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Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Cost Containment's Chilling Effect

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Failing to bill out over $1.5 million in claims?  Clearly, the provider community is frustrated 

Clearly, the provider community is frustrated by the denial of payment is palpable—about 30% of interviewed doctors' hospital admissions were 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.”
However, Underpaying primary care undermines health care reform as it frustrates a medical practices' best efforts.

Suggestions regarding having a “Discontentment Abatement Policy,” 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.
Doctor groups might then consider:
1. Becoming trained in documentation and coding for the services you provide (perhaps by bringing in a certified coding expert).
2. Buying or building templates to help capture complete information in support of coding.
3. Implementing an interoperable 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.
"Eyes Bloodshot, Doctors Vent Their Discontent" by S. Jauhar, MD (pub. 6/17/08, NY Times)

What does it take to get solid collaboration in health care working relationships?

Key Factors: 1) transparency, 2) big data collection/meta data analysis*, and 3) mutual understanding.

These data are used to provide an overview, if not a detailed analysis of "what is happening in a population and across the entire continuum of care. The health system brings a rich vein of information related to specific components of that continuum."

Transparency between payers and health systems is a given as one attempts to improve and maintain better management of healthcare dollars in the interest of delivering better value. "As providers and payers come together to manage .... populations, sharing information transparently is absolutely critical."  One must rely on the translation of data into information to be sure we know what works, what does not (and when) and in order to identify opportunities for improvement.

"The Chilling Effect of Cost Containment," published online,, June 23, 2008.
It is also noteworthy that "Physicians are experiencing an increasing number of challenges regarding their medical judgment. Payment for services can be denied based on medical necessity or contractual exclusion of a service. Patients often call and ask for help because their prescription coverage was denied. [My] approach to appealing coverage decisions....has served my patients well over the years and involves 6 key messages: (1) understand the rules; (2) act professionally; (3) understand the process; (4) accept when the coverage decision is appropriate; (5) be persistent when the coverage decision is inappropriate; and (6) effectively use evidence-based medicine to help your patient."
Elston DM, "Using Evidence-Based Medicine to Appeal Medical Coverage Decisions," Editorial in July 2012;90:9-11

"Appeal That Claim," (pdf) is a claims revenue cycle guide from the AMA. It derives from Medical Reimbursement, Inc.

The Other Side of the Story - practitioners not getting paid for legitimate work they do

According to the Medical Group Management Association, (MGMA), the typical office practice leaves up to 30% of their potential revenue "on the table" every year. Causes? Inadequate billing practices, denials of eligibility, coding errors, poor documentation, lack of follow through, lack of oversight, underpayments, etc.

Here follows a short list of recent situations that, outside of contractual obligations sought to get payment:

  • "After 7 months of claims for a certain procedure being denied, and resubmitted, to be denied again, the practice finally read the EOB and checked out the reason – the plan instituted a new pre-authorization requirement.
  • A billing company has a systems error causing claims not to be submitted, 18 months later they asked for an exception to the timely filing rule.
  • A billing company failed to bill out over $1.5 million in claims, the physician proudly said his agreement with the billing company made them responsible for his loss – not so fast, that agreement capped the recovery at the company’s fees, in this case $120,000.

While not the science of medicine, billing is a science, each practice needs to monitor its receivables.  At a minimum there should be regular reporting to assure all services are billed out, that all billings receive a payers’ response, what was rejected, and denied, and if denied, then appealed. No claim should be written off by the biller, or billing company. (Great way to cover up errors/poor performance).  Once on the books, a claim is captured, its status and aging reported." 

Goff, Robert <>  [with permission] Sept. 20, 2016, at 7:48 AM

"Estimation of treatment outcomes in meta-analyses differs depending on the strategy used." E.G., should all available trials be considered or factored in? If so, adding them can confound some of the findings, altering the conclusions derived from the analysis, which, in turn will underscore the need for systematic sensitivity analyses.

Dechartres A, Altman DG, Trinquart L, et al. "Association Between Analytic Strategy and Estimates of Treatment Outcomes in Meta-analyses." JAMA. 2014;312(6):623-630.