Decoding incident-to and provider-based billing: ensuring payment and avoiding liability

In this increasingly complex world of Medicare reimbursement, physicians must constantly review their billing practices to ensure compliance with all Medicare requirements. "Incident-to" billing and provider-based billing are two areas that present unique challenges for providers, especially those practicing in hospital-owned practices such as hospital outpatient departments. Both incident-to and provider-based billing limit providers' abilities to bill for and receive reimbursement in those practice settings. The Office of Inspector General's 2012 Work Plan Report identified both incident-to billing and place-of-service errors as two of the many areas for investigation and compliance efforts in 2012. This article focuses on identifying the unique point-of-service challenges presented by physicians practicing in hospital outpatient departments or hospital-owned clinics.     

Postmarketing surveillance of medical devices using Medicare claims

The current system of postmarketing surveillance of high-risk medical devices could be improved by taking advantage of the administrative billing data collected by the Centers for Medicare and Medicaid Services (CMS) to systematically monitor for adverse events that may signal device-related problems. In this paper we use the current concern about the excess risk associated with drug-eluting coronary stents to highlight the strengths and weaknesses of claims data for postmarketing surveillance and propose a pilot collaboration between government, industry, and academe to systematically explore the use of Medicare claims data for this purpose.     

Rule emphasizes quality and cost savings

The Centers for Medicare and Medicaid Services (CMS) emphasizes improving quality and efficiencies across settings in the Inpatient Prospective Payment System (IPPS) final rule for 2012. Hospitals will receive a 1% market basket increase in reimbursement. CMS announced a Medicare spending-per-beneficiary measures that will be used in the Value-Based Purchasing program and the Hospital Inpatient Quality Reporting program. CMS is adding new quality measures involving infection control in 2014 and 2015.     

Medicare Part B reimbursement and the perceived quality of physician care

The maximum amount physicians can charge Medicare patients for Part B services depends on Medicare reimbursement rates and on federal and state restrictions regarding balance billing. This study evaluates whether Part B payment rates, state restrictions on balance billing beyond the federal limit, and physician balance billing influence how beneficiaries rate the quality of their doctor’s care. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper finds strong evidence that Medicare reimbursement rates, and state balance billing restrictions influence a wide range of perceived care quality measures. Lower Medicare reimbursement and restrictions on physicians’ ability to balance bill significantly reduce the perceived quality of care under Part B.     

Evaluating reimbursement of integrated support services using chronic care management (CCM) codes for treatment of hepatitis C among Medicare beneficiaries

The New York City Department of Health and Mental Hygiene (DOHMH) implemented Project INSPIRE, an integrated model of hepatitis C care coordination and telementoring services, from 2014 to 2017. We evaluated the use of chronic care management (CCM) codes to sustain the intervention. DOHMH data were collected as part of a Healthcare Innovation Award from the Centers for Medicare & Medicaid Services (CMS). A retrospective cohort medical billing study was conducted by assigning INSPIRE activities to procedure codes in both facility and nonfacility settings. Rates for procedures were extracted from the CMS's 2018 fee schedules and added across the eligibility periods for Medicare enrollees. Reimbursement was adjusted on the basis of expected patient attrition and compared to costs. The minimum number needed to treat (NNT) to break even was calculated in each setting. Facility reimbursement was higher than costs, whereas nonfacility reimbursement was lower (both P < .01). The NNT was 23 patients in facilities and 33 patients in nonfacilities; 24 patients per care coordinator were treated annually in INSPIRE. CCM fees alone were insufficient to fully reimburse the costs in either setting. Implementation of an appropriate risk financing strategy is necessary to mitigate financial shortfalls when providing CCM services in facility settings.     

Registered dietitians' coding practices and patterns of code use

Coding, coverage, and reimbursement are vital to the clinical segment of our profession. The objective of this study was to assess understanding and use of the medical nutrition therapy (MNT) procedure codes. Its design was a targeted, cross-sectional, Internet survey. Participants were registered dietitians (RDs) preselected based on Medicare Part B provider status, randomly selected RDs from the American Dietetic Association database based on clinical practice designation, and self-selected RDs. Parameters assessed were knowledge and use of existing MNT and/or alternative procedure codes, barriers to code use/compensation, need for additional codes for existing/emerging services, and practice demographics. Results suggest that MNT is being reimbursed for a variety of diseases and conditions. Many RDs working in clinic settings are undereducated about code use of any kind, reporting that code selection frequently is determined not by the RD providing the service, but by "someone else." Self-employed RDs are less likely to rely on others to administrate paperwork required for reimbursement, including selection of procedure codes for billable nutrition services. Self-employed RDs are more likely to be reimbursed by private or commercial payers and RDs working in clinic settings are more likely to be reimbursed by Medicare; however, the proportion of Medicare providers in both groups is high. RDs must be knowledgeable and accountable for both the business and clinical side of their nutrition practices; using correct codes and following payers' claims processing policies and procedures. This survey and analysis is a first step in understanding the complex web of relationships between clinical practice, MNT code use, and reimbursement.     

The Status of Billing and Reimbursement in Pediatric Obesity Treatment Programs

Pediatric psychologists provide behavioral health services to children and adolescents diagnosed with medical conditions. Billing and reimbursement have been problematic throughout the history of pediatric psychology, and pediatric obesity is no exception. The challenges and practices of pediatric psychologists working with obesity are not well understood. Health and behavior codes were developed as one potential solution to aid in the reimbursement of pediatric psychologists who treat the behavioral health needs of children with medical conditions. This commentary discusses the current state of billing and reimbursement in pediatric obesity treatment programs and presents themes that have emerged from discussions with colleagues. These themes include variability in billing practices from program to program, challenges with specific billing codes, variability in reimbursement from state to state and insurance plan to insurance plan, and a general lack of practitioner awareness of code issues or reimbursement rates. Implications and future directions are discussed in terms of research, training, and clinical service.     

Coding and reimbursement for weight loss surgery: best practice recommendations

OBJECTIVE: To review the use and usefulness of billing codes for services related to weight loss surgery (WLS) and to examine third party reimbursement policies for these services. RESEARCH METHODS AND PROCEDURES: The Task Group carried out a systematic search of MEDLINE, the Internet, and the trade press for publications on WLS, coding, reimbursement, and coding and reimbursement policy. Twenty-eight articles were each reviewed and graded using a system based on established evidence-based models. The Massachusetts Dietetics Association provided reimbursement data for nutrition services. Three suppliers of laparoscopic WLS equipment provided summaries of coding and reimbursement information. WLS program directors were surveyed for information on use of procedure codes related to WLS. RESULTS: Recommendations focused on correcting or improving on the current lack of congruity among coding practices, reimbursement policies, and accepted clinical practice; lack of uniform coding and reimbursement data across institutions; inconsistent and/or inaccurate diagnostic and billing codes; inconsistent insurance reimbursement criteria; and inability to leverage reimbursement and coding data to track outcomes, identify best practices, and perform accurate risk-benefit analyses. DISCUSSION: Rapid changes in the prevalence of obesity, our understanding of its clinical impact, and the technologies for surgical treatment have yet to be adequately reflected in coding, coverage, and reimbursement policies. Issues identified as key to effective change include improved characterization of the risks, benefits, and costs of WLS; anticipation and monitoring of technological advances; encouragement of consistent patterns of insurance coverage; and promotion of billing codes for WLS procedures that facilitate accurate tracking of clinical use and outcomes.     

A Statistical Model to Detect DRG Upcoding

The Medicare program, private insurers, and managed care organizations reimburse hospitals for inpatient admissions using the Diagnosis Related Group (DRG). The DRG is determined from a complicated algorithm based on patient medical records. Previous studies generated concerns about DRG upcoding, in which incorrect DRG codes may be selected by the hospital to obtain higher reimbursement. Insurers rely on expensive manual audits of claims to verify the appropriateness of the DRG coding.A statistical system that can adaptively detect claims with incorrect DRG codes would provide a powerful improvement to current practice. This paper describes two aspects of the statistical system that provides proof that the concept is viable. The first aspect of the paper is the design of a hierarchical Bayesian model to be applied to claims data (without audit) to estimate the probability that a claim is coded incorrectly. The second aspect of the paper is the use of the Bayesian model to aid in the selection process of claims to audit by proposing that a claim should be investigated if the predicted recovery is more than the cost of auditing that claim. This approach improves upon that used currently by auditing 88% of the claims and recovering 98% of the overpayments. While these results improve upon the current approach for determining which claims to investigate, they are based on data that have been systematically selected for audit based on one insurer's past experience. Future work will create an adaptive system to determine the selection of claims to audit from the entire paid claims database, and that can be generalized for use by other insurers.     

IAC accreditation: setting the standard of care in diagnostic imaging

Maintaining high standards should be a goal of all imaging facilities. The challenge comes in being able to demonstrate that level of quality--a task that will be essential in the coming months. Accreditation provides imaging facilities with a pathway to demonstrate quality to insurance carriers, patients, and referring physicians. The Medicare Improvements for Patients and Providers Act requires that by January 1, 2012, all nonhospital suppliers of the technical component of advanced diagnostic imaging, inclusive of nuclear medicine, magnetic resonance imaging, computed tomography, and positron emission tomography, obtain accreditation as a condition for reimbursement by the Centers for Medicare & Medicaid Services (CMS). This article details the multi-modality accreditation programs offered by the Intersocietal Accreditation Commission and how imaging centers can achieve accreditation to ensure that they are in compliance with the January 1, 2012, CMS mandate.     

Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings

In response to a rising concern for multidrug resistance and Clostridium difficile infections, the Centers for Medicare and Medicaid services (CMS) will require all long-term care (LTC) facilities to establish an antibiotic stewardship program by November 2017. Thus far, limited evidence describes implementation of antibiotic stewardship in LTC facilities, mostly in academic- or hospital-affiliated settings. To support compliance with CMS requirements and aid facilities in establishing a stewardship program, the Infection Advisory Committee at AMDA—The Society for Post-Acute and Long-Term Care Medicine, has developed an antibiotic stewardship policy template tailored to the LTC setting. The intent of this policy, which can be adapted by individual facilities, is to help LTC facilities implement an antibiotic stewardship policy that will meet or exceed CMS requirements. We also briefly discuss implementation of an antibiotic stewardship program in LTC settings, including a list of free resources to support those efforts.     

Is the grass greener? Physician billing under Canadian Medicare

With the US healthcare system currently in a transitional state, medical group administrators here are becoming more curious about the way that the healthcare systems of other countries work. The experience of the Haig Clinic, a medium-sized multi-specialty family practice, is offered as a representative example of the Canadian Medicare system in the province of Alberta. Nearly one-half of all claims are now received by Alberta Medicare in EDP magnetic tape form, and total turnaround time is approximately two weeks for "clean" claims. Thanks to the dedicated efforts of man Alberta health professionals, it is an efficient system of billing, merging the world of Medicare with the world of electronic data processing.     

Be prepared: Medicare auditors increase scrutiny

The Centers for Medicare and Medicaid Services (CMS) is pushing its auditors to be more aggressive in reviewing hospital claims. CMS has set targets for how many claims the auditors should review. Auditors are encouraged to use extrapolation for denials when they find a pattern of erroneous claims. CMS has approved more than 570 diagnosis related group (DRGs) for medical necessity review.     

High-risk proposition. With CMS' 'value-based purchasing' model, struggling hospitals are wondering if they can afford the IT needed to make it work

As the CMS pushes its "value-based purchasing" model, hospitals are left wondering if they'll get squeezed by a program that will require them to invest big bucks in technology. "People need to ... understand it is a way of transforming Medicare from a passive payer of claims to an active purchaser of higher-quality, more-efficient services," says the CMS' Thomas Valuck.     

MD Referral Held Key to ‘Appropriate’ Emergency Ward Utilization

Is the provision for emergency Medicare a back door permitting hospitals not in compliance with the quality and/or desegregation requirements of the basic Medicare law to gain federal reimbursement? This possibility, suggested by the fact that two thirds of all emergency claims in the U. S. emanate from the Southeast, has been investigated by Hospital Practice's Washington editor Mai Schechter. His report follows.     

Abortion Providers' Experiences with Medicaid Abortion Coverage Policies: A Qualitative Multistate Study

Objective

To evaluate the implementation of state Medicaid abortion policies and the impact of these policies on abortion clients and abortion providers.

Data Source

From 2007 to 2010, in-depth interviews were conducted with representatives of 70 abortion-providing facilities in 15 states.

Study Design

In-depth interviews focused on abortion providers'' perceptions regarding Medicaid and their experiences working with Medicaid and securing reimbursement in cases that should receive federal funding: rape, incest, and life endangerment.

Data Extraction

Data were transcribed verbatim before being coded.

Principal Findings

In two study states, abortion providers reported that 97 percent of submitted claims for qualifying cases were funded. Success receiving reimbursement was attributed to streamlined electronic billing procedures, timely claims processing, and responsive Medicaid staff. Abortion providers in the other 13 states reported reimbursement for 36 percent of qualifying cases. Providers reported difficulties obtaining reimbursement due to unclear rejections of qualifying claims, complex billing procedures, lack of knowledgeable Medicaid staff with whom billing problems could be discussed, and low and slow reimbursement rates.

Conclusions

Poor state-level implementation of Medicaid coverage of abortion policies creates barriers for women seeking abortion. Efforts to ensure policies are implemented appropriately would improve women''s health.     

Identifying barriers to billing compliance

Programs designed toward the control of health care fraud are leading to increasingly aggressive enforcement and prosecutorial efforts by federal regulators, related to over-reimbursement for service providers. Greater penalties for fraudulent practices have been touted as an effective deterrent to practices that encourage, or fail to prevent, incorrect claims for reimbursement. In such a context, this study sought to examine the extent of compliance management barriers through a national survey of all accredited US health information managers, examining likely barriers to payment of health care claims. Using data from a series of surveys on the stated compliance actions of more than 16,000 health care managers, we find that the publication and dissemination of compliance enforcement regulations had a significant effect on the reduction of fraud. Results further suggest that significant non-adoption of proper billing compliance measures continues to occur, despite the existence of counter-fraud prosecution risk designed to enforce proper compliance. Finally, we identify benchmarks of compliance management and show how they vary across demographic, practice setting, and market characteristics. We find significant variation in influence across practice settings and managed care markets. While greater publicity related to proper billing procedures generally leads to greater compliance awareness, this trend may have created pockets of "institutional non-compliance," which result in an increase in the prevalence of non-compliant management actions. As a more general proposition, we find that it is not sufficient to consider compliance actions independent of institutional or industry-wide influences.     

Determinants of physician assignment rates by type of service.

In this article, the determinants of physician assignment rates under the Medicare program are examined separately for medical, surgical, laboratory, and radiology services. Data for this study include copies of all Medicare claims submitted by over 1,200 Colorado general practitioners, internists, and general surgeons during the periods both before and after they experienced a substantial change in program reimbursement rates. The results indicate that there is a significant positive relationship between changes in reimbursement and changes in assignment rates for medical, laboratory, and radiology services, but the relationship for surgical service is not significant. Furthermore, for laboratory and radiology services, only the change in medical service reimbursement is significant--reimbursement rates for laboratory and radiology services are not.     

PIC6 Using a Pneumonia-Specific Severity of Illness Model in Assessing Variation in Hospital Length of Stay for Community-Acquired Pneumonia Patients

Epoetin alpha (Epo) for use in dialysis patients represents a substantial expenditure for academic medical centers.
OBJECTIVE: The purpose of this study was to evaluate the efficiency and accuracy of Epo billing and reimbursement systems administered and dispensed in 8 geographically distributed academic health centers.
METHODS: A retrospective chart review was performed for 604 patients across the 8 centers, during the third or fourth quarter of 1989 or the third quarter of years 1990 through 1993. Data collected included HCFA provider number, Medicare number, quantity of Epo prescribed, quantity of Epo recorded as administered for home dailysis, number of doses of Epo not administered as prescribed, reason for missing dose, available hemoglobin and hematocrit values, and relevant information to explain skipped dialysis treatments. The number of units administered or dispensed for home use was matched to an abstract of the HCFA reimbursement files for comparison.
RESULTS: Approximately 18% of the total Epo actually administered and/or dispensed during the course of the study was not represented in the HCFA reimbursement data. This ranged from 2% to 45% in the different centers. The total volume of Epo administered or dispensed per center was not related to the percentage of under-representation in the HCFA reimbursement files.
CONCLUSION: Epo administered and/or dispensed to Medicare primary dialysis outpatients was under-represented in HCFA reimbursement data. As a result, institutions may be experiencing a significant loss of reimbursement. The exact reasons for this discrepancy are unclear. Institutions should evaluate their Epo reporting/billing policies and procedures to potentially increase revenue recovery they are due.     

Illustrating Potential Efficiency Gains from Using Cost-Effectiveness Evidence to Reallocate Medicare Expenditures

ObjectivesThe Centers for Medicare & Medicaid Services does not explicitly use cost-effectiveness information in national coverage determinations. The objective of this study was to illustrate potential efficiency gains from reallocating Medicare expenditures by using cost-effectiveness information, and the consequences for health gains among Medicare beneficiaries.MethodsWe included national coverage determinations from 1999 through 2007. Estimates of cost-effectiveness were identified through a literature review. For coverage decisions with an associated cost-effectiveness estimate, we estimated utilization and size of the “unserved” eligible population by using a Medicare claims database (2007) and diagnostic and reimbursement codes. Technology costs originated from the cost-effectiveness literature or were estimated by using reimbursement codes. We illustrated potential aggregate health gains from increasing utilization of dominant interventions (i.e., cost saving and health increasing) and from reallocating expenditures by decreasing investment in cost-ineffective interventions and increasing investment in relatively cost-effective interventions.ResultsComplete information was available for 36 interventions. Increasing investment in dominant interventions alone led to an increase of 270,000 quality-adjusted life-years (QALYs) and savings of $12.9 billion. Reallocation of a broader array of interventions yielded an additional 1.8 million QALYs, approximately 0.17 QALYs per affected Medicare beneficiary. Compared with the distribution of resources prior to reallocation, following reallocation a greater proportion was directed to oncology, diagnostic imaging/tests, and the most prevalent diseases. A smaller proportion of resources went to cardiology, treatments (including drugs, surgeries, and medical devices, as opposed to nontreatments such as preventive services), and the least prevalent diseases.ConclusionsUsing cost-effectiveness information has the potential to increase the aggregate health of Medicare beneficiaries while maintaining existing spending levels.