Reimbursement (Full Version)

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pappawheelie -> Reimbursement (November 1, 2007 10:18:40 AM)

What is a reasonable return for what's billed?  I based my business plan on 70%.  My billing agency generates way less than that.  [:(] Is 70% unreasonable?  I'm thinking I need a new billing agency.



orthotherapist -> RE: Reimbursement (November 1, 2007 12:05:59 PM)

If you are in the States then it will depend on your payor mix and contracts.




pappawheelie -> RE: Reimbursement (November 1, 2007 2:41:25 PM)

I'm in the States, the northeast (and I do know where Idaho is).  But does anyone have any ballpark figures?  Most of my contracts are around 70-75% of my fee schedule.



SJBird55 -> RE: Reimbursement (November 1, 2007 7:21:05 PM)

What do you mean by "my billing agency generates way less than this?" 

#1 you probably have contracts with various third party payors.  #2 You should probably set up your ledger to indicate what was billed in one column, another column to indicate what is expected (this would be the "real" amount you should acquire from the payor) and then another column for the paid or received amount.  Your "expected" column should always equal your "paid" column. 

If your expected column does not equal your paid column, why not?  Are you having issues with the ICD-9 codes and the CPT codes you are using with the ICD-9 code?  Are there denials because of lack of modifiers?

Ask your biller for an aging report.  What volume of claims are sitting out there in the >90 day column?

Do you receive checks and check vouchers from your payors?  Look over them - do you have a high amount of denials?  Are you being paid by third party payors as your contract indicated?  Do patients have co-pays and deductibles?  If patients have co-pays and deductibles, is your billing agency sending statements?



pappawheelie -> RE: Reimbursement (November 2, 2007 8:07:25 AM)

SJBIrd--for whatever reason (and there are many) the checks I receive from payors is far less than what I expect.  Currently we have switched to electronic billing, which requires a clearinghouse, and it looks like the clearing house isn't clearing out--they seem to be holding on to bills for some unknown reason.  In addition, a lot of claims aren't "going through" because of mistakes in filling out the forms. 

So because my "expected" column does not equal my "paid" column, I'm asking "why not?"   All of the points you bring up are helpful, and it's time to sit down with the billing agency and work through this mess.  In the meantime I'm switching to a new agency.



SJBird55 -> RE: Reimbursement (November 2, 2007 12:19:27 PM)

Okay... now I see where you are at in problem solving.  You didn't really give enough information.

I'm not the expert with electronic claims, but I have a company do my billing for me electronically.

First, you need to establish if the claims are passing through the clearing house and actually being received at the insurance company.  Often times third party payors will have online capability of you being able to review the status of a claim.  You could call your provider consultant to obtain how to have this capability - it usually just requires you having a userID and a password (the third party payor has the control in establishing this for you).  So, establish that the claims are being received.  I can look into my system that my biller uses and I can see what claims were submitted that day on what accounts.  If you don't have that luxury, then I suppose you would instead need to have a conversation of when claims are sent.

Next, you need to look at your contract with your current agency.  How frequently are claims sent to third party payors?  Also, the agency should be providing you a report monthly as to how the number of days it is taking the agency to send a claim out for a date of service AND the agency should be providing you a report monthly as to the number of days that payment is received after a claim is submitted.

Now, I believe that the clearinghouse does "talk" to your agency.  I was an idiot PT and I misuderstood that NPI stuff.  I didn't provide all my "numbers" correctly - the online process of inputting information to ease the crosswalk of stuff wasn't very user friendly for a clinician.  So, my claims were kicked out because I wasn't recognized - ALL MY FAULT.  My biller received a report from the clearinghouse that my claims were being kicked out.  I believe the issue is resolved, but I don't know.  Also... sometimes new "rules" need to be written for a clearinghouse to accept claims with "rules" outside the norm.  For example, I am non-participating for one particular plan.  I CAN be recognized at an in-network level if I and the patient and the physician complete a particular form.  In those circumstances, the numbers that go into certain fields are NOT the typical numbers and the clearinghouse WILL kick the claim out.  That took time to rectify the situation because of the circumstance. 

The next thing is that you really need to see you check vouchers.  Are you receiving payments?  Are the payments being reimbursed at the contracted amount?  Do you have denials?  Why are there denials?  Was the patient cut a check because the PT was considered major medical?  I look at every single one of mine and they are self-explanatory.  If the code was denied.... if the patient had a co-pay... if the patient had a deductible... (the terms the insurance company will use could be those terms OR "cost sharing")... not payable at place of location (not sure why the heck that happens, sometimes it is a computer glitchO... not a covered benefit...

I guess I would first establish that claims are being generated.
Then, establish that claims are being sent out to the clearinghouse.
Then... establish if claims are being received by the third party payor.
Then... establish that the third party payor is reviewing or paying claims at the contracted amount.
Then... if the third party payor is not paying claims at the contracted amount, investigate why not.



pappawheelie -> RE: Reimbursement (November 2, 2007 1:43:28 PM)

Roger that.  Good, clear, and sound advice that I will take to the biller on Monday.  I certainly let it get out of hand by not reviewing each claim on a monthly basis.  How much time do you spend per week/month on billing issues?



SJBird55 -> RE: Reimbursement (November 2, 2007 4:46:00 PM)

No problem.  I have billing issues every once in a while.  Things happen.  This year the NPI deal was a huge issue.  I applied and have 2 NPI... one for my business with a Tax ID and the other for me as a professional provider.  CMS, in my opinion, does not have clear consistent language.  Do I have a UPIN or a PIN?  What do they call my company's number?  That stuff is so confusing to me. 

If you have recently been having billing issues, it very well could be associated with your NPI numbers.  I'd take the time and check out here:  https://nppes.cms.hhs.gov/NPPES/Welcome.do  The page you'll want to find yourself and your company will be here:  https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do  Double check and have your biller double check that the information provided on yourself and your company is correct.  If there are errors, you'll need to register and complete information and fix the issues.

I review each check voucher and all communication from insurance companies as they come in.  I have a log sheet that was created by my office manager for me to note patient, account, DOS and CPT code and any comments if something isn't reimbursed.  The next step, at my convenience, is to check the ledger with what the biller had going on for that DOS.  I'm not sure how much time I spend - it's just me practicing in my clinic.  I'd guess it takes me less than 5 minutes with each check voucher.  All I look at is billed, allowed and payable... if it wasn't paid at allowed, I look across to see if the patient had a financial responsibility.  As long as I don't see $0.00 in the allowed, I keep on skimming down the column.

What I have implemented which has been awesome and has reduced denials is having my office manager check and ensure that the CPT codes I plan on using are payable for the ICD-9 code(s) I chose.  That has reduced denials big time.  She does the front end work so there aren't any headaches to deal with after claim submission.  97002 has a potential of being denied and is contract dependent.... and the self-management code tends to get denied by BCBS.

I can't really give you an amount of time.  Every month is different.  Right now I'm focusing on my aging report, so I'm spending 2-3 hours/month tracking my biller to see that things are getting done.  Calling insurance companies to figure out why claims weren't taken care of appropriately.  The biggest headache are the claims that are supposed to be recognized as in network when I'm actually out of network.  That stupid referral form and the fact that their computerized system that just had online claim submission capability for this particular situation doesn't have the bugs worked out yet.  My goal is to have no claims in the >120 day column.  Because I had a focus elsewhere for months on end, now I'm doing my time to make this goal maintained (and it isn't there yet...).  I'm hoping by January to have that goal met.  The list keeps getting smaller, but it isn't at my goal level yet.

As I sit here, I'm actually chuckling.  You know, the checks I receive from payors are always less than I'd expect too!  I'm worth WAY more than they every pay me.  LOL  And every year as I think I'm worth more, they keep paying me less.  LOL  The physical therapy business sucks.



pappawheelie -> RE: Reimbursement (November 6, 2007 3:06:48 PM)

Yeah, not getting paid for working hard stinks and makes me wonder why I do it.  Still, I have to have faith that eventually the reimbursements will be as steady as my client base--I just have to spend some time staying on top of it.  Time...something that gets more precious every year.   



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