Chapter 7 Visit Charges & Compliant Billing lecture 2 OT 232 OT 232 Ch 7 lecture 2 1 Strategies for Compliance (cont’d.) • Use modifiers appropriately – (CPT • Current Procedural Terminology) – -25 • Yes, same day. Yes, same physician. YES, clearly separate event did occur! • E/M • Ex, pg 215 – -59 • Not E/M • Ex, pg 215 OT 232 Ch 7 lecture 2 2 Strategies for Compliance (cont’d.) • Use modifiers appropriately (cont’d.) – -91 • Repeat test or procedure really was performed on the same day for patient management purposes • Should not be used due to lab errors, quality control, or confirmation of results • Ex, pg 215 OT 232 Ch 7 lecture 2 3 Strategies for Compliance (cont’d.) • Professional Courtesy – All or none billing • Discounts – Have to be clear & equally distributed – Not on a case-by-case basis – If any money collected, payer (if there’s insurance) gets percentage • Maintain Compliant Job Reference Aids & Documentation Templates – Cheats sheets – Commonly used codes in office – CAC – Computer Assisted Coding OT 232 Ch 7 lecture 2 4 Audits (dum Dum DUM!!!!) • Formal examination of a representative sample to reveal whether erroneous or fraudulent behavior exists. • External – By private payers or gov’t investigators • Prepayment – CCI edits • Post payment – IRS OT 232 Ch 7 lecture 2 5 Audits (cont’d.) • Internal – Part of compliance plan – By practice staff or hired consultant – Done to reduce the chance of an external auditor finding problems • Prospective (concurrent) – Done before claims are sent » Can reduce number of rejected claims • Retrospective – Done after remittance advice (RA) is received » Can see which codes (or people) are problems OT 232 Ch 7 lecture 2 6 Comparing Physician Fees & Payer Fees • Sources for Physician Fee Schedules – Physicians should establish ‘Usual fees’ • Charges to most patients most of the time under typical conditions • Always exceptions – Workers’ comp • Nationwide databases are published that show what percentile your fees fall under – Figure 7-6, Page 224 OT 232 Ch 7 lecture 3 7 How Physician Fees Are Set & Managed • • • • Geographic Competitive Payers – Billing Tip, page 224 PMP – Practice Management Program – Adjusted accordingly based on report that can tell what percentage of claims are paid in full or reduced • Paid in full? – Fee is lower than the max in insurance company will pay, so too low • Reduced? – Fee may be set too high OT 232 Ch 7 lecture 3 8 Payer Fee Schedules • Charge-based fee structure – Based on fees for similar services charged by providers of similar training & experience in geographic area – Create a schedule of UCR fees • Usual, customary & reasonable – What a particular doctor usually charges – 50% range of physicians with similar training & experience in geographic area – Whichever is lower! – The lower fee of what a physician usually charges and what is customary for physicians of similar training/experience in a geographic area is considered reasonable. OT 232 Ch 7 lecture 3 9 Payer Fee Schedules (cont’d.) • Resource-Based Fee Structure – Built by comparing factors • How difficult the procedure is to perform • How much overhead expense the procedure involves • The relative risk the procedure presents to the patient and provider • Very logical – Relative Value Scale (RVS) • Hybrid of the two (resource and charge) • Is some comparison involved for charges • Group of related procedures are assigned a relative ‘value’ in relation to a base unit – the higher the value, the more difficult the procedure – The base unit is assigned a conversion factor (dollar amount). To calculate the price of a service, the RVU is multiplied by the conversion factor. – Example, page 226 OT 232 Ch 7 lecture 3 10 Payer Fee Schedules (cont’d.) • Resource-Based Relative Value Scale (RBRVS) – Used by Medicare – Replaces charges with what each service really costs to provide – Three nationally uniform values are determined for each procedure • Work (difficulty, time) • Overhead • Cost of malpractice insurance (risk) – Each value is adjusted for location • GPCI – Geographic Practice Cost Index – Values are multiplied by a nationally uniform conversion factor that is kept up to date with cost-of-living increases • RBRVS fees are considerably lower than UCR • 15% difference OT 232 Ch 7 lecture 3 11 Payment Methods • To pay providers, payers use – Allowed Charges • An amount set as the most the payer will pay for the procedure – If the physician’s usual fee is lower, will pay that; otherwise will pay the allowed charge • Provider’s status in the plan – PAR vs. nonPAR » PAR providers agree to accept lower allowed charges than their usual fees » What’s in it for the PAR? OT 232 Ch 7 lecture 3 12 Payment Methods (cont’d.) • The payer’s billing rules – NonPAR providers can always ‘balance bill’ » Bill the patient for the difference between their fee and the payer’s allowed charge » The difference between a usual fee and the payer’s allowed charge must be ‘written off’ if the payer does not allow balance billing • That amount is never collected • If coinsurance is involved, it is based on the allowed charge OT 232 Ch 7 lecture 3 13 Payment Methods (cont’d.) • Contracted Fee Schedule – Fixed fee schedules with participating providers • Capitation OT 232 Ch 7 lecture 3 14