For questions, or to speak with a representative, give us a call at 405.848.8558.

New for 2016

New CMS Enrollment – NSV (National Site-visit Verification)

  • There will be an increase of onsite visits for new enrollees to Medicare.
  • Screening mechanism to prevent questionable providers and supplies from being accepted into the Medicare program.
  • Announced and unannounced site visits.
  • If found out of compliance, a revocation can last up to three years.

Data Mining

  • The government is data mining and the first agencies to identify problems are likely to be MAC and ZPIC.
  • MAC and ZPIC may believe they detect a possible pattern of fraudulent billing behavior from data mining.
  • If a large enough amount of money involved, appearance of egregious behavior, lack of contractor resources, or a whistleblower could get you at the front of the line with the OIG.

Medical Record – First line of defense

  • Indictments for incorrect use of "automatically inserted, into patient records, diseases and symptoms that the patient did not have" with services billed to Medicare.
  • Danger Zone – Incorrect use of macros.
  • Auditors will look for notes that are similar or exact between patients. This can be determined to be habitual behavior and can lead to cloned notes.

OIG 2016 Work Plan – Focus on physician practices

  • Watch for referring and ordering physicians who are not eligible.
  • Anesthesia paid by Medicare for non-eligible services.
  • EHR (Electronic health records) used inappropriately to gain additional payment from Medicare.
  • Lab test billing.
  • – If you bill for UDT (Urine drug test), it is time you verified your processes.

When to Hire a Consultant

  • There are many reasons when the best choice for your practice may be to hire a consultant. When an objective point of view is needed, if a situation requires special proficiency, the practice is facing a major crisis, or if management seems to be operating in crisis mode.

Terminating Reassignment Agreements

  • Individual practitioners should notify Medicare within 30 days of any change in reassignment agreements, since failure to do so allows the previous entity to continue billing Medicare. Individual practitioners and/or suppliers can terminate a reassignment with the designated Medicare fee-for-service contractor.

Routine Waiver of Patient Responsibility

  • "There are a few instances where a provider is allowed to write off the balance after Medicare has made payment. This is not allowed on a routine basis. The provider must make a reasonable effort to collect the coinsurance and/or deductible. Providers that routinely waive the collections of the coinsurance and/or deductible are in violation of the law pertaining to false claims and kickbacks." According to the Trailblazer Medicare Part B Newsletter No. 08-077, February 29, 2008.

Can a RAC contractor recoup money previously paid by the CMS contractor?

  • Absolutely! The RAC contractor has been authorized to request recoupment's to be handled by the CMS contractor. This type of RAC audit is known as an automatic audit process. These audits do not require a review of medical records and are determined strictly on statistical information.

We have a small practice so isn't it harder for an employee to commit embezzlement?

  • Groups of 10 or fewer physicians accounted for 70% of all cases of fraud schemes with 63% of all stolen amounts.

I got paid so it must be OK. Right?

  • Never assume if you got paid you billed correctly. A recent error report by the Centers of Medicare & Medicaid Services says 9.9% of Part B services were overpaid. Remember insufficient documentation counts as an overpayment.

Can under-coding be a bad thing?

  • Yes – It not only costs the practice hard earned money but it also could be a red-flag for an auditor. By under-coding, you could fall outside the norm of what is expected for your specialty which can lead to an audit. You never want a federal agency looking at your practice.

How can I recognize a good manager? Are there certain recognizable qualifications?

  • Raw talent. The best managers have high intellect.
  • They are self-developers. Added skills can't be forced on someone unwilling to learn.
  • They lead with tact, grace and authority.
  • They are not only efficient but also effective.
  • They have technical skills and know how each job is done within the organization.
  • They understand who the employer is and identify with the physician.

My practice seems to have a lot of no-shows. What should I do about it?

  • Do not tolerate staff members being unprofessional with patients.
  • I recommend not charging a no-show fee. However, if you elect to charge a fee, you must charge all patients the same amount including Medicare patients. Investigate and try to determine the reason behind no-shows.
  • Stay positive when dealing with missed appointments.
  • Call forty-eight hours in advance with appointment reminders.

I'm trying to decide if I should join a large group practice. Are there advantages in being a small office?

  • A "personal touch" is easier to establish and retain in a small practice.
  • Overhead is easier to control and therefore remains lower.
  • A small practice normally can function effectively with fewer employees. This in turn makes managing easier.
  • Actual office space can be more inviting rather than appearing as an institution. A more welcome feel draws new patients.

Is there any way to get claims paid more quickly?

  • Submit all claims electronically.
  • Submit clean claims by understanding the rules of coding.
  • It is recommended that follow up is performed on unpaid claims within 45 days of the original date of submission.
  • Handle denials immediately. All denials should be worked within 5 business days of receiving them.
  • Get the patient involved in the process. Whenever possible, let the patient know when payment has not been received.

As a physician, what data should I review from my manager?

  • It is vital to understand where the practice is and where it should be. The practice should be benchmarked against the Medical Group Management Association data by specialty.
  • After you have the data, monitor your 90+ past due A/R gross and net collection rate, and A/R multiple. By monitoring these indicators, you will be able to identify "red flags".

I trust my employees completely. Is that a bad thing?

  • It is not a bad thing to trust employees but it may be shortsighted for complete trust.
  • All employees need to be aware there are checks and balances built into the system. This protects them as well as the practice.
  • Make certain the money collected both from the patient and insurance companies are handled in a complete and thorough manner.

When I ask my manager questions, she sometimes seems to make up an answer. Is this a sign she may be in trouble?

  • Yes–When a manager bluffs a physician or an employee, it is the beginning of the end. Both a physician and employee will lose respect and trust in the manager.

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  • Oklahoma City, OK
  • 73118

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