Mastering The Top Five Reimbursement Challenges

Author(s): 
Harry Goldsmith, DPM

Getting paid promptly and properly is never easy. However, this renowned expert offers insights that can help you improve office efficiency, navigate through the red tape of managed care and ultimately bolster incoming revenue streams. Way back when, in pre-managed care times, physicians could expect to be paid their fees in full. Unfortunately, with the advent of the managed care era, times have changed and certainly not for the better for DPMs. Physicians, who had previously maintained an “arm’s distance” from third party payers (preferring to deal directly with their patients), have become contractually bound to those same payers. Whether it was a result of economic extortion, a fear of losing existing and potential future patients or belief in the managed care “dream,” physicians, in mass, abandoned their traditional business models in their stampede to sign any and every managed care contract placed before them. Once the physician became directly dependent on the third party payer for reimbursement (the role previously held by the patient), the physician became the consumer … and not a very good one at that. The majority of physicians simply didn’t ask the right business questions: What is the plan fee schedule? Can my practice afford the contractual discount? What are the benefit limitations? What are the patient’s responsibilities in terms of copayments and deductibles? What hospitals, specialists, laboratories, ambulatory surgical centers, etc. are the patients restricted to? Is there a provision for reimbursement for services performed “out-of-network”? How can the managed care contract be terminated?, etc. Unfortunately, most physicians signed without reading their contracts, without seeking the advice of a healthcare attorney, without considering whether they could truly afford the terms of the contract. With this backdrop in mind, there are five key challenges that are essential to master if you want to minimize managed care headaches and help ensure timely and proper reimbursement. Stay Current On The Latest Rules 1. Don’t go into battle without your weapons. Third party medicine runs on systems that are defined by rules, guidelines, benefit structures and definitions. Any practice participating in third party medicine is bound to follow defined coding and billing rules, guidelines and definitions. You can access these via sources including, but not limited to CPT, ICD-9-CM, HCPCS, the Federal Register, Medicare, national and specialty associations and societies, healthcare consultants and the payers themselves. Applying CPT, ICD-9-CM or HCPCS coding within the billing process assumes a level of definitional understanding from both you and the payer. A breech of this definitional understanding leads to a misrepresentation which, in turn, can lead to reimbursement or denied reimbursement for the service or procedure claims. It is critical that you and your staff be wholly aware and follow reimbursement rules the best you can. In order to do this, you need to set aside a sufficient budget amount each year for acquiring: • the latest CPT, ICD-9-CM, HCPCS, National Correct Coding Initiative books and databases; • companion texts (e.g., reimbursement guidelines, specialty coding/billing manuals, etc.); • newsletters (e.g., CodinglinePRINT, AMA’s CPT Assistant, Part B News, etc.); • electronic reimbursement aids (e.g., AMA’s CodeManager 2002, Encoder Pro, UCG’s CorrectCodeChek, etc.); and • attending reimbursement seminars (e.g., Codingline Business of Medicine series, APMA, state and specialty association coding and billing meetings, etc.). Not having a complete and up-to-date library of standard reimbursement manuals and information puts you and your practice at risk. Skimping on the tools of the trade is like going to battle without your weapons. The key to any successful reimbursement challenge — a denied or modified or even unduly delayed claim — begins with the ability to lace any appeal with quoted text from recognized coding and billing manuals, specialty guidelines or other acknowledged sources. Without reasonable and recognized definition, rules or guideline support, you can lose the reimbursement battle before you even begin. Being knowledgeable and meeting the challenges when it comes to reimbursement can make all the difference in the success of your practice. Develop A First-Rate Process For Collecting Reimbursement 2.

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