEffective Scripting

• ‘Attention! Unless this claim is paid or denied in ____days, I will file a written formal complaint to the insurance commissioner.’

• Attention, this claim is being audited for legal action!”

• “Attention this claim is in violation of State Law”

• “Attention, we know where you live, so don’t mess with us!”

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Actions StepsMonitor Payers- Record Calls!

• Verification and Preauthorization of Benefits‘For your protection and ours we record all calls

for prompt payment’ • Archive your calls for easy retrieval. You can

use the same process for managing patient conversations.

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Action StepsAging Reports

Payer 30 60 90 120

Aetna

Met. Life

United HC

Cigna

Blue Cross

•Check aging reports and trial balances. Make a plan to audit, follow up and file written formal complaints with your worst payers.

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Appeal Actions

• Depending on the number of bills you submit each week you should expect to spend time filing appeals letters on a regular basis.

• Address your letters to the Claims Manager or Claims Supervisor.• Make sure you send a copy to the regulatory agency, i.e., the

insurance commissioner, department of labor, or Attorney General in your state.

• Maintain and be ready to send a second appeals letter restating your position with factual information and documentation.

• Maintain fax numbers and collect e-mail address for the payers’ that you routinely bill.

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File Your Appeals

• Letter for Stalls• Medical Necessity• Benefit Reductions• Timely Filing• Refund Request• Verification of Benefits• Workers Compensation• ERISA

“I use your appeal letter templates on a regular basis. I have a new practice that I just started managing and used three of the appeal letters and was able to recover $7,000 in less than one month!”Sami Spencer, Past President, Akron Chapter

“I use your appeal letter templates on a regular basis. I have a new practice that I just started managing and used three of the appeal letters and was able to recover $7,000 in less than one month!”Sami Spencer, Past President, Akron Chapter “I use your appeal letter templates on a regular basis. I have a new practice that I just started managing and used three of the appeal letters and was able to recover $7,000 in less than one month!”Sami Spencer, Past President, Akron Chapter “I use your appeal letter templates on a regular basis. I have a new practice that I just started managing and used three of the appeal letters and was able to recover $7,000 in less than one month!”Sami Spencer, Past President, Akron Chapter

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Oregon Timely Payment

Please be advised ORS 743.866, "Payment or denial of health benefit plan claims; rules," requires insurers to pay or deny benefits on properly filed claims as follows:

• Except as provided in this subsection, when a claim

under a health benefit plan is submitted to an insurer by a provider on behalf of an enrollee, the insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the claim

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Timely Filing

• Refusing to process a claim due solely to lack of timely filing may be a violation of many states court’s rulings on the matter.

“Most recently, I got a very large claim paid that was denied for timely filing by Railroad Medicare. This claim that was already two years aged when I resubmitted the claim with the timely filing letter the

day we got back from the seminar and received payment one week later!”

Michelle Gipson, Insurance Department, Purchase Orthopedics, Paducah KY

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Verification of Benefits

Liability for false representations made during verification of benefits may be the responsibility of the insurer according to many state courts.

We believe that your obligation is to provide accurate information throughout the benefit verification process. Knowingly misstating facts and policy benefits may be a violation of state courts rulings as well as a breach of the Unfair Claims Settlement Practices Acts.

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Scripting“We Never Received Your Claim”

We know for a fact that you did receive this claim because I’m holding a receipt from the United States Postal Service (I can document an electronic transmission or a faxed copy)…” “It’s nothing personal, but my boss tells me that my job is to audit, track, and trace each and every claim form that leaves our office…”

By the way, I’m the chief executive responsible for all insurance reimbursements in the northwestern region (that’s your office!)

Shall I hold the phone while you research and process this claim, or shall I have to name you and your supervisor personally, in my written, formal complaint, signed by your premium paying subscriber, to the insurance commissioner and the attorney general in this state? What would like me to do?

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Collect from Patients

• It is predicted that providers will face up to a 25 percent decline in revenue over the next five to ten years due to reductions in reimbursement in an ever changing healthcare marketplace.

• Taking a proactive approach to collecting payments ‘up front’ will be necessary in order mitigate both bad debt and the decreases in cash flow that will invariably occur in the transition to ICD-10.

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Financial Policy

The medical practice financial policy is the most critical component for managing revenue, cash flow and collections. Your policy sets the table for how your staff will interact with patients about insurance, past due balances, and co-payments.

• Is your financial policy in writing? A financial policy that is not written down doesn’t exist!

• Is your policy up to date? Do you offer several payment options or on-line payment portals?

• Does your staff understand how to communicate with patients and what the protocols are for implementing policy; when to make exceptions or ‘hold the line’?

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Financial Policy

• Introducing to new patients• Convert Existing Patients– Review all existing patient files for missing or outdated

information.– Enclose updated forms to be completed and returned (see

sample cover letter below)– Forms that should be reviewed prior to mailing the new

financial policies to patients include; The Patient Information Form, The Insurance Benefits Verification Form, The Easy-Pay Form with Credit, Debit or Check information. Optional: Care Credit, Wellero, on-line payment authorization options.

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Financial Policy

Regarding Your Insurance, Balances & PaymentsWe accept all major credit cards, checks and cash. We are also pleased

to offer several on line, secure, easy pay options to help manage copayments, deductibles, or balances that may not covered by your insurance.

Our Patient Finance Counselors are dedicated to making sure your

insurance paperwork is filed accurately and promptly. Your partnership in this process is certainly appreciated. If you will please initial beside your type of insurance coverage listed below, this will help us to expedite your claim payment and minimize your out of pocket expenses. Thank you.

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Financial PolicyIndemnity (non-contracted) Insurance Plan:

We may bill your insurance as a courtesy. Our office, as a convenience and a service to you, will absorb all costs incurred for billing. In the event that your insurance does not reimburse us within 45 days, we will simply transfer the balance of your account to your credit, debit, or check card. Please indicate your preference.

Plans in which are a participating providers:

HMO Plans; all co-pays must be satisfied each and every visit. There can be no exceptions due to contracting and uniform compliance rules. You are responsible for getting proper referral information in advance of your appointment.

PPO Plans; we have agreed to accept the discounted rate from your plan, however all co-insurance is your responsibility. We will estimate balances to the best of our ability. Since the balances are estimates only, we may require one of our ‘easy pay’ options to guarantee any balance due after service. Once your insurance has cleared, you may leave the balance on your card, or you can send a check.

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Easy Pay I authorize [~Name of Doctor~] to maintain my credit account on file and I assign my insurance benefits to the [~Name of practice~]. Account Information: Credit Card: ______________________________________________ Care Credit: ______________________________________________ Check Acct: ______________________________________________ Other: ______________________________________________ ___ Transfer my balance to my preauthorized account on file ___ Please contact me before processing my card on file; I may want to use another option. I have read the Financial Policy. I understand and agree with this Financial Policy. Signature of responsible party X _________________________________________ Signature of co-responsible party X _______________________________________ Date _____/_______/_______• • •

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Collecting Co-Payments

AMA Opinion 6.12 - Forgiveness or Waiver of Copayments

It is vitally important for healthcare providers to collect or make an attempt to collect copayments, deductibles, and coinsurance.

Physicians should be aware that forgiveness or waiver of copayments may violate the policies of some insurers, both public and private; other insurers may permit forgiveness or waiver if they are aware of the reasons for the forgiveness or waiver. Routine forgiveness or waiver of copayments may constitute fraud under state and federal law. Physicians should ensure that their policies on copayments are consistent with applicable law and with the requirements of their agreements with insurers

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Co Pay LetterDear Patient: We are required to collect co-payments each and every visit. It may be considered fraud for us to collect from

some patients and not from others. Please be advised that should you choose not to pay your co-payments for any reason we may notify your insurance insurer, and in turn, they may drop you as a subscriber.

We refer to AMA Opinion 6.12 - Forgiveness or Waiver of Insurance Copayments which states; “Routine

forgiveness or waiver of copayments may constitute fraud under state and federal law.” Our intention is to support you by providing the highest quality of care and assist you you’re your insurance plan.

We would never want to jeopardize your insurance by not collecting your co- payment. As a convenience to all of our patients, we offer many easy payment options. Please ask [~Financial Counselor

Name~] our Patient Finance Counselor about those options. Of course, you may prefer to use check or cash. Please understand that if you come unprepared to make your co-payment, we must reschedule your

appointment. Thank you for cooperation,

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Easy Pay Scripting• “We offer easy-pay. It’s a program by which we simply maintain your credit or debit

card on file to capture any co-pays, deductibles or balances not covered by insurance. We offer this as a convenience to all our patients. Which card works best for you?”

• “Our Easy Pay payment options are very similar to many of the other on-line services you are probably already using. They are secure and simple, saving you time and the hassle of receiving paper bills in the mail and writing checks!”

• “As of [date] we will no longer be able to bill for co-pays, deductibles, and out pocket expenses. We have done that in the past but times have really changed, haven’t they! What I can do is set up one of our easy options for you.”

• “As of [date] we will no longer be mailing paper bills. Our practice is upgrading to a

secure, on line payment portal. We are doing this to improve efficiencies in billing, reduce administrative costs and increase focus on your healthcare!”

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Telephone Scripting“The minimum you can expect to pay on the first visit is $____. How will you take

care of that?” New or established patients with minimum payments due at time of service;“Can you please confirm your co-payment? How do you think you will take care of

that when you come in, cash, check or charge?”

Patient asks “why do you need this information now?”“For legal reasons, we are required to collect co-payments each and every visit.

We want to make sure you are prepared. This will avoid rescheduling if you forget!”

-or-“Our system doesn’t even allow me to block time into the schedule until I enter

how much and by what method you will be paying…it’s this dumb computer…”

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Office ScriptingAsk for the co-payment prior to service!

“The co-payment today is $____. Are you still planning to (use a credit card

or write a check) as you indicated when you called in?”

If yes, say; “Just go ahead and make that check out now paid to _____and we can get

you going as quickly as possible.” “As you can see we are very busy today. By getting your payment

information now I can process your paperwork faster…I’d hate to keep you waiting. If you’re like me when you’re ready to go- you’re ready to go!”

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Office Scripting If the patient says “no”, or says something like, “no one told me” or “can you just bill me?”

“I see that when you called to make your appointment you told Sally that you would be paying by

check. We could not have put you into the schedule unless you told us how you would be paying. You may have forgotten. Did you forget?”

If yes, then say;

“That’s not a problem; you can pay check or if you like with credit or debit card…which one works

best for you today?”

If you’ve now determined the patient has come unprepared to pay, you say; “I really wish we could do it that way, but as we told you over the phone, we are legally required to

collect your portion. We can’t collect from some customers and not others. Not only could we get in serious trouble, but also you could lose your insurance! If you don’t make your co- payment, we may be obligated to notify your insurer and they could drop you as a subscriber. We certainly don't want that, do we?"

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Collections Calls

• When working with patients on financial matters it’s best to think of your role as a ‘patient finance counselor’. Most patients do want to pay what they owe, they may have questions or they may not know how to take care of the bill. Your job is to help them.

Category 1 The good pay Existing patient with a good pay history and generally co-operative. Not much to do to get them to pay. Keep them happy!

Category 2 The slow pay Slow paying patient who are willing to work with you. They probably need more time to pay.

Category 3 The no pay Uncooperative, unwilling to work with you no matter what you do.

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Call MatrixBills Calls Payment History Dialogues Outcomes

30 days 40 Cat. 1 (good pay ) “We can take care of

the whole bill right now. I’ll ‘hold’ while you get your card or

checkbook.

Credit, debit, check card, check by phone

60 70 Cat. 2 (slow pay ) “How much more

time will you need to take of your balance?”

Payment Plan- Patient needs more time.

90 100 Cat. 3 ( no pay)

“Then you will not be paying your bill?

Not paying; Verify personal information. SS#, Bank Info.

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Collection LettersPatient to Provide Information

Dear Patient, We have received correspondence from [name of carrier] stating that they have

requested additional information from you on the matter of your insurance. As of this notice they have not received that important documentation necessary to process your claim.

Until they receive it, they will not remit payment for services rendered to you by [name of

provider or facility] on [date]. Therefore, the responsibilities of the charges incurred are due by you.

Thank you for your prompt attention to this matter. Our Patient finance counselor(s) will

be more than happy to assist you in taking care of your balance. Sincerely,Practice Manager for Dr. Jones

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Collection LettersPatient Receives Insurance Check

Dear Patient, We have received notification from your insurer that you are in possession of a check in the

amount of [ ]. In light of the fact that you have authorized this office to receive assignment from your insurer, we ask that you forward that payment to us immediately.

If we do not receive a response within 7 days, we will be forced to report that amount to the

Internal Revenue Service. IRS code states that such payments are considered income and must be reported on federal returns.

We provided service in good faith and ask that you respond in kind. [~Closing Text~] Sincerely, Dr Jones Enclose verification of social security number and IRS form 1099

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Questions?

• Need More information?Jerry Bridge

Office 760.918.6701Jerry@LifeWorksEducation.com

• Love the Appeal Letters? Want More?www.HealthcareCollections.net