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?

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

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.

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.

Many independent NP practices are concerned with the proposed changes in Medicare reimbursement. At this time, it stands at -21.2% of the physician allowable. Of course, for NPs and PAs that figure is a bit more.  The good news is the proposed cuts in payment have been delayed until March 1, 2010.

In terms of the elimination of the consultation codes, there does not seem to be any changes. Those codes will be eliminated as of January 1, 2010.

In order to see where you will stand in terms of reimbursement, visit the website of your local fiscal intermediary and download the most recent fee schedule. Dont’ know who you intermediary is? You can find it here – Medicare Intermediary , which is a PDF file and will have all the contact information for your region.

Smart offices will have been looking at this information and trying to assess what changes, if any, they will need to make in 2010. How will this affect your office and your patients, and how to you think you will respond? Feel free to leave your comments below.

This proposed change affects Nurse Practitioners and  Physicians Assistants as well as Physicians, and directly impact those of us with our own offices. Read carefully.

The Centers for Medicare & Medicaid Services (CMS) announced today proposed changes to policies and payment rates for services to be furnished during calendar year (CY 2010) by over 1 million physicians and nonphysician practitioners who are paid under the Medicare Physician Fee Schedule (MPFS). The MPFS sets payment rates for more than 7,000 types of services in physician offices, hospitals, and other settings.

CMS is making several proposals to refine Medicare payments to physicians, which are expected to increase payment rates for primary care services. The proposals include an update to the practice expense component of physician fees. For 2010, CMS is proposing to include data about physicians’ practice costs from a new survey, the Physician Practice Information Survey (PPIS), designed and conducted by the American Medical Association.

The Medicare law requires CMS to adjust the MPFS payment rates annually based on an update formula which includes application of the Sustainable Growth Rate or SGR that was adopted in the Balanced Budget Act of 1997. This formula has yielded negative updates every year beginning in CY 2002, although CMS was able to take administrative steps to avert a reduction in CY 2003, and Congress has taken a series of legislative actions to prevent reductions in CYs 2004-2009. Based on current data, CMS is projecting a rate reduction of -21.5 percent for CY 2010.

As part of health care reform, the Administration supports comprehensive, but fiscally responsible, reforms to the physician payment formula. Consistent with this goal, the Administration announced in the FY 2010 President’s Budget that it would explore the breadth of options available under current authority to facilitate such reforms, including an assessment of whether the cost of physician-administered drugs should continue to be included in the payment formula. Thus, while working with Congress to develop a more appropriate mechanism for updating physician payment rates, CMS is proposing to remove physician-administered drugs from the definition of “physician services” for purposes of computing the physician update formula in anticipation of enactment of legislation to provide fundamental reforms to Medicare physician payments. While the proposal will not change the projected update for services during CY 2010, CMS projects that it would reduce the number of years in which physicians are projected to experience a negative update.

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services. Practitioners will use existing E/M service codes when providing these services instead. Resulting savings would be redistributed to increase payments for the existing E/M services.

CMS is proposing to increase the payment rates for the Initial Preventive Physical Exam (IPPE), also called the “Welcome to Medicare” visit to be more in line with payment rates for higher complexity services. The IPPE benefit was mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to pay for an initial assessment of key elements of a beneficiary’s health status within six months of the beneficiary’s enrollment in Medicare Part B. Subsequently, Congress extended the time period for the IPPE benefit to within one year of the beneficiary’s enrollment in Part B.

In addition, CMS is proposing to refine how Medicare recognizes the cost of professional liability insurance in its payment system. While these changes would have a modest impact, they will promote payment equity by redirecting the portion of Medicare’s payment for professional liability insurance to those physicians that have the highest malpractice costs.

Taken together, refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6 and 8 percent (before taking into account the proposed update and other proposed changes to the fee schedule).

The proposed rule would also implement provisions in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) that added new Medicare benefit categories for cardiac and pulmonary rehabilitation services, and for chronic kidney disease (CKD) education, beginning January 1, 2010. The proposed rule outlines what these programs would entail, how they would be paid under the MPFS, and the criteria for covering these services.

CMS is proposing two changes to address concerns from the Medicare Payment Advisory Commission (MedPAC) and the U.S. Government Accountability Office (GAO) about rapid growth in high cost imaging services. First, CMS is proposing to reduce payment for services that require the use of expensive equipment which would produce a redistribution of the resulting savings to increase payments for other services, including primary care services. The current payment rates assume that a physician who owns this type of equipment will use it about 50 percent of the time, but recent survey data suggest this expensive equipment is being used more frequently. As the use of this type of equipment increases, the per-treatment costs for purchasing, maintaining and operating the expensive equipment declines, making a reduction in payment appropriate.

Second, CMS is proposing to implement a requirement in the MIPPA that suppliers of the technical component of advanced imaging services be accredited beginning January 1, 2012 by designating accrediting organizations (AOs) for these suppliers and utilizing the imaging quality standards that have been developed by the AOs. The accreditation requirement would apply to mobile units, physicians’ offices, and independent diagnostic testing facilities that create the images, but would not apply to the physician who interprets them. According to the GAO, spending on advanced imaging services, such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET), is growing almost twice as fast as spending on other types of imaging services, and is a significant contributor to the rapid growth in health care spending in recent years, but there is little administrative oversight to ensure the quality of care. In a separate regulatory action, CMS will address suppliers’ accountability, business integrity, physician and technician training, service quality, and performance management.

The proposed rule contains a number of provisions to promote improvement in quality of care and patient outcomes through revisions to the Electronic Prescribing Incentive Program (e-Prescribing Program) and the Physician Quality Reporting Initiative (PQRI). Eligible professionals or group practices that meet the requirements of each program in CY 2010 will be eligible for incentive payments for each program equal to 2.0 percent of their total estimated allowed charges for the reporting periods. CMS is proposing to simplify the reporting requirements for the electronic prescribing measure and to provide eligible professionals with more reporting options. CMS is also proposing a new process for group practices to be considered successful electronic prescribers.

In addition, CMS is proposing to add more measures and more measures groups for eligible professionals to report under the PQRI, to provide a mechanism for participants to submit quality measure data from a qualified electronic health record and to create a process for group practices to use for reporting the quality measures.

CMS will accept comments on the proposed rule until August 31, and will respond to all comments in a final rule to be issued by November 1, 2009. Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after January 1, 2010.

Source
Centers for Medicare & Medicaid Services

CMS Proposes Payment, Policy Changes For Physicians Services To Medicare
Beneficiaries In 2010
06 Jul 2009

The Medicare Learning Network now as a portal page for Nurse Practitioners and Physician Assistants. Here you will find web-based training programs, internet-only manuals, articles, code of federal regulations, enrollment procedures, information on PQRI and NPI and more.

In addition to all the down-loadable information, you’ll find links to documentation guidelines, quarterly provider updates as well as information regarding Medicare payment and overage to “non-physician practitioners”.

http://www.cms.hhs.gov/MLNProducts/70_APNPA.asp

Welcome to 2008! It’s already been a busy time. If you have not already done so, make sure you evaluate your fee schedules. There are new CPT codes and new reimbursements in place or will be put in place shortly.

While the intended Medicare 10% cut has not yet happened, the new rates are only good until June. Watch for impending changes…they may not be good for those of us who see lots of Medicare folks as 10% can be a huge cut in reimbursement.

At the same time, I noticed that Medicaid has cut its reimbursement and many of the commercial carriers are holding steady with last years rates.

Unlike business owners in other lines of work, health care providers, at least for now, seem to be at the mercy of the insurance carriers. While we can negotiate fees with carriers, it appears it will be a battle. I’m going to be working on one carrier shortly….I’ll let you know what happens. In the meantime to learn more, Medical Economics has published an article tis month: You Can Negotiate with Health Plans.

The storms and subsequent flooding that happened in our area last week, has been thinking about business disaster plans, and what can we do differently the next time we are affected…both at home and at the office.

Business Disease Plans can vary in length and depth depending on the nature and size of your business, but at the very least should address some common “what-ifs”.  FEMA offers this downloadable PDF document for business owners, the Emergency Management Guide for Business and Industry, where you can find additional information on planning for emergencies, response and recovery.

While natural disasters remind us that Mother Nature is in charge, man made disasters and hazards are also a potential threat. Either way…we need to be prepared.

Assuming you are running some sort of practice, here are a few things to think of. I’m sure this list will continue to grow as others provide their input.

1. Communication. Can you contact your patients and staff? Do you have phone numbers at your finger tips? Assume you have no power or cannot access your electronic database.
2. Medications, vaccines and the like that are temperature sensitive – how will you keep them viable? 
3. Charts – Can you protect them? How will you access them? If electronic, are they backed up and away from your office? Will you be able to access the back up in a different location?
4. Supplies: can you get critical supplies if necessary? What plans do your vendors have in place? (I saw UPS and the Red Cross Disaster Relief folks  driving u-haul rental vans). How will you contact them? 
5. What kind of business insurance do you have? What are the exclusions? Does your insurance include business interruption as well as coverage for fires and the like? 
6. Are you the only provider in a small town? Are you able to assist in providing emergency care to those in your locale? What supplies do you have/need in order to do so?  How will you keep yourself and staff as safe as possible (think personal protective equipment). 
7. If you need to evacuate your location, do you have routes figured out? Is your staff aware of what they need to do? Are you able to get patients out of the building if necessary? 
8. If you are in a shared building (office building, business park, strip mall, etc), how can you interact with your neighbors to make this a smoother process. We all know that we need each other during disasters. 
9. Have you made an inventory – complete with photos/video of your business and contents? Are all your vital papers together in one accessible spot? Again, do you have a back up?
10. What home preparations have you made? Assume you will be without power for days. Perhaps the water supply will be interrupted.  Heat, cold, shelter and food may be issues as well.

These are just a few thoughts to get you started thinking the unthinkable. Please add your thoughts and suggestions below.
 

I received a question from a woman who is an FNP and CNM in Oregon. She is no longer practicing as a CNM, but is opening an office as an FNP. However, she has run into a snag.

Here is what she has to say:

I have applied for insurance through NSO, Marsh and CM&F. None will cover me as long as I hold my CNM credential – even though I am NOT practicing as a nurse-midwife. I am not offering prenatal, postpartum or intrapartum care. I stopped delivering babies in 2002.

Do you have any other suggestions other than surrendering my CNM license to the state board of nursing – which is what one insurance underwriter suggested?

Having had my own issues in getting liability insurance, I can understand the frustration she is experiencing. I cannot imaging being told I would have to relinquish a license just to get insurance. We all work hard to get them, even if we are not practicing in the area anymore.

So has anyone run into this before and can anyone offer any advice to this NP?