Opportunities and Warnings about Reimbursements

Maddox Casey, CPA, MBA

"We have a problem with patients disregarding their medical provider, and that shows in many ways," says Maddox Casey, CPA, MBA, with Warren Averett healthcare division. "And one is cancellations." Those no-shows can notably lower revenue.

To fill those unplanned vacancies, practices can take a simple cue from restaurants. "Create a short list of patients waiting for appointments," Casey says. "Tell your patients requesting a visit, that if anyone cancels, you can call them back."

Unfortunately, electronic medical records (EMRs) rarely have a widget for this task, meaning the list must be kept manually. However, customization could be an option. A gastroenterologist in Florida not only had a software program that kept a list, but it alerted patients to their position. "When they got to No. 1, they knew to stay close to home and be ready," Casey says.

Code 99483

Sae Evans, CPA

A new revenue opportunity has risen this year with a Medicare option for primary care physicians dealing with geriatric patients. In January, CMS started reimbursing $242 on average to physicians for performing a cognitive assessment and developing a care plan. The test--CPT code 99483--helps determine medical decision-making, daily living capabilities, neuropsychiatric and behavioral symptoms, and caregiver abilities. "This is new," Sae Evans, CPA with Warren Averett, says. "Usually these would be limited to neurologists, but now primary care physicians can perform this function, which helps patients who never follow-up at specialists despite their physician's urging."

Eligible patients include those diagnosed with Alzheimer's, other dementias, or mild cognitive impairment. But any patient can be assessed if the physician judges that person to be cognitively impaired.

"If you've re not doing it, now you can, and you can get paid for it," Casey says, adding the service can be reimbursed every 180 days. "Physicians get paid a fourth of that for an office visit, so this is a serious revenue opportunity with such a large graying population."

Beware Changing Certifications

A potential hit to any Medicare provider's revenue could result from a recent switch in the state's claim processor. The Medicare carrier for Alabama, Georgia and Tennessee shifted from Cahaba GBA to Palmetto GBA in February. "From a reimbursement perspective, we're seeing an issue around credentialing," Casey says.

New providers may be waiting twice as long right now. "We used to see a Medicare application completed in 90 days as a rule of thumb. Now it's taking 180 days," Casey says. "You can imagine how that can impact your revenue if you're not able to claim that work."

Evans says the delay will be temporary. "When Palmetto took over, they were continuing to try to process the backlog from Cahaba," he says. "They're having difficulty working through those, so the new ones overall are taking longer which delays reimbursements."

Billing Staff Equals More Revenue

Further delays and even outright loss of revenue can result from what might appear to be a savings. "We sometimes see doctors who appreciate what the clinical staff do, but not what the billing staff do," Casey says. "So if someone quits the billing staff, the clinic does not replace them. This leaves the billing department shorthanded and only able to get today's claims out the door with no time for correcting rejections or denials."

"Working denials can be harder than working a claim," Evans says. "Time may be needed to track down why the claim was denied, along with time to contact the patient for correct information, let alone for the paperwork itself.

"The backlog will hit the practice's bottom line. For one practice, it was hundreds of thousands of dollars that we helped get caught up on. The clinic had to hire one additional billing person. Once they did that, we could effectively help collect that revenue balance."

When ignored, the losses can get outrageous. A specialty practice was found to have 90-day, past-due receivables totaling over a half million dollars in the insurance category and $400,000 owed by patients. "If insurance is that old, that means somebody is not doing their job," Evans says. "When patient receivables are that old, you're not going to get paid." Those delays can become irretrievable losses even from payers since many insurers have filing time limits.

Guaranteed Three-Percent Loss

A new payment form by insurers will soon be biting into every clinic's reimbursement totals. Single-use virtual card payments allow the insurer to fax or email a 16-digit credit card number to a physician's office as payment for claims. No more checks.

The clinic runs the number through the credit card terminal and incurs the usual interchange fee averaging three percent. "The payer saves money," Casey says. "But they're effectively lowering your fees."

The virtual card payments started about a year ago. Some larger companies have been using them, but Blue Cross has held off so far. "It will mean you're taking an initial three percent cut. And if you performed a joint replacement, that's a big number," Casey says. The chance of insurers not choosing this cheaper method is minimal, leaving providers with an inevitable three percent revenue drop. "You're forced to say, 'No, give me a check,' and wait for however long that may take now, or just take a three percent hit."


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Warren Averett; Maddox Casey; Sae Evans; reimbursement;



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