2012 OIG WORK PLAN

The Office of Inspector General (OlG) has released its Work Plan for 2012.  The OIG sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities including CMS.

The OIG plans to initiate the following NEW activities related to physician services:

1)     High Cumulative Part B Payments – The OIG will review high cumulative Part B payments to determine if they are reasonable and necessary, adequately documented, and provided consistent with Federal Regulations.

2)     Incident-to-Services – The OIG will review whether “incident to” billing has a higher error rate than that for non-incident-to-services.

3)     E/M Services: Use of Modifiers during Global Surgery Period – The OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period to determine if Medicare payments were in accordance with Medicare requirements.

To avoid potential penalties in 2012, be sure that all providers in your practice are documenting exactly what they are billing out to Medicare.  Remember, if it isn't documented, it didnt happen!!!

For more information on this topic, visit http://oig.hhs.gov/reports-and-publications/workplan/index.asp

Medical Billing Services & Solutions

OB/GYN Billing

As you know, obstetrics and gynecology are technically two separate medical specialties dealing with the female reproductive organs, differentiated by whether the woman is in a pregnant or non-pregnant state.  However, the two specialties are usually combined to form a single surgical-medical specialty which enables the physician to care for his or her patients prior to, during, and after pregnancies.  This creates a broad range of conditions that the practicing OB/GYN will treat and many different procedures that the physician will perform.

As an OB/GYN medical billing specialist, knowledge of the specialty is vital to ensuring that the billing is being handled correctly.  The medical biller must play close attention to detail.  They must understand what is included in a global obstetrical package, and what can be billed separately…for all insurance carriers.  They need to be knowledgeable on how to receive full reimbursement for all medications, injectibles, and devices the physician may use.

The medical biller must also have a complete understanding of Well Woman Exam coding.  The biller must know which insurance plans will pay when a G0101 (Cervical or Vaginal cancer screening), Q0091 (Screening papanicolaou smear), S0610 (New patient-annual gynecological exam), or S0612 (Established patient – annual gynecological exam) is submitted.  Some pay for a specific code, and some with a combination of the codes.  Other payers will pay when submitted with a Preventive Visit (9938*-9939* codes), and others when included with an Office Visit (9920*-9921* codes).  The biller must also know what diagnosis codes are required to be submitted with the above Procedure codes.

The OB/GYN specialty requires knowledgeable billers that have both education and experience handling all aspects of the specialty.  If the medical biller doesn’t understand exactly what the insurance carriers require so that the physician can receive full reimbursement, then the denied claims can accumulate rapidly.  No physician can afford an interruption in cash flow, especially if it is due to inexperience.  Every OB/GYN desires full reimbursement for his or her services, and it is vital to have a qualified biller that is up for the task.

Medical Billing Services & Solutions

Internal Medicine Billing

The billing process for Internal Medicine practitioners is different than many specialties.  The American College of Physicians defines internists as “physicians who specialize in the prevention, detection, and treatment of illnesses in adults."  Internists must be skilled at managing patients who have undifferentiated or multi-system disease processes.  Internists will see patients in the office, at the hospital, in nursing homes, and also in skilled nursing facilities.  In summary, Internal Medicine is a broad specialty with many different aspects, all of which bring something unique to the medical billing process.

As a medical biller, it is important to make sure that you understand all aspects of Internal Medicine to ensure that the job is done correctly.  Since many internists see up to 40 or more patients per day, one simple mistake can result in 200 “simple” mistakes over the course of a week.  Just as the doctor has a background in coding, medical billers must also have a background in coding to make sure that what they are submitting to insurance companies is correct.

Someone handling the medical billing for an internal medicine practice should have a comprehensive education on what constitutes a Level 1, 2, 3, 4, and 5 office visit.  They should also be knowledgeable on ICD-10 changes that will eventually occur.  An Internal Medicine Biller should understand how to handle the billing of hospital charges, nursing home visits, and SNF encounters.  Collecting full reimbursement for immunizations and injectable drugs poses its own challenges.  Properly submitting charges for in house/CLIA waived labs is another aspect of the specialty that is unique.  To top it all off, we haven’t even discussed A SINGLE PROCEDURE yet!

Due to the volume of charges that Internal Medicine Practices produce, if an inexperienced biller is in charge, it can get costly, very quickly.  It is easy to submit claims to the different insurance carriers.  It is not easy to make sure that what was submitted is correctly submitted. 

The key to receiving full reimbursement is having the knowledge of how to submit the charges correctly the first time.  Then the biller must rigorously appeal all denials to make sure that the practice receives full reimbursement.

Medical Billing Services & Solutions

Denial Management 101

Every medical practice experiences denied claims, however some experience a far greater number of denials than others.  The best performing practices can have denial percentages as low as 5%.  Other practices are seeing claims denied 25-30% of the time.  It is key to understand that once a Medicare claim is denied and appealed correctly, it will take at least 1-3 months before the provider receives payment.  In tough economic times, this cash flow delay is unacceptable for most every practice.  Healthcare professionals are always looking for ways to improve their billing performance.  The best way to improve billing performance is to prevent many of these denied claims before they happen.

For those that have been involved in physician billing for over 20 years, we know that there was once a time when claims were submitted to the payers and we subsequently received payments.  It used to be much less sophisticated than it is today.  An individual claim processor manually reviewed, processed, and paid every single claim.  Over the last two decades, much of that work is now being done by a computer.  Programs are written to make sure that the medical practice/medical billing service is "dotting their i's and crossing their t's".  If there is any doubt, they deny it.  They assume that most medical practices will not go through the trouble of following up on denied claims.  This saves the payers money.

To ensure that you, as a provider, are not leaving money on the table, it is vital to be proactive as to what the root of the denials is.  Keep track of how many claims are denied every month, identify the reasons for denials, and track your denial performance over time.

1:  Determine your Denial Percentage at the end of every month.

1. Total # (and charge amount) of claims filed to a payer.
2. Number (and dollar value) of denied line items.
3. Calculate Percentage by dividing "number of denied line items" by the "total claims filed to payer"

This will enable you to track from month to month whether or not your practice is improving.  This should be tracked as a complete practice, as well as by individual provider, location, and by payer.  This will give you insight as to where and why problems may be occuring.

2:  Determine the main reasons for the claim denials.

• Registration error
• Charge entry error
• Lack of referrals & Pre-authorizations
• Insurance Company needs info from patient
• Duplicates
• Medical Necessity/CPT Code does not match ICD-9 Code
• Documentation
• Bundled/Non-covered  {ex)modifiers}
• Credentialing

This information will enable your practice to understand why claims are being denied, and where on the job training needs to take place.

3.  Track your denial performance over time.



The details about your claims denials will allow you to focus your energy on the most frequent reasons that claims are being denied.  The provider/practice management staff will know the most efficient ways to address the problem if they know the root cause of the why claims are being denied.  Every time you reduce your denial rate you bring more money to the bottom line of your practice.  Not only do you get paid correctly and timely, you have eliminated all the labor hours involved in reworking denied claims.

Medical Billing Services & Solutions