Data Strategies | Article: Three Aspects of the... -
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Published on: 7/11/2001
Last Visited: 7/18/2002
Physician practices typically have problems related to a convergence of three crucial aspects of billing compliance: charge entry, coding and documentation, says Jim Stroud, a consultant with the Alabama firm of Warren, Averett, Kimbrough & Marino.
"All of this stuff is a giant mystery to physicians," Stroud says."That area is a huge black hole and they don't understand what happens in there.We hear physicians tell us 'I feel I am working so much harder and making so much less,' and it's partly because reimbursement rates are down and partly because of the billing process."Stroud describes four obstacles to accurate physician billing and better compliance:
(1) Inadequate staffing/training.Physicians typically put people in charge of billing who are not qualified to make the complex translations of medical care into numerical language that payers provide."If you have a person who is not a good linguist, you have trouble" - either in overpayments or false claims fines or underpayments and revenue shortfalls, Stroud says.Physicians tend to underpay the people who perform the crucial function of turning their services into revenue, and then don't invest in training them.
(2) Overdelegating.Physicians rely blindly on office staff to handle a complex billing process with little oversight, yet the physician is the one who will be responsible if false claims are submitted.Physicians "place in one person's hand all coding decisions and take themselves out of the loop.They figure 'I should just treat patients and mark diagnosis codes and whatever is entered on the claim is not my problem,'" Stroud says.But it's the physicians whose provider number is on the line and who will be the one facing fines and jail time.
(3) Sending the wrong messages.Physicians telegraph to billers to do whatever it takes to keep claims clean, which prompts billers to underbill in an attempt to stay off auditor radar screens.Billing clerks figure if they undercode or submit a code that doesn't require a paper claim, the practice will avoid scrutiny, while if they bill at a higher level or tack on a modifier or bill both surgical procedures performed at the same time, the carrier will ask questions or request more documentation.So they leave things off, "but at a terrible cost to the practice," Stroud says.Plus, Medicare carriers take note of practices that fall off the charts in terms of their billing for the lowest payment codes, so undercoding can attract its own kind of scrutiny.
(4) Mistakenly seeking billing consistency."I have seen physicians make the terrible mistake of pursuing the goal of consistency in the medical group," he says."It's a flawed goal."Physicians communicate to billing clerks to assign the same CPT codes for every patient seen by any doctor with a given diagnosis.
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Stroud says he conducted a coding dispersion analysis at one practice for all evaluation and management codes, and found that for all category of coding selections, CPT assignments were just about identical."All the physicians were remarkable similar in how often they billed a certain code, such as 99211 or 99212.Their volumes might have been a little different, but the pattern of dispersion among the different codes was identical," he says.The reason: a billing person took each diagnosis code and slapped a certain CPT code on there regardless of the services provided and documented.That spells big trouble in terms of compliance.
Ways to Improve Physician Billing Compliance
Here are five suggestions for cleaning up physician billing problems:
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For example, the physician could review coding on a test basis, Stroud says.One of his practice-clients pulls 10 charts for every physician every month and the physicians take turns reviewing the translation of services and documentation to coding assignment and suggest improvements.
(3) Get rid of the mindset that undercoding is a good strategy.It probably won't protect you and just deprives physicians of money to which they are entitled.Stroud had one physician-client who saw a huge volume of patients in his specialty but billed about 90% of them at 99212 - a low-level service - when they clearly could have been billed as 99213 and 99214.The physician just didn't want to bother with the documentation required to bill the higher level of service.Not only is that a Medicare violation, the physician was losing upwards of $90,000 in revenue every year.Stroud said the physician was better off hiring a coder or nurse to shadow him and take down the documentation.
(4) Improve communication.Doctors tend to deal only with their nurses, but they need to meet with coders and other back-office staff to improve billing and compliance.Stroud suggests routine lunch meetings to talk about coding and documentation issues.
(5) Work denied claims.Billing clerks can recover their entire salaries working through and resubmitting denied claims, which also gives practices a window into their systemic compliance mistakes so they can fix them.
Fixing an Existing Nightmare
Attorneys suggest that physicians immediately get a lawyer involved to protect the clean-up process.
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