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Smart tips to improve practice performance


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Physicians in private practice sometimes face a plateau in revenue, or worse, declining collections. However, cost cutting and control of overheads is not the only way to maintain or increase income. Here are smart ways to improve medical practice efficiency:

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Smart tips to improve practice performance

  1. 1. W ebinar
  2. 2. Robert E. Goff Formerly CEO at University Physicians Network, LLC (UPN) Recently retired following 18 years as the CEO of University Physicians, capping a 45 year career in the healthcare industry. He has seen the great transformation of healthcare delivery into the industry that it is today from the vantage points as a hospital administrator, regulator, managed care executive, and association executive. He is a founding director of RIP Medical Debt, a charity that acquires and abolishes consumer medical debt.
  3. 3. OFFICIAL DISCLAIMER The information presented is for general information only and are not meant to substitute for legal advice. Always seek the advice of an attorney on legal matters. The presenter makes no recommendation as to an individual physician’s participation or non- participation with any specific health plans, insurance company or payer. Each physician is urged to give due and proper consideration to their own individual practice needs and act independently regardless of the actions or non-action of other physicians. Legal Guidance Misuse of the handouts, copy righted © material is subject to fine of $5000 per occurrence 01
  4. 4. 02 HOW TO CONFRONT PAYER-CLAW-BACKS • Just because you have been paid does not mean you get to keep the money • Payers regularly seek recovery of payments through “post-payment” audits. • Often payers will employ outside commission based audit firms to mine paid claims data, identify alleged overpayments, and seek recovery – from you. • You have the right to protect yourself and your income from these efforts • Act promptly to confront these challenges.
  5. 5. 04 SILENT MEANS CONSENT IF YOU DO NOTHING – THE PAYER WILL “EXTRACT” THE FUNDS FROM A FUTURE PAYMENTS TO YOU When you receive a letter asking for the return of an allege overpayment you must respond timely Demand your rights - DISPUTE • Federal Fair Debt Collection Practices Act – You have the right to be presented with evidence that you in fact owe the money – The creditor has no right to harass you • US Postal Code • Disputing will – Protect your rights – Delay any recovery payment – Give you the information you need to consider their demand without doing research through your records (Maybe they are right) – Increase their costs of doing business NYS requires that plans provide at least 30 days prior notice Common “reasons” for recovery requests •Another payer was primary •Overpayment in error •Duplicate payment •Patient not eligible at time of service
  6. 6. 05 RESPOND IN WRITING - ONLY • If you receive a telephone call from the payer or their agent: refuse the call. – Train your staff to tell any callers to put the request in writing and mail it to your office. – Do not offer your fax or email information • If you receive a fax requesting a refund: – Write REFUSED on the fax, date it, and send it back – Add: use of this fax for PHI may constitute a violation of HIPAA and is reportable.
  7. 7. 06 LETTERS DEMANDING REFUNDS ARE OFTEN CRYPTIC THE REGULATIONS REQUIRE: “SUCH NOTICE SHALL STATE THE PATIENT NAME, SERVICE DATE, PAYMENT AMOUNT, PROPOSED ADJUSTMENT, AND A REASONABLY SPECIFIC EXPLANATION OF THE PROPOSED ADJUSTMENT” Your letter must state: You dispute their allegation and request: Proof that they are in fact entitled to a refund. 1. A detained explanation of the basis for their demand 2. A copy of the agreement that they are authorized to represent the payer 3. A copy of the original EOB 4. A copy of their proof that the patient was enrolled in another plan and that plan was primary (if claim is another payer responsible) 1. An explanation of why it is your responsibility to purse the patient, as the patient not disclosing the other insurance amounts to fraud. And proof that they have filled fraud charges against the patient, as they are the party making the accusation 5. A copy of the fee-schedule, certified as effective as of the date of service (if they claim overpayment) 6. A detailed explanation of how they arrived at the amount they allege to have been paid in error 7. A copy of the cancelled check in proof that you actually received payment 8. An explanation as to why state prompt payment regulations are not applicable (Those regulations allow the payer 30 days to investigate a claim prior to payment) 9. An explanation as to the time lag between he discover of the “error” and the demand to you. 10. Any other “documentation” that you believe is necessary to prove that they are owed the money
  8. 8. 07 ASSERT THE FOLLOWING IN YOUR RESPONSE 1. State that you reserve the right to request that their response be reviewed by the State Health Commissioner (or Attorney General) the Department that licenses the health plan in your state prior to acting on your demand. 2. Their request is disputed in accordance with your rights under The Federal Collection Practice Act. 3. Remind them that under The Act they can take no action prior to the provision of proof of the legitimacy of their claim 4. Remind them that State regulation specifically precludes their unilateral off-set of their alleged overpayment. 5. That your office will only consider written a response to your request, including all requested documentation, and no telephone, email or fax communication should occur.
  9. 9. 08 YOUR RESPONSE IS A DISPUTE – NOT APPEAL • Some plans and their agents like to send form letters in response that your appeal is denied. • Tack on to a copy of your letter the following and send as a response: • “Our response to your demand for a refund is a DISPUTE, not an appeal. A dispute is our right under the Federal Fair Debt Collections Practices Act, and must be treated in accordance with the provisions of that law. Your intentional falsification of our response as an appeal is a blatant attempt to deprive us of rights under the law and is now documented. If an appropriate response is not received by this office within the next 15 days, or if any action is taken to our disadvantage, a complaint will be filed with regulatory authorities” (If the demand is from a third party on behalf of a payer add: “as well as the integrity office of xxx Health plan”.
  10. 10. 09 REMEMBER – PAYERS WILL SEEK TO CLAW BACK FUNDS, EVEN IF THEY ARE NOT LEGALLY ENTITLED TO THEM “Just because NYS regulations say we can’t off-set the money, that does not mean we can’t ask for it back, physicians are expected to know their contract and the regulations” Loran Firbush, Oxford Health Plans (A United Healthcare company) NYS Regulations •Retroactive terminations – While these should always be disputed, NYS limits the exposure to 120 days from DOS. No longer can they go back years to seek recovery of claims paid. (If services received prior authorization) •Authorizations can’t be withdrawn, if required for a service, and given, unless the patient is not covered, or false information was relied upon in granting the authorization initially. •Look back at paid claims is limited to 2 years from payment, unless suspicion of fraud or abuse •Negative remits/off-sets; require at least 30 days prior notice. Time for the physician to dispute, but you must read and act on your mail.
  11. 11. 10 WHAT WILL HAPPEN • In many cases the agent/plan will abandon their demand from you, and you will hear nothing further. • If you do get a response, you may find that in fact you were over paid – the right thing is to refund the money. – If the claim is that another payer is primary – bill that payer, if they pay, you refund the payment, if they do not, for whatever reason, their denial makes the plan that paid you primary, and no refund is due. • Your dispute will delay any potential refund, potently eliminate it, and in any case, increase the plan’s operating costs. • Physician offices that push back experience less refund demands than those that readily send money
  12. 12. 10 IN SUMMARY • What is you do discover you have been overpaid? • Don’t send the money back • Cash the check • Keep the money aside • Send the money back only when they ask for it • Note: Don’t do this for Medicare –you have 60 days to return identified overpayments, and failure to is subject to the penalties of the False Claims Act • Claw-backs reduce physician income by 2% or more • If you do nothing – you will lose, and if you get a reputation for refunding or allowing claw-backs, more will likely occur • Your response • Dispute – promptly and forcefully