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Christopher Skyi, AdvantEdge Healthcare — Mon, 09 Aug 2010 21:29:46 +0000

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What Doctors Need to Know About Medicare Fraud & Health Information Technology

Christopher Skyi, AdvantEdge Healthcare — Wed, 04 Aug 2010 16:32:07 +0000

Medicare Fraud is on the Rise

On Friday July 16, 2010, federal authorities had conducted the largest ever Medicare bust across five states. This raid resulted in 33 indictments and 36 arrests. The alleged fraud totaled $251 million.

“Today’s arrests illustrate how health care fraud schemes can replicate virally and migrate rapidly across communities,” said Daniel R. Levinson, inspector general of the U.S. Department of Health and Human Services, which oversees Medicare. (NYC doctors, nurses arrested in Medicare scams).

On Thursday July 15, 2010, at a hearing of the Senate Subcommittee on Federal Financial Management, U.S. Sen. Amy Klobuchar decried the significant cost that fraud represents each year. The Attorney General of the United States Eric Holder, Jr. estimated that Medicare loses money to fraud at a rate of $60 billion dollars a year. (Medicare fraud robs billions from taxpayers, says Klobuchar).

Medicare fraud is now a huge and growing headache for the federal government, especially since the enormous Part D expansion of Medicare was passed in 2005. Management and oversight of Medicare has become such a challenge that it is now on the Government Accountability Office list of government programs at “high risk” for waste, fraud, and abuse (HomeTownSource.com). With the passage of ObamaCare and the future further expansion of Medicare, unless drastic action is taken, the amount of fraud in the system will increase.

In response to the rise of fraudulent claims, the Obama administration announced in May of ’09 the formation of a new interagency composed of Medicare fraud detection, investigation and prosecution experts from the DOJ and HHS. This agency represents the expansion of a joint DOJ-HHS Medicare Fraud Strike Force that was formed in 2007. This strike force has been successful in fighting Medicare fraud in hotspots such as South Florida, Los Angeles, Detroit, & Houston.

Doctors & Health Care Organizations will Need to Adopt New Health Information Management Technologies

Medicare Fraud Pushes Doctors to Adopt New Health Information Technology

While this stepped up effort by the government will catch more criminals seeking to defraud the system, it will also come at a cost to legitimate medical providers. This is because they will get caught up in the effort to detect and investigate fraud:

“The increasing attention by Medicare and other government agencies is translating to additional administrative/billing requirements for physicians, making an already complex process more complicated,” says Bill Gilbert of AdvantEdge, a medical billing company headquartered in Warren New Jersey. “For example, radiologists will soon have to include a national provider ID number (the number attached to physicians registered with Medicare) for the referring physician on their radiology bill. Since there are numerous well-known glitches in the NPI process (the system for NPI registration is called PECOS), there will inevitably be radiologists who don’t get paid or who have payments delayed because of the extra information required.”

Because of the increase in government effort to detect fraud, legitimate medical providers would do well to carefully document everything says Bill Gilbert:

If a practice is carefully documenting, coding, and billing (like AdvantEdge does) they have nothing to fear. However, practices that do not have formal procedures in place or that have higher error rates are going to be audited. These practices are not committing fraud and have no ill intent, but they may find themselves owing Medicare substantial sums. The definition of Medicare fraud is essentially “any improper billing” which could be as simple as submitting the wrong code.

Unfortunately, according to recent study by the Commonwealth Fund, a leading private health care think tank, few medical providers today are adopting to new modern health information technologies because of the cost involved.

However, the cost of waiting may well be higher. If the U.S. healthcare industry en mass does not start to modernize to new health information technologies now, it’s likely to soon find itself in the crossfire of the U.S. Government’s coming war on Medical insurance fraud.

Adopting Electronic Health Records Would Benefit Physician’s Bottom Line

Christopher Skyi, AdvantEdge Healthcare — Mon, 26 Jul 2010 19:47:28 +0000

. . . But Will They Do It? Can They Do It?

According to Bill Gilbert of AdvantEdge Healthcare Solutions in their article Physician, Heal Thy Practice published in “Health Information Management,” most physician offices are still in the stone age when it comes to using health information technology to manage their office and billing workflow:

[they] still take notes with pens and clipboards, double-enter patient information on computers installed years or even decades ago, collaborate via inter-office faxes, and so on.

A 2009 survey by the Commonwealth Fund agrees with Gilbert’s assessment. The survey found that the U.S. healthcare industry has an electronic health record adoption rate of only 28%, well below that of five other countries and only inching past that of Canada.

Despite a Rand study that demonstrated both cost savings and improvement in health care quality when health information technology is properly implemented, few physicians are moving forward to take advantage of modern electronic medical billing, electronic health records, and other health information technologies. Why?

One reason, posits Gilbert is rapidly rising health care costs:

. . . spiraling health care costs put intensive downward pressure on physicians’ revenue while, at the same time, put upward pressure on their costs. The result: another “catch 22″ in the health care crisis.

Specifically, according to the Medical Group Management Association (MGMA), an electronic health record system (EHR) can cost upwards of $500,000 to install. Worse, salary and training EHR operators will on average cost more than an existing labor force that manages old fashion paper records. Add on ongoing IT maintenance costs and its little wonder that all but the largest health organizations can even think about implementing such systems.

The Federal Government’s Carrot and Stick Approach | Electronic Medical Billing & EHR — or Else.

According to the St. Louis Business Journal (EHR providers continue to wait on stimulus boost), the federal government has acknowledged the high adaption costs to doctors. The government has introduced both incentives and penalties in last year’s American Recovery and Reinvestment Act to encourage doctors to purchase electronic medical billing software to take advantage of new electronic health records formats that can easily be shared across platform independent, network-connected, enterprise-wide, information systems. Legislators included $36 billion in subsidies to help doctors purchase these new health information systems. These subsidies and incentives will slowly fade out over five years – that’s how long doctors have to take advantage of them before the government begins to penalize physicians who fail to adopt electronic medical billing software and electronic health records.

Will the carrot and stick approach work? Only time will tell, and now the clock is ticking . . .

Advantages Of Outsourcing Physician Billing Services

Christopher Skyi, AdvantEdge Healthcare — Mon, 28 Jun 2010 17:38:53 +0000

Outsourcing Physician Billing Services Is Part of an Overall Trend

Physician billing and other back office administration functions impact critically on medical organization’s profit margins.

The time involved in these “revenue cycle management” tasks, as important as they are, becomes a problem for most physicians because of the enormously time they require. In order to deliver the best possible patient care, most of a physician’s time and energy, and his or her staff’s, is spent trying to keep up with constantly advancing medical technology — looking for envelopes, stamps and double checking diagnostic and testing codes on increasingly complex insurance forms is the last thing they want to be doing, even if they had the time for it, which they don’t.

So what to do? Outsource!

“The fact is that there is less waste and more efficiency when you let an outside expert take care of billing,” states Stephen G. Sullivan, Sr., Advantage Healthcare Solutions Founder and Executive Vice President.

Both types of medical practices, hospital based practices vs. office-based practices, benefit equally from outsourcing their billing needs. Often hospitals have staff dedicated to billing while office-based practice staff handles both billing and patient needs.

Outsourcing allows hospitals to reduce the cost associated with maintaining an in-house billing staff and office-based practice staff are freed to devote more time to patient needs.

CEO Langsam sums up the advantages of outsourcing as follows: “People and organizations are always looking for results. [A medical billing company like] AHS takes the risk and mystery out of the billing process.

(Source: Advantedge Healthcare Solutions (AHS) Announces Reasons for Outsourcing Medical Billing, Improving Billing Processes and Increasing Productivity; Attends MGMA Conference in Philadelphia, PA)

Find out how Advantedge Healthcare Solutions (AHS) is helping practices and centers just like yours collect more revenue and reduce days in A/R. Call us now on 877-501-1611 for your free net collections analysis. Ask for Bill, Brice, Robin, or Wade. Or visit Advantedge Healthcare Solutions’ contact us page.

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AdvantEdge Improves its Ability to Help Anesthesiologist Accurately Bill Medicare & Medicaid

Christopher Skyi, AdvantEdge Healthcare — Mon, 21 Jun 2010 18:45:08 +0000

AdvantEdge Healthcare | Helping Anesthesiologist Accurately Bill Medicare & Medicaid

Warren, NJ, and Dayton, OH—January 27, 2010–
AHS acquires MAS, leading Ohio anesthesia billing company

AdvantEdge Healthcare Solutions (AHS), one of the nation’s leading providers of medical billing and practice management services, today announced that it has acquired Medical Account Services (MAS), the premier anesthesia billing company throughout Ohio. This agreement will expand AHS anesthesia billing and practice management operations and enable the Company to serve additional anesthesia clients in Ohio.

Understanding and applying the correct coding and compliance conventions can be challenging if not overwhelming. This acquisition represents an advance in AdvanEdge’s ability to help anesthesiologist correctly bill Medicare and Medicaid for services, a necessary precondition for optimizing reimbursements.

Says Bill Gilbert, Vice President of Marketing for Advantedge Healthcare Solutions:

Today, fewer than 20 percent of physician practices outsource their billing and practice management. AHS’ proprietary software supports an optimized workflow for specialist physician billing and leads to improved revenue for their physician clients. The powerful billing technology runs on IBM System i servers. AHS is the exclusive IBM VIP Business Partner for physician billing.

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Medical Billing Software Gets More Complex | Risks & Opportunities

Christopher Skyi, AdvantEdge Healthcare — Fri, 11 Jun 2010 18:15:54 +0000

Risks & Opportunities Of Increasingly Complex Medical Billing Software

Medical billing software systems have grown more complex in response to increasingly complex medical billing procedures. Bill Gilbert of AdvantEdge Healthcare Solutions says this has created a situation “that is ripe for misusing these tools to not only accidentally over-reimburse but to submit false claims-with the attendant risks and penalties.”

This concern is not new. Back in 2000, The Department of Health and Human Services ordered its Office of The Inspector General to survey the different types of medical billing software to identify how the Medicare reimbursement process could be adversely affected. The Office of Inspector General surveyed four types of systems that existed then to identify their strengths, weaknesses, and potential for abuse.

HHS concluded that commercial grade medical billing programs “pose little risk of producing erroneous or false claims.” They considered proprietary software, on the other hand, to be more “black boxes” with a higher risk of misuse or fraudulent use. In all systems, the likelihood of human error greatly outweighed the chances of software error.

Since the HHS released this report, the medical billing industry has seen the emergence of EMR/EHR systems. “These systems generally make it easy for providers to pick procedures and diagnostic codes (e.g. from a drop-down menu),” says Bill Gilbert of AHS. “If these products encourage providers to overuse particular codes, there can be substantial risk to the practice.”

This increased complexity in medical billing software has led to an increased demand in trained medical billing workers.

The training and certification of medical billers and coding specialists is typically strict,” says Bill. “For example, many medical billing companies require their billers to be CPC (Certified Professional Code) certified, and such certification requires formal class work followed by a certification process from an industry-recognized institution.”

In short, Medical billing software is only going to get more complex going forward and the demands on medical billing providers is going to increase, but for those with the right training and experience, their employment future is looking bright

(Source: What is Medical Billing Software & Who Are Qualified Medical Billers?)

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Billing, Coding and Collection Mistakes Affect The Bottom Line

Christopher Skyi, AdvantEdge Healthcare — Tue, 27 Apr 2010 16:36:02 +0000

Simple billing, coding or collection mistakes can affect the overall profitability and efficiency of an ASC. Brice Voithofer, vice president of anesthesia and ASC services for AdvantEdge Healthcare Solutions, shares his insight on the top three billing, coding and collection mistakes he sees at ASCs — and how to avoid them.

Tips On Avoiding Costly Medical Billing Errors

3 Common Surgery Center Billing, Coding and Collection Mistakes
Written by Renee Tomcanin
Beckers ASC Review
Wednesday, 23 September 2009 21:36

1. There is no automated denial management system.
Receiving denials from payors is one aspect of the billing and collections process surgery centers deal with on a routine basis. However, Mr. Voithofer says many ASCs fail to implement a system of tracking and trending for these denials, which is, in his opinion, the most common mistake ASCs make when it comes to their billing practices.

“Most surgery centers will fix the individual denial, resubmit the claim and in many cases eventually receive payment,” Mr. Voithofer says. “But, they don’t aggregate these denials in a report to see what the root causes of the denials are.”

Mr. Voithofer suggests developing denial reports so that the center can look at denials by payor, surgeon, referring physician, procedure, etc. “Centers can use these reports to pinpoint where errors and omissions that most frequently result in denials occur and then attempt to reduce those mistakes through education,” he says.

Gathering data on the number and dollar amounts of denials can also provide ASCs with additional information when discussing problems with payors or surgeons.

“If one payor is consistently denying claims, arrange to meet with that payor to change the activity,” Mr. Voithofer says.

2. One staff member is responsible for the duties of many.
Surgery centers often only employ one or two coders and/or billers to handle all of the functions of the billing office. According to Mr. Voithofer, this can lead to errors due to the volume and variety of work the billers are required to do.

“Typically, centers find one or two employees to perform all functions, and they expect that single person to be an expert in all of them,” Mr. Voithofer says. “This rarely works. We typically see that they will excel at some, but fail at others; a Jack of all trades is a master of none.”

While some centers are able to work well with just a few billers and coders, Mr. Voithofer notes that in other centers something — compliance, cash collections, etc. — will usually suffer as a result. Adding staff or outsourcing some operations may be justifiable if a decrease in errors and increase in efficiency leads to improved financial results that cover these costs.

3. Inaccurate dictation can lead to underbilling or overbilling.

Coders rely on accurate dictation of procedures from surgeons so they can bill appropriately for them. Mr. Voithofer says that many times coders will bill correctly for the main procedures but miss add-ons if the report is not clear.

“Dictation and transcription are often done quickly so they can get to billing,” Mr. Voithofer says. “However, ASCs can take these missed add-ons as opportunities to educate staff members and find more revenue.”

Mr. Voithofer suggests having coders sit down and look over reports with the surgeons every six months.

“The coder can say to the surgeon, ‘When you do this procedure, you missed these steps in the report,’” he says. “Or the coder can help to point out trends in the surgeon’s procedures. By looking over the reports, the coder and the surgeon can try to create a thorough report so that centers are not over- or under-billing.”

Mr. Voithofer does caution that the purpose of this analysis is to address deficiencies in documentation, not to look for an opportunity to “pile on the charges.” Clinically appropriate documentation and coding is the objective.

How to Improve Ambulatory Surgery Center (ASC) Collections

Christopher Skyi, AdvantEdge Healthcare — Wed, 14 Apr 2010 21:04:13 +0000

4 ASC collection Tips from AdvantEdge Healthcare Solutions

Bill Gilbert, vice president of marketing, and Brice Voithofer, vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions, provide four tips for using quality improvement steps to boost collections at ASCs: 1) Ensure you collect enough information at pre-registration; 2) Educate surgeons on the surgery center’s billing and coding process; 3) Treat each case as though it were a workers’ compensation case; 4) Involve staff members in a bonus plan to reduce billing errors.

Using Quality Improvement to Improve ASC Collections: 4 Tips from AdvantEdge Healthcare Solutions
Beckers ASC Review
December 8, 2009
Written by Renee Tomcanin

1. Ensure you collect enough information at pre-registration. ASC staff members have a tendency to think of their jobs in terms of departments or silos. Surgical, technical, administrative staff — each focuses his or her individual part in the area of the surgery center in which they are assigned. However, it is the interactions, or lack thereof, between departments that often are the source of inefficiencies that can affect the ASC’s overall revenue cycle, according to Mr. Gilbert.

“Quality improvement is about those seams between groups and individuals, particularly hand-offs,” he says. “I think it’s human nature to concentrate on our jobs and not to think about, or even know what someone else does with our work.”

One area where these interactions can affect a surgery center’s revenue is at patient registration. “Billing is affected as soon as the beginning of the whole [surgery] process,” Mr. Voithofer says. “If done correctly, everything moves smoothly; otherwise, problems can snowball through to the back end.”

One of the errors the front desk can make when first registering a patient is failing to obtain vital pieces of patient data. For example, workers’ compensation claims require detailed information, such as date of injury, case number and the company’s insurer’s name.

“In many cases, the front desk will miss the date of injury or some other piece of data, and the claim will be billed out and then denied, or, repeated calls are made to the surgeon’s office to obtain this data – further delaying claims submission,” says Mr. Gilbert says. “The back end, then, has to chase down the missing information. If the correct information was gathered at pre-registration or at registration, phone calls and re-work could have been avoided by the collections staff.”

Mr. Voithofer says, “It is much more efficient to have staff making calls to the insurance company or patients to resolve balances versus chasing data which should have been collected at the beginning of the process.”

Mr. Voithofer notes that the longer a claim remains in accounts receivable, it becomes more difficult for an ASC to collect and also increases the likelihood that the surgery center will collect less than what is owed. “Surgery centers are actually paying more [through additional staffing costs] to collect less,” he says.

Mr. Voithofer suggests that surgery centers look at historical denied claims information, identify common problems and then update the list of questions asked at scheduling and pre-registration to account for information missed by the front desk.

2. Educate surgeons on the surgery center’s billing and coding process. Another place information hand-offs can lead to inefficiencies in an ASC’s revenue cycle is between surgeons’ operating reports and coders. Coders depend on accurate surgical reports in order to code procedures to bill insurance companies.

“This process requires understanding on the surgeon’s part,” Mr. Gilbert says. “It’s a feedback loop [between the physician and coder] that can have a huge financial impact. Errors could lead to improper billing and even compliance risks.”

Managing multiple physician groups that practice at the center can complicate this risk. Mr. Voithofer says, “Most surgery centers deal with 5 to 15 different physician groups (unless the center is wholly owned by one group), and the employees of the ASC don’t report to the surgeons, so the surgeons may not see the impact their work has on the center. They might not even know those involved in the billing department, and they won’t see that a missed code or note in the report results in three additional phone calls and delays cash for the center.”

Mr. Gilbert and Mr. Voithofer say that educating physicians about the impact of incorrect or incomplete reports on the center is an important quality improvement step. “This is not part of their training,” Mr. Gilbert says. “Ninety-nine percent of their training is devoted to how to perform surgery and not to documentation.”

3. Treat each case as though it were a workers’ compensation case. Workers’ compensation and motor vehicle accident cases typically require the largest amount of documentation and information, according to Mr. Gilbert. “These cases are more complicated, and, typically, a case manager is assigned by the employer or auto insurance company. Some claims are even filed on paper. They are different than commercial payors and usually subject to more scrutiny,” he says.

This scrutiny can be attributed to the complex nature of workers’ compensation and MVA cases that occur outside of the ASC. Mr. Voithofer says, “Insurance companies for these cases are set up for the highest level of scrutiny because they don’t want to pay for more than they have to. These claims require timely, accurate, well-monitored processes, and the claims won’t be paid until every last item is checked and is correct.”

For example, in knee surgery performed on a workers’ compensation patient, payment won’t be authorized if claims don’t include the exact number of tendons or compartments operated on, according to Mr. Voithofer.

Although many orthopedics or pain management cases are workers’ compensation or MVA cases, a surgery center may not immediately know up-front if this is the case, and, as a result, they will have to backtrack and retrieve the required information and lose time. For this reason, Mr. Voithofer suggests that ASCs treat every patient that presents to the surgery center as a workers’ compensation or MVA case.

“It should be a consistent process,” Mr. Voithofer says. “If an ASC can get it perfect with workers’ compensation, easier cases will see significant reductions in A/R.”

4. Involve staff members in a bonus plan to reduce billing errors. One more way to improve billing processes is to involve the entire staff in a bonus program that aims to reduce denied claims and billing errors. Surgery centers can do this by taking another page from the manufacturing industry.

“One key measure in quality improvement is defect rate,” Mr. Gilbert says. “Motorola, for example, can manufacture several million cell phones with only one defect. If a surgery center can set up processes to minimize defects for difficult cases, the error rate will be at least as low and probably lower in typical cases. Money is saved by reducing the time spent chasing errors.”

Surgery centers can better “reduce defects by improving their accuracy, and by providing bonuses, they can better incentivize all staff members to work to reducing billing errors,” according to Mr. Voithofer. “ASCs can involve all employees by putting them on a bonus structure; if they improve throughput while minimizing errors, they will receive a bonus. This will incentivize the staff and help them to see the impact of their behaviors on others at the ASC.”

Mr. Voithofer impresses upon his staff that it takes less time to do the job right the first time than it does to explain why it was done wrong and then perform the work again. He also notes to set attainable goals; 99.9 percent may be out of reach, but 98.5 percent accuracy might not be.

Mr. Gilbert says, “The notion of quality improvement and quality processes is well-known, perhaps taken for granted in other industries. Surgery centers can benefit from thinking along these lines. It is common sense, but many centers aren’t thinking this way.”

Drive ASC Denials Down

Christopher Skyi, AdvantEdge Healthcare — Mon, 05 Apr 2010 20:39:35 +0000

A surgery centers cost and revenues are critically depended on successful “denial management,” but what does that mean exactly? Bill Gilbert, Vice President of Marketing, and Brice Voithofer, Vice President of ASC and Anesthesia Services for AdvantEdge Healthcare Solutions simplifies and clarifies this oft poorly understanding and complicated approach to handling unresolved claims.

Drive ASC Denials Down to Reduce Costs & Drive Revenue Up
Beckers ASC Review
February 10, 2010
By Bill Gilbert, Vice President of Marketing, and Brice Voithofer, Vice President of ASC and Anesthesia Services

Billing is one of the most critical (and often overlooked) processes in the success of every surgery center. Most people involved in directing and operating ASCs know that billing and coding require daily attention to detail, trained staff and a solid understanding of ever-changing payor “rules.” Yet, somehow, the importance of “denial management” is still not understood very well, even though it is a trendy buzzword.

In fact, denial management is treated in many different ways based on the construct of a center’s business functions. Here is one successful approach for managing and preventing denials.

Today in Health Information Technology

for Technorati

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