Author Archives: brooke

Tricare and Under Payment of Rotateq

August 5, 2011 in Billing and Collections by brooke  |  Comments Off on Tricare and Under Payment of Rotateq

We have found that Customers are another set of ‘ears and eyes’ on the revenue cycle. We are fortunate to have some customers that share information they hear and see. One of our customers received an article/blog listing related to underpayment for Rotateq in patients with Tricare. Due to this information, we were able to go back an analyze all of our customers whom provided Rotateq to a Tricare patient. Although the occurrence described will not occur in all instances (some customers had no occurrences since January 2010 while others had 15 occurrences in the 18 months since the change). Although the Health Plans have many individuals and usually ‘good’ technology team, some decide to make their own rules outside the norm. Since vaccines are usually the #2 cost in Pediatrics (behind HR costs), optimizing the vaccine payment cycle is a must.

Practices that leverage the PhysicianXpress system can closely monitor the details of their vaccines reimbursements via running a report. In the practice admin section of PhysicianXpress there is a place to enter in the cost for vaccines for a date range by CPT code. If this cost information is entered into the system, there is a report that will show the # of claims per cpt code per insurance company that is paid below cost (can actually ‘drill’ down into the system to view the actual date of Service including reimbursement received). A practice admin user can also click on a different button to view the average payment above the actual cost per vaccine CPT code per insurance company.

The Issue related to reimbursement of Rotateq for Tricare Patients:

You need a Tricare patient whom received Rotateq and for which the resubmission was sent as units (we identified through this process that the unique nature of the claim submission for Rotateq at Tricare causes the resubmission – since this is not a top rejection rate across practices, it is difficult for the issue to appear on the radar as a trend). The number of patients varies for Tricare by Practice – if a resubmission was done with Rotateq as “Package” for a Tricare patient, the total amount would be paid, if resubmission for Rotateq as “Unit” the amount you indicated would be paid.

Interesting that Tricare/Healthnet is aware of this issue but appear not be updating their claim system. We called Tricare and spoke to two different representatives, Tamara (first call) and Robin (second call) to verify the contracted amount for cpt code 90680 and received a reply that Tricare pays $/unit or a $/package (for Rotateq to receive the full reimbursement – needs to be per package).
To differentiate a package vs. unit: first of all, both reps said that it is usually per unit — per 1 vial of vaccine, using 1 dose is = 1 unit; using 2 doses = 2 units and if the whole vial is used then it becomes a package. However, for Rotateq it should be considered package because of the way the Practice buys them. It is usually bought per box of 10 single dose tube (even though the doctor only used 1 single dose of 2ml).

To correct and resubmit the claims, rep advised to list the claim numbers only with patient’s names and date of service. We don’t need to send them corrected claims. It can just be in a spreadsheet and fax it to Tricare at 888-432-7077. According to these representatives, practices are allowed 6 years on corrections because of this NDC codes confusion for most practices.
We also verified of changes/updates on their system because this was not an issue prior to January 2010. The representative from Tricare EDI said there was a change on their system on 1/25/2010.

What are some questions I should ask when looking for a Pediatric Electronic Health Record (Part 1 of 2)?

August 13, 2010 in Blog, Uncategorized by brooke  |  Comments Off on What are some questions I should ask when looking for a Pediatric Electronic Health Record (Part 1 of 2)?
  • Is the product designed specifically for Pediatrics?

Pediatricians have special needs not found in other specialties. Kids are not small adults. In a Pediatric patient, there is a higher utilization/visit amount by the younger patients than the older patients. An EHR sales person will state that ‘we have a large amount of Pediatricians’ using our system. This does not mean the product is designed and easy to use for Pediatrics (might just mean that the company has a strong sales force). For example, a practice needs to verify the system has coding linked into the template for each of the well visits type. Is there an integrated vaccine management system as well scheduling logic based on Pediatrics? Does the organization understand “Denver Development” and “Bright Futures” and how to incorporate these approaches into their system?

  • How easy is the system to use and can we customize?

Many EHR systems are set-up with small boxes with many commands to learn. Some systems appear to be “Excel-like” spreadsheets with difficult operational interfaces. These systems might have been designed an older technology for a number of reasons including: the cost is too high for the organization to start over, the CIO/staff does not have the skills in the new technology, the technology team is not well integrated with what the user needs. If you see the opening scene for the 2010 Wall Street Movie, Michael Douglass is given back his large phone from the 1980s that no one uses today. You would not by a cell phone made in the 1980s or 1990s, why would you purchase an EHR system built on the technology of the past? The system should be easy to learn. A demonstration of the system is a must. Ask a practice that adopted an EHR system you are interested in how the physician, nurse/MA, front desk like the system. Recommend you either call a physician partner about the system or if possible, spent a ½ day at a practice.

  • Does the system receive lab results as data elements directly into the E.H.R.?

Some of the systems advertise that they have a method to record lab results in the EHR. There is a free EHR known as “Practice Fusion” which shows the EHR can accept a PDF file. This does not meet the requirements for meaningful use per the Health and Human Services Requirements. The real question to ask them is do they have an HL-7 interface with the ability to receive lab results directly into the EHR. If they can answer yes and show you an example in the demonstration, they have the ‘right’ lab interface.

  • Does the system have direct connection to Surescripts for both sending electronic prescriptions as well as receiving messages on formulary status?

All electronic prescriptions are routed to the pharmacy via an organization established by the large Pharmacy Benefit Managers known as Surescripts. Surescripts will allow EHR/E-prescribing vendors to link directly to their system. To do this, a vendor needs to be able to build all the systems to appropriate route the prescription as well as receive refills. Surescripts can send formulary status of patients as well. Some organizations choose to not invest the resources (they might not have capable enough programmers or enough programmers) and time to build the formulary link. A ‘short-cut’ is for a vendor to use an e-prescribing vendor to help them so that the when a physician wants to receive a formulary message the message/request is sent from the EHR vendor (e.g. Dr. first). There are two ways to identify if a vendor does this, ask them and look on their web site to see if there are partnerships with Dr. First or similar organization.

For further questions to ask, please read article “What are some questions I should ask when looking for a Pediatric Electronic Health Record (Part 2 of 2)?”