pediatrics

Verification of Proper Insurance Retractions in Pediatric Practices

January 20, 2012 in Billing and Collections by support Team  |  Comments Off on Verification of Proper Insurance Retractions in Pediatric Practices

Insurance retractions occur routinely in a busy Pediatric Practice. A retraction of money occurs when a practice owes insurance plan money due, usually, to the insurance company overpaying or incorrectly paying the practice. Some reasons why an insurance company might incorrectly pay a practice for a patient visit include:

• The patient’s insurance expired or is invalid.

• The claim system of the insurance company incorrectly paid higher than the contract amount.

• The patient has a high deductible plan and the insurance company incorrectly paid the practice prior to the patient deductible being met.

A practice management system should be able to adjust to these changes at a claim level and appropriately record the retraction. A retraction for one patient can be split over multiple payments. Note that each retraction needs to be verified by the Biller after they receive the payment summary or other documentation of the retraction from the managed care plan. These adjustments happen for various reasons and require the biller to continuously update the claim in the system.

Let’s look at an example:

Patient John Smith Visits ABC Pediatrics on January 4, 2012. ABC Pediatrics bills the Insurance provided by John Smith, receives a payment of $431 on February 2, 2012 then on April 10, 2012, ABC Pediatrics receives a statement that John Smith was not a valid member of the insurance so the practice needs to pay back the $431. The next payment is for $200 on a different patient – so the plan documents that the practice now owes the plan $231 ($431-$200) and that the EFT check for that patient is $0 (since the plan reduced the liability to the practice by $200 for John Smith’s correction).

The practice management system should have a method to update the claim for the changes so that these changes are properly documented as a credit and debit in the system. If you are unsure, call your practice management vendor for help and assistance.

Protection of Your Pediatric Practice from Theft

January 13, 2012 in Billing and Collections by support Team  |  Comments Off on Protection of Your Pediatric Practice from Theft

Unfortunately, theft is more common in Pediatric Practices than most practice owners anticipate. Businesses in general, according to some estimates, lose approximately 7% of revenue due to Theft and Embezzlement. According to a September 2010 article in MGMA Connexion, the magazine produced by the Medical Group Management Association, the Association of Certified Fraud Examiners (ACFE) estimates that the typical organization loses 5% of its revenue each year to fraud. Think that because you run background checks on all hires that you are protected? Think again – in a 2010 ACFE report, 86% of individuals that were charged or convicted of fraud were first time offenders.

Some examples of fraud in a Pediatric Practice include: employees stealing through theft of receipts, cash on hand, disbursements such as forging or altering a check, submitting fictitious invoices, paying personal expenses with company funds, payroll and expense reimbursement. More than 50% of the time the employee stole alone and had 3 or more years of experience.
Using Risk Management principle of trust and verify with proper oversight and systems can mitigate much of the risk. This includes:

1. Assess your processes and monitoring for high risk areas including co-pay management, payroll, reimbursement, patient refunds.

2. Make sure the front desk team and other members understand that there is an on-going audit of these activities (if a partner is monitoring 1 hour/1x per week, there should be enough clarification each month for the employees to understand there is an audit system).

3. Minimize the individuals involved with high risk areas (such as access to banking, payments and payroll) and insure there is a partner in the business that audits this function (recommend switching this role in a larger group so all partners have an equal share in the audit function).

A well-designed Pediatric Practice management system should have the ability to print the co-pay report per day so that the practice can insure that the books balance. This is similar to a bank teller verifying that the cash balances in their drawer. If you are unsure how to use their audit system, obtain some training then implement this with the front desk team each day. If your Practice Management system vendor does not have this function, request that they build this into the software since this is an important function. Insure that your Pediatric practice is not one of the practices that loses a percent of their revenues each month due to not implementing auditing systems and controls. By consistently implementing an appropriate audit system, you can minimize your risk of fraud/theft, protect your practice, and maybe even sleep a little better at night.

http://www.mgmaconnexion.com/connexion/201009?pg=40&pm=2&u1=friend#pg40

10 Ways to Improve the Bottom Line of Your Pediatric Practice

January 3, 2012 in Blog by support Team  |  Comments Off on 10 Ways to Improve the Bottom Line of Your Pediatric Practice

Managing a Pediatric Medical Practice is full of opportunities and challenges today. In the ‘old’ days managed care plans had minimal influence on the bottom line of your practice, Malpractice rates we’re relatively inexpensive and patients were flexible to meet 9-5 office hours. Today, much has changed in society as well as in managing a Pediatric Medical Practice. Other ‘conservative’ services such as banking have changed drastically in the last 15 years. Look how easy it is to gain access to your bank/bank account today versus 15 years ago. You can be successful in Pediatric Medicine today by understanding how to meet the needs of Patients and Managed Care Plans. Patients want good access to a good Pediatrician while Managed Care Plans know that seeing a Pediatrician is more economical then using the ER or Urgent Care Centers. Also, many Pediatricians act like a Medical Home that provides continuity of Care. Managing a pediatric practice needs to be done in an objective manner by providing goals while measuring and monitoring success toward these goals. Here are 10 suggestions to improve the bottom line of a Pediatric Practice:

1. Optimize New Patient Additions: how many patients are in your Pediatric Practice? What are the ages of these patients? What is the average # of New Patients joining your practice per month? How do your hours, location(s), facilities, and staff compared to other choices for Parents? The more practices in the same location, the stronger the value proposition needed for your practice to be successful. Patients choose a Pediatrician to obtain good advice and treatment. They need to feel heard, have their questions managed and feel that your practice provides the best options. If a provider is not meeting these needs, the practice manager/physician Partner needs to discuss the importance of service. Suggested reading, although in the Hospital Segment, includes “If Disney Ran You Hospital, 9 ½ things you would do differently”. http://www.amazon.com/Disney-Ran-Your-Hospital-Differently/dp/0974386014

2. Provide and Measure Quality Care/Patient Satisfaction: Quality Care is important in any Pediatric Practice. How do you measure “Quality” in your practice? You should be able to set up reports in your E.H.R. system to measure HEDIS measures such as the % of patients that were vaccinated per a pre-determined vaccine schedule. The patient and parent have an opinion of the care in your Pediatric Practice. If you provide them an option on each visit to provide feedback either via a ‘Feedback Box’ or an online link, you have a great opportunity to see trends in the perception of the care provided by your practice. If the patient survey is created and implemented correctly, you will also be able to use the tool to view feedback per provider. This can be used as a tool to constantly improve care and/or the perception of care. To receive continuous improvement in your practice, you need the feedback and the providers need to choose to change based on the feedback.

3. Leverage the “Right” Technology: Patients and parents are use to convenience via their smart phones and home computers (look at the dramatic increase in on-line sales in 2011 versus 2010 as an indicator). Does your Electronic Health Record System have the ability for parents to schedule appointments, view select information through a patient portal (determined by the Pediatrician), and pay bills on-line? If you are not sure, ask your E.H.R. vendor what options they have the cost for the options. Also inquire if you and the providers on call can view all your patient records via a smart phone. The system used on a smart phone should be configured for a smart phone.

4. Managed the Fee Schedule: I am surprised at the number of practices that have established their fee schedule significantly below appropriate levels established by consultants in the field of Medical Practice Management as well as recommended levels provided in practice management courses through the Medical Group Management Association (MGMA). Generally, the billed rate per CPT code should be 2-3x the Medicare reimbursed amount for that code. The practice needs a consistent and well thought out fee schedule that is reviewed at least 1x per year. If you are unsure how to establish appropriate fees, contract with an organization that manages Pediatric Offices or does consulting for Pediatric Offices. This is not a task for companies that primarily sell software and have services as an afterthought. If you want to learn on your own, recommend attend courses provided by MGMA.

5. Review Contract Rates with Plans: The fee schedule is one component, what the actual contract rate with each insurance company is an important component to improve the bottom line of your pediatric practice. The fee schedule should be re-visited each year. Look at the difference between your fee schedule and the contract rate for each of the top 8-10 plans. There will be a few plans that will try to not give an increase in their rates. There were two plans I worked with for a Pediatric Practice that try to sell in ‘no increase’ from the previous year while the plans increased their profitability by 15-20% year versus year and the CEO’s of the plans made millions in salary and bonus. Remember, that Pediatricians are usually the lowest paid specialty in Primary Care and Pediatricians help the managed care plans reduce ER visits, Urgent Care centers as well as inappropriate use of the health care system. No increase in a fee schedule is a decrease in your salary since the costs associated with Rent, Employees, taxes, insurances, supplies and vaccines increase each year. You might need to cap or discharge a particular ‘poor’ performing insurance from the practice. Many of the patients from a particular plan will stay with your practice. Obtain good advice and use appropriate consultants that understand contracting.

6. Evaluate Payer Mix: What is the payer mix of your practice? Some practices have minimal patients that utilize Medicaid and/or Managed Medicaid Insurance while other Pediatric Practices are >75% Medicaid. Understanding the geography and plan mix will help you make informed decisions. You should become with some of the reimbursement and desires of the plans that comprise greater than 80% of the revenue for your practice. Analyze the capitation rate per patient per month for each of the insurance companies as well as the facility usage rate for the average capitated patient. Does your practice management system track the monthly capitation payments? What % of your monthly revenue is from the capitation checks? If you added a new provider or have a new practice, you should be more flexible on the insurances that you accept as well as the ‘cut off’ for contract rate. If you are unsure how to evaluate the payer mix, seek advice from your billing team (if you use a vendor that specializes in Pediatric Billing) or a Pediatric Practice Consultant. Recommend evaluating the payer mix at least 1x per year to determine what changes are needed.

7. Monitor Collection Rate: Net collection rate is the % collected versus the contract amount. For example, if your fee schedule for 99214 is $145 and the contract amount for the fee schedule is $100, a 99% Net collection rate means that $99 was collected of the $100 contract amount. The contract amount could be broken into three areas: co-pay collected at front desk, amount paid by insurance and amount due by patient. Let’s do an example with the $100 for a 99214 (assuming this was the only code for the visit). Let’s say the patient had a $20 co-pay and $50 paid by the Insurance per the Explanation of Benefits and another $30 due by the patient. The back-end billing team needs to bill the patient for the remaining $30. MGMA benchmarks show that the average collection rate for charges >120 days aged is approximately 95%. MGMA establishes a goal of 97% of Net collections. What is the Net Collection rate for your practice? Do you monitor this monthly? Do not settle until the collection rate is above 99%….when contracting a vendor; ask for their range in collection rates for the Pediatric Practices that they manage. When you use your own internal billing team, make sure and monitor multiple patients per week to insure that billing and write offs are appropriate per the protocols of the practice. Any person can upload charges to a clearing house, but not all practices have systems that manage the entire Pediatric Revenue cycle. An average collection rate can cost a practice thousands of dollars in lost revenue.

8. Monitor AR Days: Accounts Receivable days or AR days is a simple formula of taking the total $ in Accounts Receivable and dividing this by the averaged $ generated per day. Again, benchmarks are important to monitor on a monthly basis. The MGMA averages are between 42 and 50 with

9. Evaluate Front Desk & Providers: Both the Front Desk team as well as the providers in a Pediatric Office have a significant impact on the Revenue Cycle. The front desk team needs to verify the insurance, scan the insurance card, and collect the co-pay as well as any outstanding balance on a patient account. The Pediatric E.H.R./Practice Management system should have a system for the Practice Administrators/Physician Partners to monitor/audit the collection of co-pays. Note that some resources report that approximately 70% of practices have theft at the front desk. If you have a strong audit system that verifies the amount each day (like a bank teller) you can avoid revenue being taken from your practice. The providers have a responsibility in the revenue cycle to make sure they capture the work/advice they provided to the practice. Strong Pediatric Practice management systems should be able to simplify the choices so the providers just select from one of the most common Diagnosis codes and CPT codes.

10. Review E&M Coding: The “bell” shaped curve is the ‘ideal’ for Pediatric Practices. Some high quality based might have a curve that has slightly to the right. Some practices either under or over code. This either reduces the appropriate level of revenue for the practice or places the practice at an audit risk for which they could owe revenue back to the insurance company. The E&M coding should be reviewed by provider and practice at least 1x/quarter. If there is a provider that is ‘under’ or ‘over’ coding, consider enrolling in an on-line course provided by either MGMA or the American Academy of Pediatrics.By implementing these 10 suggestions early in 2012, your Pediatric Practice can benefit from appropriate changes for the entire year. A well-managed Pediatric practice leads to happy providers, staff members, and patients.

2012 Pediatric Practice “To-Do List” or Establishing Goals

December 22, 2011 in Billing and Collections by support Team  |  2 Comments

As we head to the end of 2011, it is a good time for administrators of Pediatric Practices to establish goals for the practice. To establish appropriate goals, the practice needs to take some inventory on how they are doing in different areas of Pediatric Practice Management. Some of these areas include:

• Practice Growth: What is the average growth rate in new patients to the practice per month in 2011 vs. 2012? How can the practice increase the growth rate? Does the practice have appropriate staffing to manage the growth rate of the practice? What are the total patient visits in 2011 vs. 2010 and % change? Was there a change in average revenue per patient visit? What marketing channels should the practice invest that provide the best return on investment? Which marketing channels in the past has yielded the best return?

• Patient Satisfaction: Does the practice have a formal or informal feedback system related to patient satisfaction? If the system is informal, it is important to establish a formal patient feedback system that can help the practice identify areas to improve. If the system is already formal, in what areas has the practice increased their patient satisfaction versus last year? What areas has the practice decreased patient satisfaction? Some areas to consider are front desk interaction, Medical Assistant/Nurse Interaction, Physician/Provider interaction, website, tools and treatments. Evaluate the patient satisfaction scores by provider. There can be good feedback to provide a specific provider on how to improve their impact with patients.

• Provider Satisfaction: Which providers are most satisfied with treating patients? What are their drivers to obtain optimal performance? Which providers are least satisfied with treating patients? What are the reasons for their level of satisfaction (e.g. patient interaction, challenging patients, call schedule, disconnect between their expectations of position and actual position)?

• Billing & Revenue Cycle Management Operations: What is the collection rate for the practice? Is this above or below the Medical Group Management Association (MGMA) benchmarks? What systems can the practice implement to further improve the collection rate in 2012? What is the cost of paying the Billing Company or Billing Staff (remember with own staff to include cost of facility space, postage, taxes, management time for billers)? Is this cost above or below the MGMA Benchmarks?

• Update Practice Charges: This is a good time to review all the CPT codes on the super bill and make updates in the billed rate as well as cash rate. Also, include a plan that requires a review of the insurance contracts and reimbursement rates for the top 4-6 carriers. The insurance company, in general, will pay a reimbursement rate that is the lowest of the Billed amount or the contract amount with the insurance company. There are practices that have not updated their billed rate whom send bills to the insurance company that is below their contract rate. A strong billing team will be able to manage this appropriately and proactively. Physician partners should verify this each year by obtaining a list of the CPT codes, the current billed rate for the practice.

• Cost Structure: Review the primary cost items to the practice. How can the practice appropriate reduce overhead expenses while still providing high-quality care? Some areas to review include: leases for facilities, general and Malpractice insurance, telephone charges, supplies, vaccines, general office equipment. Health plans are just beginning to understand that higher overhead does not mean higher quality care. In fact, there is an acticle in the Boston Globe on December 20,2011 titled “Insurer to Reward Patients for Finding Cheaper Care” – Harvard Pilgrim plan seeks to reduce costs.
http://bostonglobe.com/business/2011/12/20/insurer-reward-patients-for-finding-cheaper-care/a6ajBBBu2hpHZ1IyiRPmLP/story.html
The article provides some background on what is occurring in the state of Mass: “Two reports from Attorney General Martha Coakley over the past two years have documented disparities in what hospitals and doctors are paid by insurers for the same services.” If this is just the ‘start’ then there could be a major change in payments which would benefit high quality Pediatric Groups with lower overhead (regardless of size).

Being proactive on the 2012 goals for the Pediatric Practice early in January of 2012 should help the practice optimize the benefits of these results.

Reliability and Redundancy of Electronic Health Record (EHR, EMR) IT Systems

December 16, 2011 in EHR Selection by support Team  |  Comments Off on Reliability and Redundancy of Electronic Health Record (EHR, EMR) IT Systems

I am sure that most practices do not spend time thinking about redundant systems to manage and maintain their EMR, EHR, and Practice Management System. We had a major slow down earlier this week when we needed to move all practices to the back-up systems. This made me think of what does a physician office do if their server is down? Do they lose production for a ½ day, a day, two days, or a week? Does an office have a back-up plan if the systems are down? What is the disaster recovery plan? Good cloud-based companies have thought through these issues to maintain your data. When there is a system outage, how a team reacts, learns and improves their systems is important for minimizing the down time for practices.

One of our practices placed the outage disaster recover into perspective for me. Prior to switching to PhysicianXpress, this large practice had a server in their office for the practice management system. A practice in the same building complex moved to a server-based EMR System a few years ago. This year, there was a major lightning storm that ‘fried’ the router of the practice we served and ‘fried’ the server of the practice that was on a server-based practice. Our client needed to install a new router and they were back up and running with no loss of data. The other practice was not so lucky. A server in the office can deliver faster speeds; the down side is that the practice needs a qualified team of IT personnel either on staff or on call to insure back-ups are occurring multiple times per day. Even in this case, not many practices have redundant systems (2+ servers hosted in different locations to minimize chance of loss in a disaster like a building fire).
No system is available 100% of the time. An up time average of 99.95% means that there are >4 hours a year that the system is down. We evaluate system components and design to identify areas to increase system up time as well as verification of data back-up systems. We are in the pursuit of the perfect system design and operation – this requires continuous improvement reviews and changes. When evaluating a system, there are some good questions to ask including: how many locations and how often is the data backed up for my practice? Who is responsible for the back-up? What has your company done in the last 12-24 months to improve the back-up and recovery? If using a cloud based system, can I maintain a daily copy of our records and schedule on a local computer for read-only access?

There are a number of reports related to the reliability of the data in Electronic Health Record Systems. In fact, there are even international publications looking at the actual reliability of the data in the system (see http://www.scielo.cl/pdf/jtaer/v4n2/art06.pdf
By Alhaqbani, Josang, and Fidge). This component shows that there are data errors by other systems or users of the system. In the United States, some insurance companies calculate the HEDIS scores of practices (e.g. evaluating the vaccines given to a select number of patients versus an established recommended vaccine schedule). Their systems miss data routinely (e.g. they capture the vaccines given in the office but not the vaccines given in the Hospital or other locations). This is another area of Medical Reliability compared to the reliability of the hardware or software.