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Billing of Influenza Vaccinations in a Pediatric Practice

September 27, 2012 in Uncategorized by support Team  |  Comments Off on 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

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

August 20, 2012 in Uncategorized 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.

Minimizing Accounts Receivable Days (AR Days) in a Pediatric Practice

July 20, 2012 in Uncategorized by support Team  |  1 Comments

All practices have accounts receivables. There is a wide distribution of how efficiently Pediatric practices manage the revenue cycle to minimize the amount of revenue in accounts receivable. A common measure in the industry for benchmarking how well a practice manages the revenue cycle is Accounts Receivable Days or more commonly known as AR Days. What are AR days? Let’s look at an example. If a practice has an average of $100,000 in gross charges a month and currently has $200,000 in accounts receivable (waiting to be paid by insurance companies and patients), the practice has approximately 60 AR Days. All practices should continue to optimize their processes and systems until the practice consistently operates at less than 30 AR days.

There are many inefficiencies that slow down the revenue cycle for practices. For instance, some practices leave a copy of all their charges each week for a biller to ‘pick up’ then send to the insurance company. The biller/billing company then needs to enter these charges in their system, review and send to the clearing house. In some cases, at least two weeks pass prior to the claim being uploaded to the insurance company. I am aware of some hospital systems that wait to the end of the month to send all claims – what a wasteful practice! A strong Pediatric Billing company measures, monitors and benchmarks these processes and looks for ways to improve the AR days for the practice. This usually requires best practice sharing and routine evaluation of pain points in the revenue cycle. This is difficult for an average biller of a practice to do successfully due to their time and focus need to focus on the daily management of claims. Pediatric practices are dependent on the practices systems, processes and back-end billing team to minimize the AR days for the practice.

How the front Desk Team Optimizes the Front End of Pediatric Revenue Cycle and Billing

May 24, 2012 in Uncategorized by support Team  |  Comments Off on How the front Desk Team Optimizes the Front End of Pediatric Revenue Cycle and Billing

The revenue cycle for a Pediatric Practice consists of a front and back end. The processes and procedures of claim submission and patient statements are usually established and led by the group that manages the back-end of the revenue cycle. If you outsource your billing for your Pediatric practice, this is the Medical Billing Company that manages the billing of insurance companies and patients. This billing company should have defined processes and systems to manage their billing and collections for clients. They should provide the practice with a billing manual on how they manage the billing for the practice. This manual helps insure there is good communication and compliance with a process. Make sure to select a company that has processes and procedures with focused experienced in Pediatrics. If your practice utilizes a biller in-house, you need a practice administrator to develop processes and procedures then monitor these processes on a routine basis to insure adherence to these systems. Some questions include: what % of claims is sent to the insurance company within 3 days of being seen in the office? What is the rejection rate at the clearing house? What are the trends in re-submissions? How often do you train your billing team? Is the biller aware of the current changes in codes and coding rules? What is your management plan? Although physicians have the intellect to learn these items, does this extra management and learning reduce revenue generating areas like new patients and alliances with other providers? No matter if the billing is managed by a professional billing service or in house, the practice will need to manage the front end of the revenue cycle.

What is the front end of the revenue cycle? The most important aspect of the front-end of the revenue cycle is managed by the front desk team. Prior to a patient checking in, a front desk team member needs to verify the patient’s insurance, collect the co-pay, scan the insurance card and collect any outstanding bills. How well the ‘back end’ casino online of the revenue cycle communicates with the front end is important to optimize the payment due from payments. This level of coordination and communication is dependent on the system being used as well as the people using the system. For instance, a good system will allow the billing team to flag a patient that has a balance so that this information shows up on the schedule when the person checks in. The staff at the front desk needs to be coached and provided feedback on their consistency on collecting any flagged balances. A person in the practice (usually a physician partner) should be reviewing each week to verify that all co-pays are collected, insurance cards scanned in and patient balances collected when the patient shows up.

These are some examples of what the front desk team needs to do. Managing the front end of the revenue cycle is usually very simple and not time consuming. No matter if the practice leverages a professional billing company or decides to utilize their own billers, it is in their best interest to manage the front end of the revenue cycle.

Phase I Meaningful Use for Pediatric Practices: The Need to Change or Modify Practice Processes

May 18, 2012 in Uncategorized by support Team  |  Comments Off on Phase I Meaningful Use for Pediatric Practices: The Need to Change or Modify Practice Processes

I was on the phone with one of our valued customers this morning discussing Phase I Meaningful Use and the details on the “how” related to Meaningful Use. The overall goal of Health and Human Services is that providers utilize a certified E.H.R. in a meaningful way. A group of individuals invested months of discussions and feedback to obtain a list of parameters. One challenge for the group is to provide a universal list that applies across all fields of medicine. Some of the parameters in Pediatrics only apply to a certain segment of the population. For example, smoking status is for patients greater than 13 years of age. There are core measures that each provider needs to meet the benchmark for all these measures during the 90 day period being measured as well as selecting a list of 5 of the 10 menu measures.

A good E.H.R. system should provide a simple manner for a physician and/or Practice Administrator to evaluate performance of each of these benchmarks as well as very easily ‘drill down’ to identify how to correct/update patient data associated with the measure. How to use a meaningful use dashboard should take minimal training and review. The E.H.R. vendor should be able to guide an individual in the practice on the process via a web meeting or teleconference. So if you selected the ‘right’ E.H.R. system for Pediatrics, using the software and monitoring meaningful use should be straight forward.

The ‘tough’ part of Meaningful use: Changes to how the practice operates. For example, most practices did not record language, race and ethnicity as part of their intake/demographics. This needs to be captured for over 50% of patients seen during the 90 day measurement period for Phase I. If your E.H.R. system is well design, the practice should be able to click on a link and show the patients that do not have this information during the 90 day period. The most efficient way to enter this information is to capture the data when the patient visits the office. The “ah-ha” moment for many individuals is when they first run a meaningful use report, then they make the changes to their office flow and intake forms as needed.

Some questions to ask related to Meaningful use and your Pediatric Practice: Are we entering all medications in the system and sending medications via electronic prescriptions? Do we list the problems for each visit and maintain the patient problem list? Are we maintaining our Medication list and Allergy List? Does our standard protocol for demographics include recording smoking status of patients >13 years of age? Do we record vitals on each visit? Can we connect to the immunization registry? Are we connected to the lab companies that we send the majority of our labs?
This is not meant to be an a complete list of questions but a list to stimulate thinking around meaningful use. There are many resources, websites and references to obtain detailed information. Good luck on meeting Phase I Meaningful Use!