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  • The bonus payment, subject to a cap, is the equivalent of 1.5% of total allowed charges for services paid under the Medicare physician fee schedule for services provided from July 1 through December 31, 2007.
    Those who successfully report quality measure data on claims for services between July 1 and December 31, 2007, will be eligible for a single consolidated incentive payment in mid 2008.
    The Tax Relief and Health Care Act section 101 specifies that, for 2007, CMS must use the taxpayer identification number (TIN) as the billing unit, so any bonus incentive payments earned will be paid to the holder of the TIN. For those who assign their benefits, that entity will receive the bonus payment.
  • The Bonus Incentive Payment Cap may apply when an eligible professional reports relatively few instances of quality measure data. As previously mentioned, the more measures that are selected and reported, the more likely the cap will not affect the bonus payment.
    The Cap is calculated by multiplying (1) the total instances of reporting quality data for all measures they submitted by (2) a constant of 300% by (3) the national average per measure payment amount (NAPMPA).
    Here is an example -- Assume that the NAPMPA is $100. This is multiplied by 300% to get $300. If the individual only reports 10 times on one measure with limited application to the practice, then the cap would be $3000. This may be below the full 1.5% that they are eligible to receive.
  • Transcript

    • 1. Managing Cancer Practices in Whitewater Times ANCO Membership March, 2008
    • 2. Many Thanks To RemitDATA for the cool statistics herein
    • 3. Areas for Improvement  Managing Managed Care  Managing the Top Line  Managing the Cash Cycle  Managing Efficiency  Summing It All Up
    • 4. Get Over It! 0 5 10 15 20 25 One Two Three Four Five Six Seven Eight Nine Ten Self Score Ability to Negotiate With MC Payers Series1 From my survey of 120 practice managers in 2006 who rated themselves on a scale 1-10 in terms of negotiating skills.
    • 5. Think You Can’t Negotiate? Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S. © RemitDATA All Rights Reserved Primary Payers only Per Unit Allowed amounts by procedure HCPC Average 90765 105.41 83.46 71.53 92.47 90767 56.44 47.78 40.00 52.14 96413 269.00 199.00 161.00 214.82 99214 109.78 95.87 84.68 97.25 99245 292.59 245.96 213.93 253.48 Per Unit HCPC Medicare J0640 3.75 2.31 1.12 $0.86 J0881 5.49 3.92 3.05 $2.89 J0885 15.00 12.01 10.65 $8.96 J9265 165.82 55.00 15.12 $13.58 J9310 555.40 517.36 499.13 $508.66 75th 50th 25th Data included is for all claims with a Check Date between 10/1/2007 and 75th Percentile 50th Percentile 25th Percentile
    • 6. Think You Can’t Negotiate?  CPT Codes: Range of Allowed Payments Compared to Medicare Allowed amounts by procedure 90th 75th 50th 25th 10th Average Medicare % Medicare Procedure RVUs 90765 1.97 $122.41 $105.64 $83.46 $71.53 $64.00 $92.55 $73.89 125% 90767 1.02 $133.96 $87.72 $52.70 $42.51 $36.75 $72.17 $38.09 189% 96413 4.27 $319.30 $269.00 $199.00 $161.00 $146.58 $215.06 $161.49 133% 99214 2.53 $118.09 $109.78 $95.87 $84.68 $69.83 $97.32 $89.89 108% 99245 6.25 $310.00 $292.59 $245.96 $213.93 $192.62 $253.48 $220.90 115% Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S. © RemitDATA All Rights Reserved
    • 7. Think You Can’t Negotiate?  Conversion Factors (Medicare = $38.0870) Procedure RVUs 90th 75th 50th 25th 10th Average 90765 1.97 $62.14 $53.62 $42.37 $36.31 $32.49 $46.98 90767 1.02 $131.33 $86.00 $51.67 $41.68 $36.03 $70.76 96413 4.27 $74.78 $63.00 $46.60 $37.70 $34.33 $50.37 99214 2.53 $46.68 $43.39 $37.89 $33.47 $27.60 $38.47 99245 6.25 $49.60 $46.81 $39.35 $34.23 $30.82 $40.56 Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S. © RemitDATA All Rights Reserved
    • 8. Think You Can’t Negotiate? . Per Unit HCPC Medicare J0640 3.75 2.31 1.12 $0.86 J0881 5.49 3.92 3.05 $2.89 J0885 15.00 12.01 10.65 $8.96 J9265 165.82 55.00 15.12 $13.58 J9310 555.40 517.36 499.13 $508.66 Data included is for all claims with a Check Date between 10/1/2007 and 75th Percentile 50th Percentile 25th Percentile Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S. © RemitDATA All Rights Reserved
    • 9. Managing Managed Care  Basics  Know your RBRVS  Know your drug payment methodologies  Know your patient profile  Know your “walk away”
    • 10. RBRVS Basics  3 inputs go into the total RVUs  Work = Face-to-face physician time, plus intensity of work  Practice expense = practice expense relative to other procedures (with no intensity of expense)  Malpractice insurance costs (< 5%) = malpractice risk  Equation is ((W*WGPCI)+(PE*PEGPCI)+(M*MGPCI)) times the conversion factor = Fee Schedule AllowableFee Schedule Allowable for all codes except labs and drugs
    • 11. Know YOUR RBRVS  How are managed care companies using RBRVS?  Not! Using a percentage of Medicare.  Using a different conversion factor  Using no GPCIs  Using old fee schedules--good and bad
    • 12. RBRVS Talking Points  The Medicare conversion factor is a governmental aberration that has nothing to do with economic conditions.  RBRVS was developed for procedural specialties. It does not work for specialties who have indirect physician participation.  Most drug administration code payments have nothing to do with cost. Many actual costs have never been captured by anyone.  Most private payers pay hospital outpatient services based on charges. It is cheaper for patients to stay in the community setting.
    • 13. Know your drug payment methodologies  What are they using?  Average Selling Price, plus  Average Wholesale Price • Red Book • Orange Book • Medispan  Wholesale Acquisition Cost  Widely Available Market Price  Average Manufacturers Price
    • 14. Managed Care Bottom Line  Medicare RBRVS  What is the the net allowable that is paid by Medicare versus the MCO?  How does that translate into a conversion factor? More later…  Drug payment  Figure out whether their methodology meets their contract language  Ascertain by regimen what tumor types are “underwater” as appropriate using PROTOCOL ANALYZER®  Can you ask for more???
    • 15. Know Your Patient Profile  Develop statistics for the following:  Patients in their plan who are out of treatment and are alive per year.  Hospitalizations/ patient and per patient aggregated per thousand for your practice  Average back to work time  Average payer cost per patient; per tumor type  Compare your data to national norms
    • 16. Patient Profile  Helpful national statistics  Discharges/1000 = 117.44*  Average inpatient LOS per cancer patient = 6.8 days*  # of ER visits per 100 persons =39.6*  Average days missed for young women with breast cancer in one study = 29 days within three months of initial treatment** *National Committee on Health Statistics ** “Quality of Life Among Young Woman With Breast Cancer”; Journal of Clinical Oncology, Vol 23, No 15 (May 20), 2005: pp. 3322-3330 © 2005 American Society of Clinical Oncology.
    • 17. Know Your Walk Away  Number of patients in treatment  Past net reimbursement  Projected annual net reimbursement  % rise or fall  What is their net conversion factor?  Net collected service reimbursement divided by total relative values = CCF  Net direct cost per paid RVU = DCCF  CCF-DCCF = Profitability per RVU  Can add a “fudge factor” for hassle factor, e.g. pre- authorization, slow payment, referrals
    • 18. Know Your Walk Away  Drugs  “Underwater” or net profit after co-pays  Regimen-by-regimen comparison  Public relations  Contract confidentiality  Coordination of patient benefits  Out of network
    • 19. Managing the Top Line  Integration  Backwards • Hospital-Physician networks • Hospital-Physician Cancer Care Networking • Cancer Care Hospital formation? Physician-owned?  Forwards • Radiation • Radiology • Pharmacy • Gyn-Onc • Ped-Onc • Hospitalists • Surgery: Ports, PICCs, Biopsies
    • 20. Managing the Top Line  Can you reset your fees?  National Ranges® from multiple public and private databases. • 90767 = Range $39-86 • 90772 = Range $29-42 • 96413 = Range $230-303 ® MAG Mutual Healthcare Solutions, Inc. All Rights Reserved
    • 21. Managing the Top Line  Billing for all allowable services  Smoking Cessation  PQRI  Discharge > 30 minutes  Missed Appointments  Care Plan Oversight Services  Home Health Certification
    • 22. Tobacco Cessation Getting Paid  Effective March 22, 2005, Medicare covers tobacco cessation counseling for patients who smoke and have a tobacco-related disease or whose therapy is affected by tobacco use.  Effective January 2006, Medicare's prescription drug benefit covers smoking cessation treatments prescribed by a physician.  Carriers are supposed to start paying new codes January 1, 2008.
    • 23. Smoking Cessation Billing for tobacco cessation counseling CPT codes  99406 (was G0375): Smoking and tobacco use cessation visit; intermediate; counseling for 3-10 minutes  99407 (was G0376): counseling for more than 10 minutes  Can be used for all payers now…
    • 24. Smoking Cessation Billing for tobacco cessation counseling CPT codes  8 visits annually allowed in 12 month period (4 sessions per attempt).  Counseling < 3 min covered under E&M code.  Can have an appropriate E/M service on same day, use modifier -25 as long as there is no duplication of therapy.  Face-to-face counseling time can be “incident to”.
    • 25. Tobacco Cessation Billing for tobacco cessation counseling ICD-9-CM codes  305.1: Tobacco Use Disorder or  V15.82: History of Tobacco Use  Provide other clinically relevant diagnosis code, such as cough, lung cancer, chemotherapy, etc. that is adversely impacted by smoking.  Document time spent counseling for tobacco cessation  There are PQRI measures that go with this…
    • 26. Tobacco Cessation  99406, Intermediate  WRVU = 0.32  Fee = $12.19  99407, Intensive  WRVU = 0.65  Fee = $23.99
    • 27. To PQRI or Not to PQRI?  What is PQRI?  It is the Medicare Physician Quality Reporting Initiative. In plain English, CMS will pay you a bonus to report what they want you to report.  It is a strictly voluntary program in 2008. It is reported by National Provider Identification Number. According to my estimates about 40- 50% of Medical oncologists are participating in 2008. This varies geographically.  There are 119 measures to choose from and they can be found at http://cms.hhs.gov/pqri • Use measures that apply most your mix of services. • Use those that might help you reach a reporting or quality goal for your group. • Know that every group is different in terms of what measures are applicable to them. All measures should be reviewed with providers.
    • 28. Physician Quality Reporting Initiative (PQRI)  Bonus Payment  Participating eligible professionals who successfully report may earn an approximate 1.5% bonus, subject to a cap • To earn it, each provider must report 80% of at least three measures. Providers can report fewer measures, but this will be subject to statistical validity testing. • 1.5% bonus calculation based on total allowed charges (the sum of all billed allowables) during the reporting period for professional services billed under the Physician Fee Schedule. This does not include laboratory services or drugs. This bonus will not be determined until the end of 2008, but it is expected to be 1.5%.  Bonus payments will be made in a lump sum in mid-2009 to the holder of record of the Taxpayer Identification Number (TIN)  No Medicare Advantage patients will be included in your calculation.
    • 29. Physician Quality Reporting Initiative (PQRI)  Bonus Payment Cap  A Cap may apply when relatively few instances of quality measures apply and are reported and will be applied to each NPI. You will be paid the lesser of the cap amount or your 1.5%. This is why frequency of reporting is important.  Cap calculation = (Individual’s instances of reporting quality data) X (300%) X (National average per measure payment amount, which is not known until the following year) National average per measure payment amount = (National charges associated with quality measures) / (National instances of reporting)  Example is if you had 100 incidents of reporting x 300% = 300 and the hypothetical national payment average amount was $100, the CAP for you would be $30,000. If your 1.5% allowed revenue exceeds $30,000, you would be paid the CAP.
    • 30. PQRI Participation--Good or Bad?  Hypothetical example of a Hem-Onc practice without Radiation or other ancillary services…  Six-physician Oncology Practice, 4.0 NPs  $22.7 million in total allowed charges projected for 2007 • 50% Medicare • $2,200,000 = Procedures (mostly drug administration) • $3,100,000 = Evaluation & Management • $17,400,000 = Drugs • No lab in office • Does not account for patient portions  1.5% of one year of procedures = approximately $40,000 if they all report and exceed the CAP.  BUT, if your practice has procedure-based services, this can be much larger…
    • 31. Discharge Over 30 minutes  Must be the discharging MD  30 minutes of FLOOR time; must be documented in the medical record  Billed 30,067 times in 2005 by Hem-Onc’s with 5% denial rate (less than average)  22% of 2005 discharges billed by Hem-Onc’s  2008 RVUs = 2.67  Average Medicare Reimbursement = $92.93
    • 32. Medicare: Missed Appointments  Transmittal 1279, CR 5613  May charge Medicare patients as long as you charge all patients equally at the same amount for missed appointments, unless contractually you are unable to do so (Medicaid).  May not charge for a specific item or service but for a ‘missed business opportunity’.  May not charge these to Medicare, but to the patient directly.
    • 33. Care Plan Oversight Services (Medicare)  Complex billing rules with heavy denial rate and audit follow-up.  G0181, Home Healthcare Oversight, 30 minutes per month= $103.98  G0182, Hospice Oversight, 30 minutes per month = $107.79  G0181 billed 1253 times by Hem-Onc’s in 2004 with 25% denial rate.  G0182 billed 2313 times by Hem-Onc’s with 33% denial rate
    • 34. Care Plan Oversight Medicare  Billing Requirements (Section 180.1, Chapter 12, Claims Processing Manual)  Chapter 15, Benefits Policy Manual are met; may not be billed ‘incident to’  No other services may be billed on the same claim  May only bill at the end of the month in which services were rendered.  Bill for one unit of service  Must have the provider number of the HHA or hospice.
    • 35. Care Plan Oversight (Private)  99374-99380  Start at 15 minutes  Includes Nursing Facilities, which Medicare does not.  BUT, physician involvement and documentation requirements are steep.
    • 36. Home Health Cert/ Re-cert  G0179-G0180: Billed 2541 and 5227 times in 2004; denied 12% and 7% respectively.  G0179: Home Health Re-certification = 1.22 RVUs = $44.56  G0180: Home Health Certification = 1.61 = $58.27
    • 37. Home Health Cert/ Re-Cert  Code G0180 can only be billed when the patient has not received Medicare- covered home health services for at least 60 days.  Code G0179 can only be billed when the patient has had services for at least 60 days (one certification period) and is reported every 60 days.
    • 38. Keeping Your Revenue  Fraud Issues  Benefit Integrity Unit Screening  Qui Tam • Place of Service • “Incident to” • Free drug billing • Billing for non-delivered or undocumented services • Billing under wrong provider # • Knowingly billing the wrong codes to maximize revenue  Kick-backs
    • 39. Keeping Your Revenue  Recovery Audit Contractors  Documentation of/ accounting for WASTE  Unbundling/Modifier -59  Modifier -25  38221/38220-59  ESA dosing  Other drug dosing  Odd coding
    • 40. Medicare: Drug Waste  Medicare does not pay for drug waste, unless it is administered to a patient.  "CMS will cover the amount of drug necessary for the patient's condition. If a portion must be discarded after the patient is treated, Medicare will cover the discarded drug along with the amount administered." This is published in the Medicare Claims Processing Manual, Chapter 17 – Drugs and Biologicals (section 40-Discarded Drugs and Biologicals).  While that is not at all clearly stated in the waste section, I refer you to the Medicare Benefit Policy Manual, Chapter 15, Section 20:  " Part B expenses for items and services ...are considered to be incurred the day the beneficiary RECEIVED the item or service, regardless of when it was paid for or ordered..."  And, Medicare Benefit Policy Manual, Chapter 15, Section 30:  "The physician must render the service for it to be covered."
    • 41. Drug Wastage  Empire New York Part B  Recent reviews by Medicare contractors indicate that providers are not adequately documenting, in their medical records, the provision and administration of drugs in the office setting. Empire Medicare Services expects that providers adhere to the following guidelines:  Physicians and non-physician providers should enter the drug ordered in their plan of care for the encounter.  The dose and route should be included along with the name of the drug.  The encounter should be dated and signed in the medical record (or electronically if using EMR).  The person actually administering the drug should enter into the record that he/she administered the drug, include the dose, route, and site of administration, and sign/date that entry.  It is recommended that providers include the drug lot number when documenting the administration of the drug.  If the drug was administered by the ordering provider, it would be sufficient for that person to enter “given” next to the order in the plan of care (and also include the site of administration and lot number).
    • 42. Drug Wastage  Empire New York Part B (Cont’d)  A provider may indicate that the drug will be administered over a number of dates in the future, in a single plan of care. However, each subsequent administration of the drug must be separately documented as noted above.  Signatures should be legible (you may want to print your name under the signature, if necessary).  If the full amount of a single-use vial is not administered, the provider or staff administering the drug should enter a note in the patient’s medical record indicating the amount not administered (discarded) as wastage.  These guidelines are intended to document the provision and administration of drugs that are covered under the Medicare “incident to” benefit (the drug is administered by the physician/non-physician provider or staff in the office). Use of these documentation guidelines will not extend Medicare coverage to any drug not otherwise covered (e.g., drugs that are usually self-administered, drugs that are not Food and Drug Administration (FDA) approved, drugs provided for indications that are not considered medically necessary, etc.). Drugs provided in the physician office may not be billed to Medicare unless they are also administered by or incident to the same physician/group.  Furthermore, providers should not bill Medicare for visits (Evaluation & Management (E&M) services) when the purpose of the encounter was for the administration of the drug.  Providers should retain drug invoice records to document the purchase of the drug, if requested by a Medicare contractor
    • 43. Keeping Your Revenue  Look at the updates each quarter to ASP from prior quarters. It happens each quarter and you can go back and get the $$.  http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01b_2007ashttp://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01b_2007as  Can amount to a great deal of $$$ QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture.
    • 44. Keeping Your Revenue  Private Payers  Do not use Medicare parameters for ESAs, if your clinicians do not agree with them.  Get as much verified up front as possible • Codes • Co-pays/ Coinsurance • Referrals or authorizations necessary  Match actual reimbursements with contract terms.
    • 45. Accounts Receivable/ Cash Cycle  What is the cash cycle?  Cash incoming from Receivables, Interest, Dividends, honoraria, and revenue from clinical trials  Cash outgoing for ongoing costs including drugs, payroll, rent, utilities, and other ongoing costs.
    • 46. Aged Cash Report  From 1500+ Community Oncologists: • 0-30 days = 80.3% • 31-60 days =12.9% • 61-90 days = 2.6% • 91-120 days = 1.2% • 121-150 days = 0.7% • 151-180 days = 0.5% • > 180 days = 1.8% • AVERAGE DSO = 32 days Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S. © RemitDATA All Rights Reserved.
    • 47. Denial Reasons  National Statistics from CashRetriever Current as of 1/28/08... Denial Code Description # Remits Denied Amount 1 18 Denied-duplicated claim/service 156,441 $635,428,071 2 B13 Denied-previously paid 57,178 $412,746,854 3 42 Denied-chgs exceed fee schedule or allowable 68,149 $317,812,521 4 23 Pmt adjusted-paid by another payer 89,876 $259,859,561 5 16 Denied-lack of needed information 55,362 $228,030,930 6 22 Pmt adjusted-covered by another payer 53,462 $217,472,439 7 125 Pmt adjusted-submission/billing error 12,531 $153,920,852 8 96 Non covered charges 60,248 $137,100,636 9 119 Benefits exceeded 12,511 $89,316,829 10 27 Denied-expenses incurred after coverage 43,787 $80,281,087 Source: http://www.cashretriever.com/home/835denialstatistics.html
    • 48. Denial Reasons  From RemitDATA (all Specialties) All payers = top 10 Reasons (CODE) for ALL data transaction_count 1516196 code count % description CO18 230951 15.23 Duplicate claim/service. OA109 131330 8.66 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. PR204 71133 4.69 This service/equipment/drug is not covered under the patient’s current benefit plan OA18 67236 4.43 Duplicate claim/service. CO176 66412 4.38 Payment denied because the prescription is not current. CO97 66119 4.36 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure CO50 63677 4.20 These are non-covered services because this is not deemed a `medical necessity' by the payer. CO150 59637 3.93 Payment adjusted because the payer deems the information submitted does not support this level of service. PR96 50941 3.36 Non-covered charge(s). COB15 38260 2.52 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. CO16 35160 2.32 Claim/service lacks information which is needed for adjudication. Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S. © RemitDATA All Rights Reserved
    • 49. Denial Reasons  From RemitDATA for ONCOLOGY Only All Payers = top 10 Reasons (CODE) for ONC specialty transaction_count 405450 code count % description CO97 59222 14.61 Payment adjusted because the benefit for this service is included in another service. CO18 55006 13.57 Duplicate claim/service. OA18 38817 9.57 Duplicate claim/service. PI97 24676 6.09 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that ha CO45 18466 4.55 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. COB15 15311 3.78 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. PR16 11331 2.79 Claim/service lacks information which is needed for adjudication. PR27 11058 2.73 Expenses incurred after coverage terminated. OA23 9443 2.33 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments. CO16 8468 2.09 Claim/service lacks information which is needed for adjudication. PR96 8269 2.04 Non-covered charge(s). Source: RemitDATA ERA allowed charge data of 1500+ Oncologists across U.S. © RemitDATA All Rights Reserved
    • 50. Denials  Duplicate claims are dangerous From Noridian Part B Medicare  ”If more than one claim is submitted for the same item for the same date of service, the second claim will be denied as duplicate. Submitting duplicate claims: 1. May delay payment; 2. Could cause you to be identified as an abusive biller; or 3. May result in an investigation for fraud if a pattern of duplicate billing is identified.”
    • 51. Denials  Duplicate Claims are dangerous for other reasons  Inflated A/R  Inflated cash projections  Poor utilization of staff in terms of investigation and write-off’s  Opportunity cost of not working real denials
    • 52. Denials  Duplicate Claim Resolution (TRAILBLAZER)  Step 1: Please allow Medicare 30 days from receipt date to process the claim for payment. If the provider is not enrolled in Electronic Funds Transfer (EFT), an additional seven to 10 days should be added for mail time. Although electronic claims may be processed in as few as 14 days, it could take as long as 30 days to process the claim.  Step 2: The provider should call the Carrier IVR to check claim status. If Medicare has not received the claim and enough time has passed after filing the claim for Medicare to have received it, the provider should re-file a new claim. If the IVR indicates that Medicare has received the claim and it is in process, the provider should allow time for the claim to continue processing and wait for the Remittance Advice (RA).  Step 3: Many times providers overlook zero-pay RAs due to the allowed amount being applied to the patient’s deductible. Providers should pay special attention to zero- pay RAs in order to determine if the claim should actually be re-filed to Medicare.  Step 4: If the same procedures are performed multiple times on the same day, the provider may refer to specific claims filing guidelines for multiple servicing and/or use of any appropriate modifiers. POE may be contacted for help with filing these services.
    • 53. Denials  Service included in another service that has already been adjudicated (C097)  Unbundling items like fluids, supplies, etc. • Is it worth it to keep writing these things off? • How much are you paid on average?  Code edits--increased uptake can lead to audits.
    • 54. Denials  Qualifying service not received/adjudicated (COB15)  Remember that add-on codes need to be on the same claim with qualifying service: • Add on codes: 90761, 90766, 90767, 90768, 90775, 96411, 96415, 96417 • Make sure they are paired with the CPT rule codes. Example: 90768 with 90765, 90766, 96413, 96415, 96416
    • 55. Denials  Missing/Incomplete/Invalid Group Practice Information (CO-16,PR16) Description The information reported in Item 33 of the CMS-1500 claim form is not correct or is missing. The provider of service must enter the provider of service/supplier’s billing name, address, ZIP code and telephone number in Item 33.  Resolution Providers should make sure the information in Item 33 of the CMS-1500 claim form is correct. If the claim is filed as paper, Item 33 is the proper place to report this information. If the claim is filed electronically, the completion of certain loops and segments is necessary.
    • 56. Denials  Claims billed to wrong payers  Patient should be asked each time they appear if their insurance has changed  New Medicare patients should be asked if they • Still have insurance through their employer • Have “another” Medicare plan  Patients, unless their plan contract specifies otherwise, should sign a statement stating that they are liable if they do not update insurance information, if it changes.
    • 57. Denials  Problems due to poor patient intake  Lack of referral or authorization  Poor knowledge of policy limits such as payment ceiling leading to exhaustion of benefits  No information on payment cap or catastrophic coverage leads to missing payment opportunities
    • 58. Common Coding Errors in Medical Oncology  Two “initial” codes  Billing an add-on code (e.g. 90766) without a qualifying service  Billing 96523 with other services  Billing of concurrent hydration  Hydration versus therapeutic infusions  Consultations  Incorrect diagnosis with drug
    • 59. Cash outlays  What can you fix?  Payment terms that lead to constant cash shortfalls.  Interest rates on charge cards, loans, lines of credit, and other interest-bearing items that will change as interest rates go down.  Rent and office leases will soon become negotiable as the economy inspires a “buyer’s market.  Salary raises that are automatic as opposed to incentive-based.
    • 60. Efficiency  Do benchmarks apply to you?  Automation  Access to capital  Space efficiencies/inefficiencies  Skill set of clinical staff  Access to mid-levels  Cross-training and staff coverage  Severity index of patients
    • 61. Benchmarks  Levels  Level I--Compare yourself to yourself over a time period  Level II--Compare yourself to your ‘peers’ in the oncology community  Level III--Custom benchmarks for you or for peer cohort(s)
    • 62. Efficiency  Internal measures (Level 1)  Financial • Cost of Goods Sold (Direct Revenue-Direct Expense) • Net Revenue/ FTE • Cost/ FTE • Net Advantage/ FTE • Revenue/ Patient Encounter • Cost/ Patient Encounter • Net Advantage/ Patient Encounter • Net Advantage/ Hour of Operation • Net Drug Reimbursement plus Rebates/ Drug Cost FTE = 40 hours per week or 2080 hours per year
    • 63. Efficiency  Internal Measures (Level I)  Physician Productivity • Visits/ Physician • New Patients/ Physician • E/M Net Reimbursement/ Physician • RVUs/ Physician* • FTEs/ Physician • Treatment Chairs/ Physician • RN FTE/ Physician • Net Advantage/ Physician
    • 64. Efficiency  Internal Measures (Level 1)  Nursing • Chair Turn • Patient Encounters/ FTE of Nursing • Drug Administration* Net Revenue/ Chair • Drug Administration Net Revenue/ FTE Nursing • Net Benefit**/ FTE of Nursing • Drug Admin Patients/ RN *Includes drugs and admin **Drug admin net revenue-direct nursing cost (S+B)
    • 65. Efficiency  Internal Measures  Billing (FTEs are all billing) • $ over 60 days • $ in AR/ FTE • Cash Collections per FTE • Patient Balances per FTE • Denied dollar per FTE
    • 66. Efficiency  Benchmarks: Hem-Onc (Level II)  Physician Productivity (Mean Value) • New Patients/ FTE physician/yr = 300 (342 with NPPs) • Established Patients/ FTE physician/yr =3481  Staffing (Mean Value) • FTE/ Staff Physician = 7.3 (6.6 for multi-specialty) • FTE Nurses Administering Chemo/ FTE MD = 1.7 • FTE Mid-Levels/ FTE MD = 0.7 Source: Journal of Oncology Practice; Volume 3, Issue 1, January 2007: Benchmarking Practice Operations; Acksin, J, Barr, T. and Elaine Towle
    • 67. Efficiency  Benchmarks (Level II)  Resource Utilization (Average or Mean) • Treatment Chairs /FTE Physician = 5.7 • Treatment Chairs/ FTE Chemo Nurse = 3.8 • # of Patients/ Chemo Chair/ Working Day = 1.3 • Patients/ FTE Nurse/ Working Day = 2.1 Source: Journal of Oncology Practice; Volume 3, Issue 1, January 2007: Benchmarking Practice Operations; Acksin, J, Barr, T. and Elaine Towle
    • 68. Efficiency
    • 69. The Codemistress Treasure Trove of Efficiency Tools  Benchmarking  Oncology Circle http://www.oncomet.com/OncologyCircle/Oncolohttp://www.oncomet.com/OncologyCircle/Oncolo gyCircleHome.aspxgyCircleHome.aspx  Encoders--All the codes you ever want to know and all the rules/ limitations around them.  DecisionCoder® : www.decisioncoder.com/www.decisioncoder.com/  Encoder Pro Professional http://www.medicalcodingbooks.com/codingsofhttp://www.medicalcodingbooks.com/codingsof  Flash Coder http://www.flashcode.com/http://www.flashcode.com/
    • 70. Treasure Trove of Efficiency Tools  Drug Coding and Pricing  Reimbursement Codes.com http://www.rjhealthsystems.com/reimbcode.htmhttp://www.rjhealthsystems.com/reimbcode.htm  Fees--Great information about setting fees and coding rules too! One of my favorites for twenty years.  MagMutual www.magmutual.comwww.magmutual.com  EOB Analysis  RemitDATA* www.remitdata.comwww.remitdata.com  PBIS http://www.p4healthcare.com/go/Oncology/practicemahttp://www.p4healthcare.com/go/Oncology/practicema nagementnagement *-Special relationship with ION
    • 71. Treasure Trove of Efficiency Tools  Physician E/M Audit http://www.intelicode.com/http://www.intelicode.com/  Physician E/M Profiles http://www.cms.hhs.gov/MedicareFeeforhttp://www.cms.hhs.gov/MedicareFeefor SvcPartsAB/04_MedicareUtilizationforPaSvcPartsAB/04_MedicareUtilizationforPa rtB.asp#TopOfPagertB.asp#TopOfPage  Protocol Analyzer® www.iononline.comwww.iononline.com  PQRI Input/ Documentation Forms http://www.ama-http://www.ama- assn.org/ama/pub/category/17493.htmlassn.org/ama/pub/category/17493.html
    • 72. In Summary  Do not give up on negotiating with MCOs. Persistence may pay!  Know your entire situation for each payer where you are losing money for the protocols you use.  Do not rule anything out in terms of what your practice may look like in the future…think outside the lines.  Bill for the services that you perform---ALL OF THEM!  Don’t lose $$$ because you did not look hard at your data aberrancies.
    • 73. In Summary  Cash is king, queen, jack, and ace. Know what, why, where, and when about your cash $$$.  Figure out what your real A/R is.  Re-negotiate interest-bearing expenses.  Be careful to only use benchmarks that apply to your type of facility. But, use data to gauge performance and performance improvement.  But, do use benchmarks to create physician and staff incentives.
    • 74. Keep Paddling!!!!

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