Medical Billing Blog

At my last EMR conference, there were well over 600 EMR’s on the market.  Some were certified but even more were not.  From the latest research according to Mark Anderson from the AC Group, less than 12% of the physicians are using their EMR programs as they were promised or intended.  A recent survey indicated that 38% of physicians where unhappy with their EMR’s, and many were seeking to get out of their contracts.  Since 2008, more than 5,000 practices have decided to replace or drop their EMR vendors. Many have paid upwards of $40,000 per provider for their EMR products only to find out that the product was oversold, did not meet the practice needs, or found that the vendor went out of business shortly after the implementation.

Currently, under ICD-9, a 453.42 code is for acute venous embolism and thrombosis of deep vessels of distal lower extremity.  Included under this code is a diagnosis involving a thrombosis or embolism to the calf, lower leg NOS, or the peroneal or tibial veins. All possible combinations are included under this one code.

With an estimated $60 Billion wasted in Medicare fraud annually, our government has enacted various laws in an effort to reduce healthcare fraud.  They are going after healthcare fraud in a major way as part of the effort to balance the national budget, and there are a few new programs that are making a significant difference in healthcare reimbursements.  They are RACs, MACs, ZPICs and Strike Forces.

In any medical practice or clinic, the objective is to provide the best care possible and be reimbursed at the highest possible rate.  The former is in the hands of the provider—usually the clinic or practice owner—who has a vested interest in making sure that “best care possible” proposition is carried out.  He has direct control and authority over the level of care patients receive, and can easily make adjustments when circumstances warrant.  He is comfortable with his level of knowledge and education, knows his limitations, and brings in consultants when necessary to compensate for any lapse in quality he may feel would detract from the care scenario his patients receive.  We all know this is a full time job—and then some.  So what about the latter—being reimbursed at the highest possible rate?  Usually the physician has some knowledge of coding requirements that comes through osmosis from filling out encounter slips for the patients he sees, but there is hardly enough time in the day for a physician to double check every code on every chart processed by his billers and coders.  He is justified in expecting that the biller or coder will exhibit the highest commitment to excellence in knowledge, professional standards, compliance and ethics, even though the biller or coder does not have the ownership interest in the practice that the provider has. 

Do not fall into the trap of downcoding just to be ‘on the safe side.’ As a physician, it is your responsibility to code based on your documentation. If you continue to downcode, you’re not only at risk of losing thousands of dollars in revenue per year, but you’re also potentially triggering an audit of your practice.  

By now every provider should be aware of 5010. 5010 is the new electronic claims transmission format that becomes effective January 1, 2012. Commercial and grvernment payers are all required to use this new format.

In our current economic recession, medical practices across the nation are facing ever increasing bad debt from their patients.  With an average of 10% unemployment, high foreclosure rates, never-to-return jobs, and high insurance deductibles, patients are avoiding paying their doctor bills, and more and more patients are being sent to collections.  But there is an easy way to reduce patient bad debt starting today.

As part of an ongoing effort to reduce fraudulent payments from Medicare and Medicaid, CMS announced the launch of the Recovery Audit Prepayment Review Demonstration Program.  In the prepayment review program, recovery auditors will review medical billing claims before they are paid to ensure that providers comply with all Medicare payment rules. Recovery Auditors will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments.

Beginning this month, the Office for Civil Rights will begin auditing Covered Entities and Business Associates in order to gauge their level of compliance with regard to the HIPAA Privacy and Security Rule and Breach Notification Standards.  These audits, called for under the HITECH Act by the Department of Health and Human Services, will be part of a pilot program to be conducted through December 2012 intended to determine if guidelines relating to privacy are being followed. 

On September 20, 2011, Governor Rick Snyder signed into law a 1% tax on all health care claims paid in the state of Michiganfor the purpose of funding it’s Medicaid program.  Michigan will now be eligible for an additional $780 million in federal funding for Medicaid patients.  The new law, aptly called the Health Insurance Claims Assessment Act, or HICAA, is a blanket 1% tax on all payments expected to cover previous losses.  The law will be in effect for one calendar year, starting on January 1^st, 2012 and ending on December 31^st, 2012.