Monthly Archives: August 2012

Delay of ICD-10 until October 2014 is good news for Pediatric Practices

August 27, 2012 in Billing and Collections by support Team  |  1 Comments

A few days ago, Health and Human Services secretary Kathleen Sebelius issued a press release related to delaying ICD-10 implementation from October of 2013 to October 2014. There is much controversy related to ICD-10 codes. The proponents state that ICD-10 is a more precise method of coding since there are over 65,000 codes compared to over 14,000 for ICD-9. The protesters state that 14,000 codes are more than enough codes and there will be much confusion and cost to the healthcare system by moving from 14,000 to 65,000 codes. Since the Healthcare system would like to move toward ‘bundled payments’ for services, moving to a more complex coding system does not seem in alignment with the movement to bundled payment. Delaying ICD-10 by at least a year is a good idea for Pediatric Practices as well as other areas of Medicine. I believe the leaders of Policy, like Kathleen Sebelius, see the benefit of delaying this decision as well. With the changes of additional Medicaid lives and Health Exchange lives in the next few years, there is uncertainty as to how this will impact primary care pediatrics.

Adding the burden of Pediatric offices needing to identify how they should be coding with a new ICD-10 system as well as introducing millions more lives into the Health system might have a negative impact such as a major shortage of Pediatricians to patients. How many Pediatricians want to go home after seeing 20-30 patients in a day and read about 50,000 additional codes? Do we want our primary care Pediatricians focused on these details versus how to optimally diagnose and treat patients? The good news is that currently ICD-10 is over 2 years away. Much can happen in two years that should help the decision makers evaluate if we should migrate to ICD-10 at all or decide to delay again. Most Pediatricians are losing thousands of dollars per year due to improper coding, lack of systems that track each claim as well as the wide range in abilities of Pediatric offices to manage the revenue cycle. Pediatricians do not deserve to be under paid due to these controllable issues.

Is there a Potential Impact on Pediatric Practice Revenue due to Aetna Acquisition of Coventry?

August 20, 2012 in Billing and Collections by support Team  |  Comments Off on Is there a Potential Impact on Pediatric Practice Revenue due to Aetna Acquisition of Coventry?

The Healthcare environment in the United States is evolving rapidly due to the pressures to reduce costs. The Affordable Card Act (ACA) has provisions that expand coverage via Health Exchanges as well as expansions of the Medicaid program. Due to budget pressures, states are migrating from State run Medicaid to Medicaid being managed by Managed Health Care Plans. Coventry has a significant presence in the Managed Medicaid market. Aetna significantly increases their presence in Managed Medicaid and lower priced insurance plan options with the recently announced acquisition of Coventry. Given the migration of new patients to lower priced insurance plans (via the future Health Exchanges) as well as expanded Medicaid coverage, this is a potential growth opportunity for Aetna. Appears that Aetna believes in this potential opportunity due to the premium they paid for Coventry (over $5.0B).
For your Pediatric practice, it is critical to monitor the reimbursement trends by plan as these changes in the Healthcare system continue to occur. Pediatric offices usually provide one of the lowest costs of Healthcare delivery from the perspective of plans and employers. Leveraging the facilities of a Pediatric Office is in alignment with the interest of the Healthcare system by promoting wellness versus ‘sick care’. Also, services in pediatric offices are more cost effective than in hospital settings. Small Pediatric Practices can effectively manage this complex environment by adding new patients, providing quality care, and by implementing strong management of the practice revenue cycle. If a practice is unable to grow patients as well as manage their Pediatric Practice Revenue cycle effectively, they will eventually dissolve or merge with a Hospital System or large Medical Group.
Health insurers identify how to save money by lowering reimbursements – unfortunately, many use the ‘squeaky wheel’ type of rewards/evaluation. For example, a Health Insurer will not increase rates on all providers on their ‘independent products’ while negotiating high single digit rates with the Hospital System that uses their size as leverage. If the small Pediatric office does not have solid IT systems that allows them to evaluate their reimbursements, they might be underpaid compared to the Hospital System located in the same area. If your Pediatric practice provides high-quality and consistent medical care, the practice show be rewarded on the care provided. The Health Insurance companies prefer that practices are managed like the average Pediatric practice country versus Pediatric practices that consistently achieve collection rates above 99% of the contract amount. This is a good time to benchmark the collection rate and check the controls and systems in place that optimize not only the collection rate but also the Accounts Receivable (AR) days. Through good benchmarking and management of the revenue cycle, your practice can be confident on how to manage the changes in the Healthcare market like the Aetna acquisition of Coventry.

Proper Management of the Front Desk Team & the link to High Collection Rates for Pediatric Practices

August 3, 2012 in Billing and Collections by support Team  |  Comments Off on Proper Management of the Front Desk Team & the link to High Collection Rates for Pediatric Practices

The Revenue cycle is comprised of a front, middle and back end. Practice Managers need to optimize all three components for a practice to achieve an optimal collection rate. The front end of the revenue cycle is the front desk team in the practice. The front desk team members of a practice need to verify insurance eligibility as well as collect co-pays and any outstanding balances. Insurance eligibility can be verified via an automated link from the practice management system/clearing house to the insurance companies, Navinet or by calling the insurance companies. The owner as well as the practice manager of a practice need to insure that this activity is occurring accurately and consistently by the front desk team. The practice should check that the co-pay report for the day matches the co-pays collected. Also, the practice owner/manager should check-in with the back end billing team (billing company) to obtain feedback on the rate of accuracy of entering insurance and demographics by the front desk team. “Sloppy” work and/or lack of attention to detail by the front desk team can cause loss of revenue and/or delays in revenue.

The middle of the revenue cycle is comprised of the providers and clinical team properly documenting the charts as well as recording the diagnosis and CPT codes. This should be completed during the day of service and accurately. The back end of the revenue cycle is the billing team ‘scrubbing’ and verifying complete claims prior to sending to the insurance company. Additionally, the back end team will re-submit claims (make appropriate corrections) as well as send out patient statements and communicate to the front desk team for patients that have balances. The front desk team needs to effectively work with the back-end billing team to close the communication gap. When the front, middle and back-end of the revenue cycle is optimized due to good practice management, practices achieve better collection rates and faster payments than the average. For instance, we have practices that are 50% paid by the insurance company five days after the month closes (e.g. July is 50% paid for all insurance charges by August 5th).

Each member of the team needs to understand their role in the revenue cycle. Practice Managers as well as physician partners should be monitoring performance of the front desk team, the providers as well as the work of the back end billing team. Collaboration and cooperation as well as a skilled and dedicated team are critical to achieving the best success.