Pediatric Office Revenue Cycle Management/Medical Billing – Today vs. Yesterday

October 12, 2011 in Billing and Collections by support Team  |  1 Comments

I am amazed at the number of Pediatric offices for which the partners use modern technology in their
home life and have a dated revenue cycle for their office.  Their home activities are expenses while the
office revenue cycle provides the revenue stream for their practice and their income.   Because the insurance companies routinely update systems and processes, the average Pediatric office is at a disadvantage to managing the revenue cycle.  Interesting that I have observed a practice owner drive to the nearest cell phone dealer and within an hour walk out with a new phone and abandon the old phone.  This same practice owner is unable to make a change that will increase their compensation.    Many pediatricians have systems in their office that were either designed prior to the 21st and still being sold today or are using a system that the practice purchased before the start of the 21st century.

I have met ‘Sally the biller’ whom has done the billing for years but is years behind on optimal coding
techniques for the office.  Also, we have picked up work from ‘Sally the biller’ for which thousands of
dollars have been missed in charges not resubmitted or reprocessed correctly.  It is expensive and time
consuming for a practice owner to continuously train and challenge their billing team.  Consultants have a solution – hire them to manage the billing team.   This could increase their billable hours – might be better approach to utilize the consultant a few times a year to audit account and measure versus national benchmark (if they are a high skilled consultant, they are probably busy and flexible on the arrangement).  Hiring a practice manager to manage the billing team as well as other functions might or might not be a good idea based on the size of the practice.  These challenges are especially difficult for a 1-3 physician Pediatric group where the extra headcount might only add cost and complexity to the practice and actually reduce the profit margins.

Some of the items to manage for back office revenue cycle management include: insure qualified Pediatric billers are continuously managing the revenue cycle, monthly deep dive into the account to calculate benchmark performances and evaluate aged claims, auditing, training, change of codes, change of claim file standards, change of scrubbers and claim edits, evaluate distribution of sick coding.   The larger practices also require other factors like the evaluation by provider.  Most pediatric practices become more profitable by focusing on increasing patients and revenue versus spending significant amount of time on these management issues.

Why are major corporations outsourcing?  Because the activity is being outsourced is not the core activity
of their business.  Xerox has run an advertisement campaign that they announce Marriott, a hotel, and
Ducati, an Italian motorcycle manufacturer, outsource their back office operations to Xerox so these
companies can focus on serving their customers.  Shouldn’t a pediatric office focus on their patients and
not back office management?  Optimizing profit margin and reducing administrative burden is always on the ‘grid’ for executives in companies.  Business owners of Pediatric Practices either become too busy to think strategically about this approach or might not have the proper advisers.  The links below show these videos:

Xerox – Ducati http://www.youtube.com/watch?v=e6reT9Ux_gI

Xerox – Marriott  http://www.youtube.com/XeroxCorp#p/c/7/wdi43UA2ofE

Xerox – Virgin Airlines  http://www.youtube.com/watch?v=4YFK54c2qYA

It is confusing for a practice owner to know how to identify a company that performs consistently in
Pediatric back office operations/medical billing.  There are many companies not meeting their growth
objectives of their EHR software and/or consulting practice so they might add in Medical
billing as a service.

When evaluating a company/business to manage your revenue cycle some questions to ask include: what is your collection rate, what % of your customers/clients uses your billing service vs. only your EHR.  Since you have been in
business, what % of the time have you been actively managing pediatric billing and the revenue cycle? If
they have been in business for more than 5 years and started medical billing within the last 5 years, their
processes and company systems were not built from the ground up around the revenue cycle
management of clients.  How do you audit my account?  How do I audit your actions?

Transitions from the old model means some changes for the practice:  new systems, processes and potentially a new
billing team.   If done properly, at the end of the rainbow is additional revenue, higher profit margins, reduced work and more free time for the practice owners!

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.

Hidden Costs and Reliability Issues of Client-Server EHR systems

March 14, 2011 in EHR Selection by support Team  |  Comments Off on Hidden Costs and Reliability Issues of Client-Server EHR systems

While traveling to a potential customer, I met an individual that has 10 years experience as an IT consultant.  He worked at Accenture, then the Government and for the past three years works at an IT outsource company managing a department.  This IT professional reminded me, through his position and experiences, the issues that customers face when an application has multiple copies and versions.  He described the higher operating cost for the client-server systems and the difficulty at times identifying the issue due to variation of version, install, and local equipment (their team needs to travel occasionally on site to correct issues).

He expressed to me the advanages of cloud-based systems:  more consistent access for the IT support team to correct issues, continuous updates and lower operating costs.   He was familiar with the change from ICD-9 to ICD-10 and the impact on vendors of EHR/EMR and billing systems.   We discussed with client server systems, updates would need to be completed and verified with each location.   This is extra work for the vendor of client-server EMR systems as well as their clients.  Will client-server vendors use the ICD-10 changes as an opportunity to pass a cost on to their clients?  Well designed cloud-based EHR systems provides pediatric practices routine updates at a lower operating cost compared to client-server EMR systems.

The Future of Medical Billing for Pediatric Practices

March 7, 2011 in Billing and Collections by support Team  |  Comments Off on The Future of Medical Billing for Pediatric Practices

The credit card machine changed the methods that vendors collect bills due from customers.   Prior to the credit card, the customer had to have enough cash on hand, have a check or receive store credit.   Only a few generations ago, businesses needed staff and resources to collect on this store credit.  Once credit cards became available, businesses accepted credit cards for which the business would pay a percent of the charge to cover the costs associated with the credit card company collecting from the customer.   These businesses were able to eliminate or reassign the staff that managed the store credit. 

Medical billing is moving through a similar path.  Prior to the 1990s change to managed care, offices had individuals that prepared the bill and collected from the patient.  If the patient had insurance, the patient would take a receipt from the doctor’s office and submit to their insurance.   As managed care began the process of “In-network”;, offices utilized their billers to submit to managed care companies.  This process started simple (via paper) until the managed care plans invested in computers, software, and coding scrubbers.  Insurance companies learned that the skill of the ‘average’ office as well  as flaw in billing system/methods were not sophisticated enough for their systems.   The managed care plans were able to post strong profits.

Many offices still maintain medical billers.  Some invest well in training, people and Technology, others do not and/or do not know how.  Maintaining a medical biller is very difficult for smaller practices since they do not have enough revenue to justify the cost of a qualified biller as well as appropriate systems.   Even if a practice has the level of revenue to support a medical biller, many are not able to set up and
maintain a medical billing team with appropriate skill sets.   Practice Managers and practice consultants have a portion of their job dedicated to coaching, mentoring, hiring and training medical billers.  Is this
the best model?  Having a medical biller in the office has direct costs, indirect costs as well as an
additional burden to manage.  Interesting that many large Dow 30 companies outsource functions (such as payroll)…..shouldn’t physician practices?

Practices that adopt physicianxpress for EHR and medical billing achieve, to date, 99% collection rate
(contract amount) at a cost that is within the range of benchmarks for backend billing processes.   These practices can audit the claims for their practice real time and they do not need to invest in the cost of a biller, management of the biller, cost of training and retraining.   The medical billers at Doctor Office Management receive quarterly training from various sources (AAPC, AAP, MGMA).    It is much easier to be an auditor and ‘Monday morning quarterback”; than to hire, train, manage and audit a billing team on a continuous basis.  Since payers are becoming more complex to interact with, medical practices will see the benefits of moving the billing operation out of the office.

The advantages of Auto Formulary Advice in Pediatric Electronic Health Record Systems

March 1, 2011 in EHR Selection by support Team  |  Comments Off on The advantages of Auto Formulary Advice in Pediatric Electronic Health Record Systems

Let’s face it; parents are much busier today than a generation ago.  Kids have more activities at a younger age.   There are more medications today than a generation ago with varying degrees of managed care coverage.   If there are three asthma medications in the same therapeutic category, prescribing the ‘on-formulary’ medication saves time for parents.    

A Pediatric office accepts health insurance from multiple plans each with differences in formulary coverages.   A ‘typical’ drug formulary is three tiers.   Tier 1 is the generics tier, tier 2 is the preferred branded tier, and tier 3 is the non-preferred branded tier.  Each plan has a range in cost to the patient.  For example, tier 1 usually ranges $5-$10, tier 2 is $15-$35, tier 3 is $35 and up.  Since the formulary status of medications at plans changes routinely, staying up to date would be a full time job for a busy Pediatric practice.   This is where a well-built system that uses auto-formulary advice can save a practice time, lower costs to patients, and increase the adherence to a managed care plans formulary.

E-prescribing vendors and Electronic Health Record vendors have different options when they design and develop their systems.   Surescripts/Rx Hub maintain the data on products on formulary for each plan.  Many vendors link directly to the source (All Scripts, Nextgen, Physicianxpress) while others choose an indirect route via linking to another vendor (Dr. First).  Either source is dependent on the Internet to check formulary and send the prescription (another reason to choose cloud-based system).   When there is a problem with formulary advice:  a vendor with a direct connection to sure scripts needs to only diagnose their own system and communicate with sure scripts while a vendor that connects to another vendor whom connects with Surescripts has three systems that there could be a problem.

Reliability Engineering confirms that more systems in a series lead to more chances of failure/error.   Six sigma concepts also support less steps in the process.  When selecting an EHR, ask if the vendor if their system has directs links and achieved certification directly from sure scripts for formulary advice and sending scripts/refill requests.

Over the next two years there will be some significant branded drugs that lose patent protection.  This change in the market place will motivate managed care plans to further change and control formularies.   Pediatric practices that routinely use the formulary advice feature of an ‘optimal’ system should reduce their administrative burden while reducing costs for patients and payers.