Review EOBs and determine where denials are originating and their root cause
While reviewing EOBs practices need to determine if a trend can be established that identifies the root cause for why claims are being denied. Trends can be established by asking if most denials are originating in your patient access and registration departments, or are denials occurring because of insufficient documentation, or due to billing or coding errors?
Due to the increasing number of forms being required these days it is all too common for practices to get lost in the vast terminology, rules, and coding requirements that have to be followed as well. An area that practices have one of the most difficult times with is operationalizing the issuance of an ABN properly. I am frequently asked to consult for practices that ask who does which part, when, and with whom in regards to ABNs? In other instances, many practices I have worked with simply make the mistake that they can solve the complexities of trying to understand the nuances of how to properly utilize ABNs by deciding to issue ABNs to every Medicare patient for every service which is not a viable option either. The solution that many offices try that I just described is called issuing blanket ABNs, which in turn may cause Medicare to invalidate all issued ABNs from the practice, including those that may been appropriate which is why it is very important that blanket ABNs are never issued.
One thing in common with practices that issue ABNs in a proper manner is that they all have a process in place for identifying potential denied services prior to delivering them. To many practices this may sound easy, but to ensure that your practice is as effective as possible it will take some claims data analysis to ensure that your practice is capturing all potential opportunities for ABN issuance. The aim of this article will be to provide practices with 5 steps that will make ABN issuance easier.
FMVs are at the heart of healthcare regulatory compliance when money or anything of value changes hands in a healthcare business setting. Why? Two reasons:
Healthcare laws (Stark, the Anti Kickback Statute and the Patient Brokering Act) all target money changing hands in the healthcare business space; and
There are clear exemptions and exceptions that have as an essential ingredient that the compensation (or pricing) is consistent with “fair market value.”
How it Goes—A Six Part Process
Locking down an externally performed FMV (part of the “gold standard” in regulatory compliance) is a process. Here’s what it should look like:
Step 1. The healthcare business person or his/her advisors (often accountants) find someone who specializes in performing FMVs for the specific matter (e.g. compensation, price of a business to be acquired);
Step 2. The LAWYER for the healthcare business is immediately involved in the process BEFORE the FMV firm is engaged;
Step 3. The LAWYER engages the FMV firm on behalf of the healthcare business client;
Step 4. The parties (including the lawyer) get on the phone or in a meeting with the “FMV guy” and has a very extensive conversation re the project;
Step 5. Once the FMV process done, a DRAFT FMV study is prepared and discussed interactively with the healthcare business and the lawyer;
Step 6. Once finalized, an execution copy is prepared and provided to the lawyer.
There have been a rise in cases recently, in which practices that operate under a Health Care Clinic License have been brought under scrutiny by insurance companies trying to recoup funds through any means possible. In an effort to claw back funds insurance companies are beginning to claim that medical directors are failing to meet their statutory obligations under Florida Law which in turn can have serious monetary repercussions. Due to the clinics allegedly failing to meet their statutory obligations the insurance companies are filing suit to recoup any payments made while violating the Health Care Clinic Act obligations, and to stall any future payments due until such cases are heard.
By law, a medical director must be a health care practitioner that holds an active and unencumbered Florida license as a medical physician, osteopathic physician, chiropractic physician, or podiatric physician. The type of services provided at a clinic may dictate who would be able to serve as a clinic’s medical director, because a medical director must be authorized under the law to supervise all services provided at the clinic.
A recent Department of Justice $500,000 settlement with a cardiology practice underscores the need for ensuring tighter compliance by medical practices. There, the practice billed Medicare for cardiology procedures for which interpretive reports were also required. Medicare paid for the procedures, but upon audit, CMS could not find the requisite interpretive reports. The False Claims Act case settled for $500,000, but it’s likely that (1) the reimbursement by Medicare was far less, and (b) the legal fees behind the settlement weren’t too far behind the settlement amount! Had the practice self-audited each year, would they have found the discrepancy?
Medical practices have felt the weight of price compression and regulatory load more than probably any segment in the healthcare sector. They are doing far more for far less. And regulations expand faster than viruses! Hence, many have a strategy of regulatory compliance that can best be characterized as a combination of facial compliance (“We bought the manual and put it on the shelf”) and hope (“They’re not really serious about this, are they?”). Unless you’re part of a practice of more than 20 doctors, it’s likely that you can do more to ensure regulatory compliance.
In another article, we provided an update to the autonomous practice law for Nurse Practitioners in Florida. For NP’s that qualify, that means they can open a primary care practice without a supervising physician. For most, that means learning about opening and operating a company. Here’s what that entails:
DOES YOUR BUSINESS NEED A MANDATORY VACCINE POLICY?
Given the above, does a mandatory vaccine policy make sense for your organization? This may depend on several factors, including the following:
Are your employees in direct contact with clients/customers/patients?
Is that contact prolonged and in indoor spaces where air circulation may be limited?
If one or more of your employees become ill, does that jeopardize continuity of your business?
If you answer “YES” to one or more of these questions, you may want to consider implementing a mandatory flu vaccine.
In order to effectively implement a mandatory vaccination policy, you must develop both the policy and the process to manage exceptions (i.e. requests for accommodations). The process generally involves the submission of an employer-developed form along with any additional supporting documentation. The accommodations process should include review of information submitted by the employee in support of the accommodation, request for additional information as and when appropriate, an interactive process between the employer and employee in evaluating any potential accommodation, and ultimately a determination if the requested accommodation poses an undue burden that is more than de minimis on the employer.
For some reason, wearing or refusing to wear masks has become a point of personal expression and a topic charged with much emotion. We hear stories every day about confrontations with consumers in the retail industry. But what about when a patient refuses to wear a mask?
In many states and counties, face coverings are still mandated in public. Failure to wear a mask can result in civil or criminal fines or penalties. In a medical practice, even where not required by local authorities, masks may be required. In fact, some of the state Boards of Medicine have adopted minimum standards for safe practice. Those standards frequently include the requirement for both provider and patient to wear masks during all health care encounters. Where the regulations or Board of Medicine standards require all individuals to wear face coverings, a health care provider is well within his/her right to enforce those regulations within the office where health care services are being provided and to discharge a patient who refuses to comply. However, caution must be exercised when discharging a patient from a medical practice.
In general, the state Boards of Medicine do not require physicians to treat patients who are physically and mentally capable of wearing face coverings but refuse to do so. But there are circumstances where a physician may have a duty to provide care and, in such instances, exceptions to the general rule may apply.
Thinking about joining an integrated or group practice? The average employment contract exceeds twenty pages, not including exhibits. While some parts might seem simple and non-legalistic, many simply do not contemplate important terms that have serious impacts on Acupuncturists daily lives. An employment contract is the most significant financial decision of an Acupuncturists lifetime. The same can be said for each subsequent contract, which means that understanding, and negotiating, your contract is the most valuable investment you can make prior to entering into a contract.
To understand what’s in your employment contract, simply read it over a few times. To understand not only how those terms affect you, but also what isn’t in your contract, hire an experienced health care lawyer. While it’s important to understand what is in your employment contract, it’s equally as important to know what is missing from the contract and what to ask in regards to what is included. The below list considers terms that are important both during and after employment.
The following are nine items you should consider including in or asking about your contract:
Health law is the federal, state, and local law, rules, regulations and other jurisprudence among providers, payers and vendors to the healthcare industry and its patient and delivery of health care services; all with an emphasis on operations, regulatory and transactional legal issues.