A NY Times essay laments the underpayment of primary care and how that frustrates a medical practices best efforts.  

To set the stage for this discussion, please see: 

See "Eyes Bloodshot, Doctors Vent Their Discontent" by S. Jauhar, MD Pub. 6/17/08.  I was referencing that in I piece I wrote for HCPLive.com, "The Chilling Effect of Cost Containment." (Published Online: Monday, June 23, 2008.)

Clearly, there’s frustration from the denial of payment, with 30% of one interviewed doctor’s hospital admissions taking a hit. And then, according to the Times article, “there’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’”

 

That doctor continues: “Ninety percent of doctors I know are fed up with medicine. And it is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or MRI scans for routine symptoms are rife in doctors’ lounges. Malpractice worries also remain at the forefront of many physicians’ minds, compounded by increasing liability premiums that have forced many into early retirement.”

  

As one physician remarked, "There is no doubt that the system for providing medical care in the country is in need of major reformation, and that the system of training the providers of that care is in need of major transformation, but the medical community needs to get a grip on their whining. This article, with slight changes, could have been written 30 years ago as well.”

 

Other suggestions were provided with regard “Discontentment Abatement Policy.” It’s therapy for the mess we’re in.

 

Worth 5% to 10% coding/documentation challenges

Physicians can be timid or even paranoid when it comes to challenging insurers; they are unsure if their documentation will stand up to scrutiny, or they want to "stay under the radar." Nevertheless, studies indicate that physicians’ own, inadvertent down coding can run $25,000-$40,000 per doctor per year.

 

Here’s what I am recommending that doctor groups consider:

1. Become trained in documentation and coding for the services you provide (perhaps by bringing in a certified coding expert).

2. Buy or build templates to help capture complete information in support of coding.

3. Implement an EMR with integrated PMS (practice management system) that includes a code-checker to compare documentation in compliance with documentation requirements.

 

Worth 5% to 7% services provided but not billed

Some services in the office are never picked up for billing, and services in the hospital may be lost, or not documented to be billed by the office. Here’s a to-do list:

 

1. Count your daily billings and make sure you send out as many bills as patients seen each day.

2. Review medical records before billing for billable services.

3. Implement an EMR with integrated PMS that "sweeps" services in medical record to billing.

4. Prepare a simple record card or system for in-hospital services and record all the usual care provided in that venue.

 

6% to 15% timely filing denials

Reports obtained by our group practices show they have issues getting claims submitted in a timely fashion. How long does it take your office to get a claim out the door? I suggest physicians make the following a priority:

1. Count patient visits daily and make sure that billing count equals claims billed.

2. Implement an EMR with integrated PMS or a clearinghouse that confirms receipt of billings by the payer.

3. Verify status on payer web site for claims not paid at 50 days. If not found on the payer's web site, re-bill.

  

5% to 15% rejections, not corrected and re-submitted 

Ten to 30% of claims initially submitted are rejected, and 50% are not resubmitted or are not submitted in a timely fashion. CMS data shows a rejection rate of 26%, with 40% of rejections never resubmitted. Others report rejection rates between 30% and 55%, with 18% at the lower end and, with 50% never re-submitted. I suggest the following:

1. Make sure your clearing house or PMS can identify all rejections, and the reason, as well as having reminders of outstanding claims requiring resubmission.

2. Know the difference between a denial and a rejection, and treat accordingly.

3. Monitor EOBs.

 

3%  to 7%  denials, not appealed 

MGMA reports the average denial rate of 7% to 14%. Yet, 42% of practices in a national survey don't know what their denial rate is. Half of all denials are never appealed, but appeal approval rates can run as high as 70%. What to do? 

1. Create a file of model appeal letters and use them.

2. Create a log of denials to record the denial and the reason, as well as the resulting action you took.

3. Review EOBs on a timely basis and appeal. (Appeal everything that should be appealed.)

4. Learn from the denied appeals, changing practice policies as necessary.

 

6% payments less than the allowable

Many practices do not audit their paid claims to be sure that they are being paid the contracted rate. Consult the AMA’s recent report card on payers where it indicates pay rates in the 62% to 72% range.

1. Audit paid claims against allowable fee schedule; appeal underpayments.

2. Don’t hesitate to sign up for the payer’s Electronic Remittance Advice (ERA) and automated auditing software (e.g., Right-Remit™ by CureMD that helps in fee schedule application and in appeals).

 

2%+ post-payment recoveries

These are the payer's efforts to recover money back from contracted physicians. Some physicians do not respond to such retroactive demands for repayment and allow the payer to simply offset the amount against future claims.

1. Do not ignore recovery letters

2. Dispute everything in contention with the understanding payers often ignore state regulation and even their own policies that limit the ‘look back’ period.

 

Jeff Kaplan, MD, MS

Article: Elston DM, "Using Evidence-Based Medicine to Appeal Medical Coverage Decisions," Editorial in www.cutis.com. July 2012;90:9-11