Billing and Collections

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.

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.