Medscape  recently posted the results of a survey where physicians rated insurance companies in terms of best and worse to work with and the factors that lead into those ratings.

This got me to thinking about us. Insurance reimbursement for NPs and other Advanced Practice Nurses is all over the board. Some companies recognize Nurse Practitioners and reimburse them for the work they do, other companies seem to be ignorant of the work we do. Then it also varies by state and region.

For example, here in Washington State, for the most part, I don’t have difficulty with insurance reimbursement. I am credentialed with the two “Blues” in our state, yet I hear from NPs in another state where the “Blues” refuse to credential NPs. Does not make sense does it.

If you have having difficulty, contact the American Academy of Nurse Practitioners and get in touch with the Multi-State Reimbursement Alliance people for your region.
OK. Let’s hear from you. What state are you in? Who is credentialing and who is not? What have you found that works and what doesn’t. Advice for others in your area about insurance reimbursement?

Those of you practicing in California during the summer of 2009 likely remember all too clearly when the state of California issued IOU’s for health care services you provided. This came to mind this past week when an insurance company in my state was “outed” for delaying over 300,000 claims to providers since Jan 2011 when they took over the state employee health care plan.

Given the current economic and health care crisis, I fear we may experience more situations where payment is not forthcoming, or significantly delayed. While there are many ramifications, the issue we need to discuss today is this: are you prepared for slow-downs or lapses in getting paid in your practice? And what can you do to get prepared?

To begin with, take a good look at the mix of payers you work with in your practice.  How many are commercial insurances and how many are Medicare and Medicaid or other state plans, and even cash? And even if you have a big percentage of commercial payers, you’ll want to make sure that you have different payers in that group. You want to make certain that in the event something happens to one of your main payers your practice will be able to continue.  Remember your mothers advice…“Don’t put all your eggs in one basket!”

Once you know your breakdown by payer, you’ll calculate what percentage of your patients are covered by each payer. With this information, it’s time to play some “what ifs”. To do this, calculate the percentage of income you receive from each payer. Set up a spreadsheet and enter your data and you should be able to run some scenarios to see how your income and practice might be impacted by the loss of one or more payers.

Next, you’ll want to come up with some possible responses to the loss of a payer regardless if it’s a slowdown in payment or a complete loss of that payment source. Ask yourself how you would handle this right now? What resources do you currently have at your finger tips to help you deal with such an event?

Do you have cash reserves your practice could draw from? Or do you have an established line of credit you could fall back on? If your answer is “No”, ask yourself what contingency plans you need to put in place to be prepared?

As a practice owner you must be monitoring your accounts receivable (AR). Work closely with your billing person to make sure it’s watched daily. Know the average length of time it takes for you to get paid from your payers. And if payments are not coming in as expected does it just involve a few claims or does it involve numerous patient and claims?

If you run into problems with receiving timely reimbursement, check with the payer to see if there is an issue. Make sure you document who you have spoken with and what their response is. You will need this later on when you follow up with them.

Depending on the size of the problem, you may want to let your patients know what is going on. Often times the plan members can do much to move the process along.

Unfortunately, there is no such thing as free health care. Without income you simply cannot run your practice and provide services for long. Obviously the last resort may be to no longer accept plans that don’t provide timely (and competitive reimbursement). There may come a time when you have to rethink which payer you can and cannot work with.

This is a situation we don’t like to think about. However, it’s happened before and it will likely happen again. Being prepared for cash flow disaster, just like being prepared for natural disaster, can help your practice get through potential rough spots, survive and thrive.

(c) Barbara C Phillips, NP

Billing incident to is a question I frequently find in my inbox, on listserves, social media groups and at conferences. I’ve even seen this discussed, often erroneously on medical billing and coding discussion groups and listserves.

In most situations, this applies to  Medicare, but it is possible that your state Medicaid payer, as well as some commercial insurers have adopted, or will adopt these rules.

So what’s the deal about incident to?  Many practices that employee advanced practice clinicians (NPs and PAs) like to bill incident to. Why? Billing incident to allows a practice to collect 100% of the Medicare physician allowable reimbursement. As you know, advanced practice clinicians (NPs and Pas) are allowed only 85% of the physician allowable. Since profit margins are low, it makes sense that a practice wants to collect 100%.

Of course, it makes sense for clinicians to be paid for the same work…but that’s another story for another time.)

However, there are several rules which must be met when billing under incident to. It is your responsibility to understand the billing that takes place in your name. Ignorance is not a defense should the office be investigated for billing fraud.

Here’s a run down on the incident to requirements (references at the end of this article):

1. The Advanced Practice Clinician must be employed by or contracted to the physician or physician group.
2. The physician must see the patient first, establish the diagnosis and the treatment plan and remain actively involved in the patients care.
3. The services must be an integral part of the patient’s normal course of treatment, and are generally included in the physician’s bill.
4. The APC is follow up on the established treatment plan and is NOT addressing any new problems.
5. The physician must be immediately available and in the suite at the time the APC is seeing the patient to follow up on the previously established plan.

There are several problems here for any APC. The most common is the fact that when we are seeing patients, there is almost always something new to be discussed. A visit is rarely just about the hypertension and the medication that the physician prescribed. A new problem that must be addressed negates the visit as being incident to.

For those of us that are practice owners, it is highly unlikely there is a physician on the premises and we are not employed or contracted to a physician or physician group and a physician has not seen the patient first to establish the diagnosis and treatment plan.

As you can see, meeting the incident to rules is something that does not happen in our day to day clinical lives, regardless of who we work for and how we practice. It’s imperative that we understand and adhere to these rules, and that we educate those we work with.  If your practice is billing incident to, you’ll want to proceed with extreme caution. Being associated with healthcare billing fraud is something you want to avoid…like the plague.

You can learn more about the Medicare incident to rules as well as brush up on health care fraud at the sites listed below

• MLN Matters Number: SE0441 http://www.cms.gov/mlnmattersarticles/downloads/SE0441.pdf
• Medicare Information for Advanced Practice Nurses and Physician Assistants http://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf
• Stop Medicare Fraud:  http://www.stopmedicarefraud.gov/
• Office of the Inspector General:  http://oig.hhs.gov/

(c) Barbara C. Phillips, NP, All Rights Reserved

There are three updates that Medicare has recently posted that Nurse Practitioners, Physician Assistants and other clinicians (and their billing staff) will want to be aware of.

1. Summary of Policies in the CY 2011 Medicare Physician Fee Schedule (MPFS) and the Telehealth Originating Site Facility Fee Payment Amount – http://www.cms.gov/MLNMattersArticles/downloads/MM7264.pdf

2. Emergency Update to the CY 2011 Medicare Physician Fee Schedule (MPFS) Database- http://www.cms.gov/MLNMattersArticles/downloads/MM7300.pdf

3. Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing Guide – http://www.cms.gov/MLNMattersArticles/Downloads/SE1039.pdf

4. HCPCS Quarterly Update:  http://www.cms.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp

Nurse Practitioners and other clinicians should be aware of the changes  that are taking place when it comes to diagnostic coding.

On October 1, 2013, medical coding in U.S. health care settings will change from ICD-9-CM to ICD-10. The transition will require business and systems changes throughout the health care industry. Everyone who is covered by the Health Insurance Portability and Accountability Act (HIPAA) must make the transition, not just those who submit Medicare or Medicaid claims. The compliance dates are firm.

If you are not ready, your claims will not be paid. Preparing now can help you avoid potential reimbursement issues in the future. Ask your clearinghouse, billing service or software vendor what you need to do to be ready for ICD-10.

To learn more, visit http://www.cms.gov/ICD10/. Start now.

Are you a Nurse Practitioner or Physician Assistant? Do you see Medicare patients? If so, you’ll want to make sure you are listed in PECOS – Provider Enrollment, Chain and Ownership System.

CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now. If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.

Visit this CMS  page to learn more.

Early in the process of starting up your Nurse Practitioner practice, or even after you have been open for a while, you will be faced with what to do about billing. Your options are limited: you hire someone to come in, you do it yourself, or you outsource the billing. My choice, when I first opened was to outsource and while I thought that I was making good choices, my experience was less than poor. Let me share with you what I’ve learned since then so you can avoid my mistakes.

When you are looking for a billing company to outsource to the first thing you want to do is ask around. Who are your colleagues using? Why do they like/dislike them? Check the forums and social media where they are likely to talk about billing, like the EMR support forums or the coding forums. And of course, you can check the NPBO™ forum. And don’t forget to network with colleagues at conferences and gatherings.

When you find companies that you are interested in, Google them. Look for complaints as well as praises. If it’s an individual, are they certified? And if they say they are, can you get proof? You’ll also want to check references, but not just those listed (few people will give you the name of someone who will give them a bad reference). Again, ask around about this company or person and try and find references that are not listed.

So what are some of the questions you should ask?

1. What are their qualifications?
2. How long have they been in business?
3. How many people are handling the claims?
4. How are follow ups handled?
5. What happens when there is a denial?
6. Who is managing the accounts receivable (AR)? How often is it evaluated and worked? Who is responsible?
7. Communication Issues: What forms of communication are available? Is there a time difference? Is there a language difference?
8. Do they specialize in a particular area of billing such as primary care or surgery?
9. What kind of reports will you receive? Can you read them? Can you get help with them?
10. Is the company familiar with your regional issues?
11. Does this company know about NPs and are they familiar with some of the issues in billing for us? Are they familiar with your state regulations?
12. What other services do they provide?

This is not by any means an all inclusive list, but it will get you started when thinking about hiring a biller.

Nurse Practitioners that accept Medicare in their practices need to be aware of how this will impact their practices. With the exception of Midwives, NPs are allowed only 85% of the physician allowable. Here is the update:

The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010. At this time, Congress is debating the elimination of the negative update that took effect June 1, 2010. The Centers for Medicare & Medicaid Services (CMS) is hopeful that Congressional action will be taken within the next several days to avert the negative update.

To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers paid under the MPFS, CMS had instructed its contractors on May 27th to hold claims for services paid under the MPFS for the first 10 business days of June (i.e., through June 14, 2010). This hold only affects MPFS claims with dates of service of June 1, 2010, and later.

Given the possibility of Congressional action in the very near future, CMS is now directing its contractors to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.

This action will facilitate accurate claims processing at the outset and minimize the need for claims reprocessing if Congressional action changes the negative update. It also should minimize the provider and beneficiary burdens and costs associated with reprocessing claims.

We understand that the delayed processing of Medicare claims may present cash flow problems for some Medicare providers. However, we expect that the delay, if any, beyond the normal processing period will be only a few days. Be on the alert for more information regarding the 2010 Medicare Physician Fee Schedule Update.

Source: LEARNRESOURCE-L Email Update, National Institutes of Health, U.S. Department of Health and Human Services dated June 14, 2010

Posted: 6/14/2010

Once again, Medicare is asking Nurse Practitioners and other providers to hold our Medicare Claims for 10 days until Congress can prevent a 21% reduction in reimbursement to providers.  We will not know the outcome until after Congress has a chance to reconvene on April 12 and they approve a pay patch.  However, it’s unclear to me, just how long before we will be faced with this issue again.

If you have not already done so, take a look at your payor mix. Do a bit of forecasting and determine how this will impact your practice overall. You may need to make some adjustments.

I’ll post more as it becomes available.

Nurse Practitioners, along with other health care providers can expect to have payments held for “up to the first 10 business days of January”.

According to CMS:

The President has signed the Department of Defense Appropriations Act of 2010 which provides for a zero percent (0%) update to the 2010 Medicare Physician Fee Schedule for a two month period, January 1, 2010 through February 28, 2010.

The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule, beginning January 1, 2010.  In this regard, CMS has instructed its contractors to hold claims for services paid under the Medicare Physician Fee Schedule (MPFS) for up to the first 10 business days of January (January 1 through January 15) for 2010 dates of service. This should have minimum impact on provider cash flow because, by law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt. Meanwhile, all claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures.

The holding of claims allows Medicare contractors time to receive the new, updated payment files and perform necessary testing before paying claims at the new rates. CMS has instructed contractors to begin processing claims at the new rates no later than January 19, 2010.  Please note that most contractors are closed on the January 18 Martin Luther King Day holiday. Therefore, even absent a new update, most claims likely would not have been paid any sooner than January 19, 2010, given the aforementioned statutory 14-day payment floor.

CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010- therefore, the enrollment period now runs from November 13, 2009, through March 17, 2010.

The effective date for any Participation status change during the extension, however, remains January 1, 2010, and will be in force for the entire year.

Contractors will accept and process any Participation elections or withdrawals, made during the extended enrollment period that are received or post-marked on or before March 17, 2010.

In addition, be on the alert for more information about other legislative provisions which may affect you.