Trifecta Tips

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Trifecta Tips

Dash for Cash

Compliance Plans and Audits

Money Walks and Money Talks

Sponsored by:

American Academy of Physical Medicine and Rehabilitation AAPM&R Annual Assembly 2015 Boston, Massachusetts Presented by:

Cheyenne Brinson, MBA, CPA

Cheyenne Brinson, MBA, CPA Consultant and Speaker For over 15 years, Cheyenne Brinson has helped physician practices ranging in size and specialities solve business problems. She draws upon her experience as a CPA and her hands-on management experience to help surgeons across the country streamline workflows, increase efficiency, build solid internal controls, reduce overhead, reduce risk and increase revenue.

Areas of expertise Operational practice evaluations New practice set-up Fee schedule and contract rate analysis Practice Manager recruitment and coaching Strategic planning retreats Customer service training

Cheyenne works extensively with Orthopaedic, Otolaryngology, Plastic Surgery, Neurosurgery, General Surgery, and Vascular Surgery practices, from solo practices to group practices, private practice to hospital employed, to increase efficiencies to improve collections and leverage overhead costs. Prior to joining KarenZupko & Associates, she was a Director in a primary care practice where she turned around the practice from operating in the red to a profit in less than one year. She led an implementation team to open a new clinic site – fully functional on an EMR. Key recent accomplishments include: Saved a practice $89k in staff costs by appropriately implementing technology and improving efficiencies



Speaking Topics Practice and Financial Management EHR Meaningful Use and PQRS Overhead Reduction Internal Controls/Financial Security

Published in The American Journal of Orthopedics Business of Hand Surgery Newsletter NERVES News Plastic Surgery News Association of Plastic Surgery Assistants Network Publication

Memberships Illinois Medical Group Management Association (ILMGMA), Past President



Revamped the surgery coordination process to increase patient collections by 10-25%

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Identified $5,500 in annual cost savings for credit card processing and 20% savings on ASC medical supplies

As a speaker, Cheyenne draws upon her experiences in the field as a practice management consultant and delivers relevant, timely, and anecdotal information in a friendly, upbeat fashion. She is an instructor for KZA’s national coding and reimbursement workshops sponsored by the American Academy of Orthopaedic Surgeons (AAOS) and American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF). She also frequently speaks for state specialty societies and administrator organizations. Cheyenne holds a Master of Business Administration and Bachelor’s degree in accounting from Troy State University (now Troy University) in Troy, Alabama. She is an inductee to the Accounting Hall of Honor in recognition of her professional accomplishments.

Medical Group Management Association (MGMA) Text and Format © 2015 KZA, Inc. 2015 AAPMR_Trifecta Tips (CB) 100115

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Dash for Cash

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Key Questions on A/R 1. How does our practice compare to national statistics? 2. What percentage of our accounts receivable is owed by patients?  Deductibles  Co-insurance  Co-pays  Uncovered services 3. How old are the patients’ balances?  Are the dates accurate? 4. How have the totals and percentages changed in the last two years? 5. How have our internal systems changed to improve patient collection balances? A/R as of 12/31/12

What is your percentage goal for improvement? 10%

15%

20%

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25%

30%

Adjustments                      

Non-Contractual Adjustments •Bad debt write off

  •Bankruptcy

•Deceased patient

  •Missed appeal deadline

•Missed filing deadline (or

  Timely filing adjustment)

•No precertification •No referral authorization   •Non-covered service •NSF check   •Payment plan default •Preexisting condition not   covered •Recovered from   collection agency •Risk management •Sent to collection agency •Service recovery •Small balance write off (under $5.00) •Risk management adjustment •Service recovery •Professional courtesy  

Contractual Adjsutments •Contractual Amounts (plans for which the practice is contracted with) •List carriers individually •Adjustments from NonContracted/ Out-ofNetwork Plans •List carriers individually

Treated as Contractual •Bundling denial – appeal denied •Bundling denial – not appealable •Charity care •Financial hardship discounts (these are discounts and not full charity care) •Medicaid secondary contractual adjustment •Multiple procedures (-51 and -59 modifiers) •Professional courtesy adjust (other physicians, medical community) •Self-Pay discounts (i.e. prompt pay discounts) •Surgical assistant not covered

** Absolutely, positively, no use of Miscellaneous, General, Other or Administrative Adjustment Codes. Everything has a specific reason!** Text and Format © 2015 KZA, Inc. 2015 AAPMR_Trifecta Tips (CB) 100115

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Sample H.E. Plans What plans are you on? 

 

In or Out? 

 

 “All products clauses.” Beware! What are the allowable for these plans?  

 

Can eligibility be verified online? 

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Improving Point of Service Collections (POS) 1.

New patient pre-registration is the first step.

2.

Verify Demographics for existing patients.

3.

Know About Insurance Coverage Before Patients Arrive.

4.

Verification of Eligibility and Benefits – Benefits You!

Ask your clearinghouse vendor:  “What can you do to help us verify benefits more effectively?”

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Use Claim Estimators 5.

Use Claim Estimators

Who Offers? How to Get info?  www.Availity .com. Free! Single source sign on! o Include s Aetna, Cigna, and some Blues Plans.  Or www.navinet .com.  Or direct from plans: United Health Care.  

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Patient Estimators Work! 6.

Implement Recurring Payment and Reduce A/R! You can add a card‐on‐file contract 

08/30/2013

01/20/2013

   

Three ways (plus one!) to handle recurring payments: 1. Debit Card 2. Credit card 3. Checking account withdrawal 4. HSAs

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Patient Estimators Work! 7.

Collect at Check-In and Check-Out!

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Money Walks and Money Talks

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Your Technology Assessment

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Employee Embezzlement: It Can Happen to You By Cheyenne Brinson, MBA, CPA Consultant and Speaker, KarenZupko and Associates Physicians are easy targets for employee theft. A recent MGMA survey revealed that 83% of practices have experienced theft by an employee in amounts ranging from $250 - $250,000. Headlines across the country share this disturbing trend: “Practice Assistant Charged with Embezzling Over $1,000,000 from Boston Hospital,” “Former Office Manager Accused of Embezzling almost $215,000 from a Local Physician” and “Former Michigan Office Administrator Arrested For Allegedly Embezzling More Than $200K.” Undoubtedly, it has happened to a colleague or even yourself. Employees who embezzle do not wear a T-shirt to work that says “I steal from you.” However, there are steps you can take to protect you and your practice from employee theft. Background and credit checks. Know who you are hiring before you make an offer. According to national recruiting data, nearly 30% of all applicants provide false, inaccurate, misleading or incomplete information. Plan to spend $50-$100 per applicant. Don’t think it’s worth it? A background check would have prevented a Chicago practice from losing $250,000+ from embezzlement. The employee had previously been convicted of embezzlement - a background check would have revealed this. Trusted Employees provides this service at a reasonable fee. http://www.trustedemployees.com/index.php Physicians sign checks. One of the best internal controls is to limit check signing authority to physician owners. It protects the practice and protects the honest employee. Proper back up must accompany the check. Additionally, physicians need to review the bank statement looking for any unauthorized transactions. Segregation of Duties. Proper segregation of duties is the cornerstone of good internal controls. Even small offices can provide adequate segregation of duties. The person who opens the mail should not have access to posting payments or writing checks. Too often, the same person posts all charges, payments, adjustments, and refunds; prepares the bank deposit slip; and does the month- end close. This is a ticking time bomb for embezzlement. Computerized Receipts. The person who collects the co-pay is the appropriate person to post it into the practice management system and issue a computerized receipt to the patient. Handwritten receipts compromise internal control. Perform a Formal Daily Close. Balance payments collected at check-in to the practice management system. Many practices believe they are performing a daily close but are

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Employee Embezzlement: It Can Happen to You “balancing” the system to the system. The next step in the monthly close process, and an often missed step in practices, is to balance payments recorded in the practice management system to the accounting software (e.g. QuickBooks, Peachtree, etc.) To summarize: 

 

When performing the daily close, another staff member, other than the person posting the payments, counts the money first and runs an adding machine tape. The practice management system journal is then compared to the money on hand. Two staff members involved is a good check and balance. Compare the bank receipt to the adding machine tapes to ensure the correct amount was deposited. Compare actual deposits in the checking account (and accounting system) to practice management system reports at the end of the month. The two totals should match, except for deposits in transit.

Encounter form reconciliation. Account for all scheduled visits and walk-ins at the end of the day by using the practice management system’s encounter form reconciliation tool. Account for surgeries in the same manner. Not only is this an increased internal control, it will stop revenue leaks from unbilled visits and surgeries. Write-Offs. Closely monitor adjustments and write-offs. Select ten EOBs to see if adjustments were properly categorized. Less than scrupulous employees will cover up their embezzlement by writing off a patient’s balance to contractual allowance. Prohibit credit card refunds. If a refund needs to be made, issue a patient a check signed by a physician. Monitor the credit card daily reports to ensure no refunds are made. Why? Making refunds to one’s own credit card or friend’s credit card is a common fraud scheme. Utilize EFT and ERA. Electronic Funds Transfer (EFT) is direct deposit of your insurance checks. Electronic Remittance Advice (ERA) is auto-posting of the Explanation of Benefits (EOB). Use of EFT and ERA eliminates staff from handling insurance payments, funds are available more quickly and it saves time in posting payments. Use RDC or lock box. Remote deposit capture (RDC) is a scanner that converts paper checks to direct deposits. Scanning checks upon receipt reduces risk (but does not eliminate it) and it saves time since there is not a deposit slip to complete or a bank run to make. Use of a lock box serves as an elevated audit control, eliminating the possibility that staff could embezzle mailed checks.

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Employee Embezzlement: It Can Happen to You Proper internal controls can significantly reduce the opportunities for employee embezzlement. As an extra protection, speak to your insurance broker about employee dishonesty coverage.

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Audit Controls for PMRs Check Up

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I review the income and expense statement monthly.

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The report is clear and understandable to me.

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I receive timely financial reports. As an example, I review the February month-end report no later than the 2nd week in March.

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Revenue expense + categories are detailed and broken out.

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I review write offs and adjustments.

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I know and approve staff overtime.

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Audit Controls for PMRs Risk Area: Cash Handling Action Steps

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Establish a set of written policies and procedures for the following:  The receipt of money received: Always generated by the computer system.  Steps in the daily close process.  Require two people, at a minimum, to be involved in the process.  Charge Capture o Timely submission o Reconciliation process

■ ■ ■ ■ ■

Review “Credit Balance Report” monthly

■ ■

Collection at the time of service.

Cash handling protocols Petty cash Change fund Financial policy regarding bad debt and referrals to a collection agency. Run small balance report monthly.

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Audit Controls for PMRs Risk Area: Cash Handling Action Steps

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Require background checks on all new employees who handle money.

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Set up credit card machine to automatically submit transactions to the bank.

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Monitor inventory.

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Generate “Missing Ticket” report. Monitor “no shows.”

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Number charge tickets/encounter forms.

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Signup for electronic remittance.

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No delegation of check signing.

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Bond all employees with cash handling responsibilities or check your office umbrella policy.

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Audit Controls for PMRs Banking Services 1. Private Banker 2. Credit Card Processing 3. EFT (ERemittance) 4. Remote Check Deposit 5. MMF – Practice 6. Line of Credit 7. Lock Box

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Compliance Plans and Audit Avoidance

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The Alphabet Police Roles of Various Medicare Improper Payment Review Entities Acronym

How selected All claims where hospital submits an adjusted claim for a higherweighted DRG Expedited Coverage Reviews requested by beneficiaries

Volume of Claims Very small

All Medical Claims

Randomly

Small

All Medical Claims Randomly

Randomly

Medical Review Units* at MACs

All Medicare FFS Claims

Targeted

Medicare Recovery Auditors*

All Medicare FFS Claims

Targeted

PSC/ZPICS

All Medicare FFS Claims

Targeted

QIO

CERT*

PERM*

OIG

Types of Claims Inpatient Hospital claims only

All Claims

Type of Review  Prepay & Concurrent (Patient still in hospital)  Complex Only

 Postpay only  Complex only  Postpay only

Small

 Automated & Complex

Targeted

Depends on number of claims with possible improper payments for this provider

 Prepay & Postpay

Depends on number of claims with possible improper payments for this provider

 Postpay

Depends on number of potentially fraudulent claims submitted by provider

 Prepay and Postpay

Depends on number of potentially fraudulent claims submitted by provider

 Postpay

 Automated, & Complex

 Automated and Complex

 Automated and Complex

 Complex

*Overseen by OFM/PCG

Source: https://www.cms.gov/CERT/downloads/Overview_Review.pdf .

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Purpose of Review To prevent improper payments through DRG upcoding To resolve discharge disputes between beneficiary and hospital

Other Functions Quality Reviews

To measure improper payments

None

To measure improper payments

None

To prevent future improper payments

 Education  Appeals

To detect and correct past improper payments

None

To identify potential fraud

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To identify fraud

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Meet the Public Sector Auditors • FY2013: $3.65 billion in overpayments, $102.4 million in underpayments identified. • Incentive to RAC for recoupments.

RAC

• The new RAC contract period is to extend from 2014 to 2018 • Contractors make public the “issues” list. For example, physician issue is E&M during global (pre- or post-op period).

• Measure error rates by reviewing randomly selected claims.

CERT

• Signatures, physical therapy and E&M codes are big issues! • 2012: 8.5% $29.6 billion • 2013: 10.1% $36.0 billion

FY 2013

Incentive for money collected.

MAC

HEAT

• Focus on billings that are higher than the majority of providers and noncompliance with LCD’s (medical necessity).

• Also conduct pre and post payment audits.

• Interagency team to combat criminal fraud.

• Investigate areas of overpayment.

OIG

Tip: Private payors are also increasing their audit efforts. Pay particular attention to medical policies related to coding and your specialty.

• Highlight areas for payor audits. • Publish audit targets (work plan) each year.

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Read the entire 2015 document at: http://oig.hhs.gov/reports-andpublications/archives/workplan/201 5/WP-Update-2015.pdf

OIG Workplan

Physicians and Suppliers — Noncompliance with Assignment Rules and Excessive Billing of Beneficiaries Billing and Payments. We will review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. We will also assess the effects of their participation and claim assignments on the Medicare program (such as noncompliance with assignment rules) and on beneficiaries (such as excessive billing of beneficiaries’ share of charges). Context—Physicians participating in Medicare agree to accept payment on “assignment” for all items and services furnished to individuals enrolled in Medicare. (Social Security Act, § 1842(h)(1).) CMS defines “assignment” as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or other supplier. The physician or other supplier in return agrees to accept the Medicare-allowed amount indicated by the carrier as the full charge for the items or services provided. (OEI; 07-12-00570; expected issue date: FY 2014; work in progress) Physicians — Place-of-Service Coding Errors Billing and Payments. We will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Context— Prior OIG reviews determined that physicians did not always correctly code nonfacility places of service on Part B claims submitted to and paid by Medicare contractors. Federal regulations provide for different levels of payments to physicians depending on where services are performed. (42 CFR § 414.32.) Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center. (OAS; W-00-11-35113; various reviews; expected issue date: FY 2014; work in progress)

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Ancillaries on the “Hit List” Part B Imaging Services—Payments for Practice Expenses. We will review Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. Practice expenses are those such as office rent, wages, and equipment. Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expenses. Diagnostic Radiology—Medical Necessity of High-Cost Tests. We will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment. Medicare will not pay for items or services that are not “reasonable and necessary.

Prepare for 2015 IRF Final Rule Changes – Mediware http://www.mediware.com/rehabilitation/blog/item/irf-2015-final-rule-decisions-cms-1608-f

Is the 2015 OIG Plan for IRF Actionable? – Mediware http://www.mediware.com/rehabilitation/blog/item/irf-incidence-of-adverse-and-temporary-harm-on-oig2015-plan

Proposed Fiscal Year 2016 Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities (CMS-1624-P) – CMS.gov https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Factsheets-items/2015-04-23.html Text and Format © 2015 KZA, Inc. 2015 AAPMR_Trifecta Tips (CB) 100115

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Ancillaries on the “Hit List”

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Ancillaries on the “Hit List”

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E&M Utilization: Why You Should Care PMR Practice Physcial Medicine and Rehabilitation – 2013 CMS Data

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E&M Utilization: Why You Should Care Evaluation and Management Profile Analyzer Dr. Smith Pain Management - 2013 CMS Data

Evaluation and Management Profile Analyzer Dr. Doe Physical Medicine & Rehabilitation - 2013 CMS Data

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Private Health Insurer Retrospective Audits: What You Need to Know  Based on paid claims—you already have the money and have typically spent it!  Goes back several years. Defies the “well, they always pay me” and “everyone else gets paid” philosophies.  Do not ignore these notices as an inconvenience.  Call a health care attorney. The American Health Lawyers Association.

Why Might You Be Selected?  Level of code; E&M especially. Do you use 1995 or 1997 guidelines?  High service volume compared to peers.  High volume of modifier 25.  Non-conformity—congenital unbundling.  Whistle blower complaint file. Former staff, former partners.

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Sample Compliance Plan for Physician Practices (Your Practice Name) voluntarily implements a compliance program aimed at fraud, waste, and abuse prevention while at the same time advancing the mission of providing quality patient care. Our compliance efforts are aimed at prevention, detection, and resolution of variances. The eight elements of (Your Practice Name) Compliance Plan are: 1. Commitment to Compliance A. Standards of Conduct B. Reasonable and Necessary Services C. Coding, Billing, and Claims D. Reliance on Standing Orders E. Compliance with Applicable HHS Fraud Alerts F. Marketing G. Anti-Kick-Back/Inducements H. Retention of Records/Documentation 2. Designation of a Compliance Officer/Committee 3. Conducting Training and Education Programs 4. Communication 5. Disciplinary Guidelines 6. Auditing and Monitoring 7. Corrective Action 8. Response to Government Investigator or Auditor Copyright © 2013 Medical Risk Institute

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