One of the first steps to optimizing the revenue cycle for a Pediatric Practice is to develop and incorporate a consistent Billing Processes, Procedures and Policies Manual for the practice. This manual should be customized to the practice based on how the revenue cycle is managed for the Pediatric Practice. Some items to include in this manual are:
• Payment Plan Agreement
• Examples of letters that will be used for final collections, payment plan, etc.
• List of responsibilities for front desk team members
• Registration forms
• Notices such as privacy policy
For all of our new billing clients we develop or edit the Billing Processes, Procedures and Policies Manual to the needs of the practice. This written document helps to provide clarity to all parties involved related to the Processes, procedures and policies for managing the revenue cycle of the Pediatric Practice. Developing and implementing this manual is an important first step to optimizing the revenue cycle for the Pediatric Practice. If you develop your own manual, recommend you obtain assistance from either a Pediatric Practice consultant or from another Pediatric Practice Administrator to identify if the manual is within the current standards of the industry. We have obtained new clients that were managing the practice based on revenue cycle rules of the late 1990s. In some of these cases, the practices were missing thousands of dollars a month in unrealized revenue due to outdated practices and processes.
Does Your Pediatric Practice have a clear and consistent Billing Policy Manual?
Billing of Influenza Vaccinations in a Pediatric Practice
It is very typical for Pediatric practices to begin the process of vaccinating patients with the flu vaccines during September. Although most Pediatric practices maintain a protocol for medical billing related to giving flu vaccinations, it is a good idea to review the common billing practices.
Some questions to ask related to the influenza vaccine include: Will the physicians be examining the high risk patients as part of the flu vaccination process? Will the office set up a flu clinic for which either a Medical Assistant or Nurse administers the vaccine? Will the practice allow flu shots to be administered on weekends or after hours?
Below is the list of CPT as well as vaccination administration codes associated with influenza vaccination.
90655 Influenza virus vaccine, split virus, preservative-free, for children 6–35 months of age, for intramuscular use
90656 Influenza virus vaccine, split virus, preservative-free, when administered to 3 years of age and above, for intramuscular use
90657 Influenza virus vaccine, split virus, 6–35 months of age, for intramuscular use
90658 Influenza virus vaccine, split virus, 3 years and older, for intramuscular use
90660 Influenza virus vaccine, live, for intranasal use
Vaccine Administration Codes also need to be associated with Flu Vaccinations
If the patient is 18 years of age or younger and obtains vaccine counseling by the physician or other qualified health care professional Report CPT code 90460. If both of the criteria are not met (either over 18 years of age or does not obtain vaccine counseling by the provider), utilize the appropriate code from the 90471-90474 series. Utilize CPT Code 90471 if the influenza injection is given as the only vaccine or CPT Code 90473 if the intranasal form is the only provided vaccine. If the influenza vaccine is provided with other vaccines and the patient is either over 18 or the provider does not provide counseling, report 90472 for the influenza injection or 90474 if the intranasal form. Note that the appropriate diagnosis code for the flu vaccine is v04.8
Potential Impact of the 2013 ACA changes in Medicaid Reimbursements to Pediatric Practices
We hear that children are the most important aspect of our Healthcare system and that preventive care has the best return on our health care dollar. So, why are Pediatricians continuously receiving the lowest average pay when compared to other physician specialties? There are many reasons for the low reimbursements including the significant gap in payments between Medicaid and Medicare. Family Practice and Internists rely both on Medicare and Medicaid while Pediatricians, due to almost all their patients being
Patients without a primary Pediatrician seek some of their care at the Hospital ER. Besides breaking the Medical Home concept, treating at the hospital is far more expensive than in a Pediatric office. The formers of the Affordable Care Act made a choice to invest in primary care versus urgent care by changing the law so that Medicaid reimbursements = Medicare Reimbursements. This change should help providers increase their panel of Medicaid patients and should benefit the cost curve as well. Lastly, the patients should see increased access to a Pediatrician. States would see >$10B in new funds from Health and Human Services to pay for the expanded cost (this is an investment by the Federal Government). The goal of this investment is to reward the primary care physician for preventive care.
When will this take effect? Starting in 2013, the reimbursements for Medicaid are to increase to Medicare Levels.
What does this mean? There are a few states that Medicaid currently pays above Medicare (Alaska, Wyoming) according to some reach by Sandra Decker whom is an Economics at the CDC (see article in the Washington Post dated August 6, 2012 http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/08/06/study-one-third-of-doctors-wouldnt-take-new-medicaid-patients-last-year/ )
Overall, statehealthfacts.org by the Kaiser Family Foundation (http://www.statehealthfacts.org/comparetable.jsp?ind=196&cat=4 ) shows that Medicare to Medicaid Fee index is .66 for the United States. The lowest states are Road Island (.36), New York (.36), New Jersey (.41), District of Columbia (.47) and CA (.47).
Will the New Medicaid pay the same as commercial Insurance? Generally, the answer is no. The reason is that although Sick and Well visits should, in most states, see an increase in reimbursement being paid, there will continue to be a significant gap in payments for Vaccine Administration codes by Medicaid. Recommend read the press release below. If your practice currently does not accept Medicaid Patients due to the low reimbursements, now is the time to consider changing the policy for the practice.
http://www.hhs.gov/news/press/2012pres/05/20120509b.html
Some Potential Effects on Pediatric Care due to September 11th, 2001
My 9th grade daughter asked me, as an assignment for school, where I was and what was my first reaction when I learned of the news related to the tragic events of 9-11-01. Most of us whom were adults at the time could describe the exact location and what we were doing when we learned this shocking news. The tragic events of this day changed many things in our country. What are some of the potential additional treatments in Pediatrics due to 9-11-01? The answer to this question is that it depends.
If you were a Pediatrician in New York, NY, you might have children that had early development of asthma. The Pediatrician would need to do a detailed history to see if there is any link to the events of 9-11-01. Where was this patient on 9-11-01? Where their parents exposed to the debris and air associated with 9-11-01? Asthma is not the only disease that the Pediatrician needs to complete a detailed history. Other potential diseases such as acid reflux, depression, anxiety, or sinus congestion might also might have a link.
Today is a day to remember the tragic events of that day as well as to remember our brave fire fighters, police officers, and other public servants that risked their lives to help others in a difficult situation. Although 9-11-01 was 11 years ago, the negative impact is still felt today.
A Virtual Accountable Care Organization (ACO) and the link to Pediatric Practices
With Healthcare costs increasing at a rapid rate in the United States, there are a number of payment models being investigated that look to encourage preventative care while reducing costs. Although most practices generate the majority of their revenue from Fee for Service insurance products, there is much talk as well as movement related to Accountable Care Organizations (ACOs). The concept of ACOs is that an organization manages a large group of providers and hospital systems to provide patient care. The ACO and the providers would be compensated for management of a population. The leaders in this field are exploring many different methods for payment – a set fee per patient for all care, bundled payment per episode of care as well as other risk sharing arrangements. ACOs are most thought about as hospital systems that purchased provider groups (e.g. Integrated Delivery Systems) and form an ACO entity. In this case, the Pediatric Group would need to be owned by the hospital system to participate in the ACO.
Although the Medicare Shared Savings Program ACO sponsored by the Centers for Medicare and Medicaid Services (CMS) has the most publicity, the commercial payers are beginning to experiment with ACO payment models as well. The Medicare Shared Savings Program ACO shares the savings of ACO effort between the ACO and CMS (the providers continue to receive Fee for Service payments at this time).
There is another type of ACO model known as the Virtual ACO or community ACO. This model would be an organization that is the contracting agent with payers and would like to privately owned practices. For example, ABC Pediatrics (privately own), could participate in a virtual ACO without selling their practice. The virtual ACO would develop the guidelines on how to participate as well as the payment stream. There is much question as to how this will impact Pediatrics. The good news is that private practices should not be required to sell their practices as the ACO model evolves.
Practices and practice managers should continue to keep an eye on the payment methods in the field. Improper coding as well as low collection rate continues to be a very common issue with Practices that if managed appropriately, optimize the revenue to the practice. In Pediatrics, this requires a team that receives routing training in Pediatric coding, systems that gain intelligence as payers change reimbursement policies and consistently reporting and follow-up. So although there is much talk and experimentation with new payment models, most practices need to look how to appropriately manage the revenue cycle in today’s payment system.
