7 mistakes dc’s can’t afford to makestrategicdc.com/wp-content/uploads/2013/12/wsca-7... · 7...

7 Mistakes DC’s Can’t Afford to MakeWith Billing, Coding, Documentation, Compliance & Your Business

Presented by Tom Necela, DC, CPC, CPMA, CCP-P

www.StrategicDC.com

Mistake 1: ICD-10 Procrastination

Mistake #1: ICD-10 Procrastination

Realizations

1. Deadline is set -

October 2014

� ICD-9 & ICD-10

Closed for revision!


2. All Dx Codes Change…

PLUS the 7th Character Extenders

� Initial Encounter = A

� Subsequent = D

� Sequela = S


Hip Spr/Str(843.8) �� Becomes 19 codes!

� S73.191A

(right hip spr, initial)

� S73.192A

(left hip spr, initial)

� S76.111A

(right quad spr, initial)

� S76.112A

(left quad spr, initial)

� S76.119A

� (unspecified quad, initial)


Realizations

3. More specificity for Dx and Documentation

4. Doctors & Staff BOTH Affected

5. No Exceptions


Preparation

1. Estimate 3-6 mos

2. Start Feb-Apr 2014

3. Train DC & staff

4. Train by June to practice

5. Ready to be “live” in October 2014

Mistake 2: Billing Metrics

Metrics to Monitor Your Money

Collections Performance as % of Services

• Gold Standard goal = 100%

• Acceptable = 80-85%

• Below Avg = less than 75%

Metrics to Monitor Your Money

Healthy A/R

• <1.5x gross services

• 2x is danger zone

• >2x = problem

% of Cash, Ins, PI can vary

Know When to Fold ‘Em

� Outsourcing

• Timely Claims Pd – 80% < 45 days

• Low % of duplicates

• Insurance balances vs Pt balances

• Billing cost – Norm = 4-15%, avg = 8%

� Collections Agency

� Forgiveness

Mistake 3: Ignoring Audit Patterns

Mistake #2: Ignoring Audit Patterns

1. Random Audit

• Target = your license

• Trigger = none

• Defense = Correct coding & documentation

• Offense = Prompt response and appeals

<9 % Appeal, >64% Appeals Win


2. Specialty Audit

• Target = rehab, radiology, etc

• Trigger = high usage patterns

• Defense = understand payer policies, coding

& documentation

• Offense = Appeals (more $, tougher to win)


3. Outlier

• Target = anyone outside the curve

• Trigger = high usage patterns

• Defense = understand parameters

• Offense = Appeals (more $$, tougher)

Mistake 4: Medicare Mess Mgmt

� Mandatory Reporting

Par and Non-Par

� Pain & Function

Each Visit

� 30 Day Episodes

G8539 Initial FOA

G8942 FOA <30 days

The Impact of Meaningful Use

� DOI

• Box 14

� Update Dx Codes

• Box 21 Claim

• Documentation

� Exacerbations

• Temporary Worsening

• (Date in Box 19)

The Impact of Meaningful Use

Mistake 5: Documentation Denial

CERT Documentation

Checklist

� History

• Mech of Trauma

AT = Active Tx

Acute or Chronic

Noridian Medicare CERT Checklist

� PART Exam OR Xray

• Pain

• Asymmetry

• ROM

• Tenderness

Xray

• Box 19 date


� Tx Plan

• Duration

• Frequency

• Objective Goals

• Measures


� Encounter specific

Daily doc

� All Spinal Levels

Documented

� No Ongoing Imp =

Maintenance

� Signatures


Mistake 6: Shelving Compliance

1. Manual ≠ Compliance

• Must be interactive

2. HIPAA

• Deadline Sept 23, 2013

• OCR or Dept of Justice

Mistake #6: Shelving Compliance

2. Fee Schedule

• Dual Fees / TOS Discount

• Payer Phone Snoop

• Website Woes

Mistake #6: Shelving Compliance Concerns

3. Coding

• Understanding Rules

Example: 97140 & 9894x

• Understanding time

CMS (8-22 min) vs CPT(15 min)

• Creative

Mistake #6: Shelving Compliance Concerns

Mistake 7: No Pre-Auth Strategies

2.0

Regence/CareCore Pre-Auth Program

Includes

• All Regence plans

• Medicare Advantage

• For In and Out of Network Providers

Excludes

� Uniform Medical Plan

� Federal Employee Plan

� If Regence is Secondary

� Medigap, BlueCard


Trial Date

• Trial period starts November 1, 2013

• Pre-authorizations in operations

• No denials issued

• Data tracked and education issued


“Live” Start

� Full program starts February 1, 2014

� Pre-auth requirements according to Tiers

� Denials issued


Tier A (approx 50%)

• Submit Notification w/in 7 days after Initial Exam

• May Tx for 30 days

• No info given for Tx beyond 30 days


Tier B (approx 25%)

• Submit Notification w/in 7 days after Initial Exam

• Receive approval for 6 visits (DC) / 4 for LMP/Lac

• Initial approval waiver good for up to 60 days

• Tx >60 days or 6 visits requires pre-auth

• Subsequent episodes require immed pre-auth


Tier C (approx 25%)

• Submit Treatment Request + Notification @ Exam

• Wait for Tx Request approval to continue care

• Approved # of visits given within 2 days


Pre-Authorization Denial Differences

Denial

INNo Tx

No Pay

OUT Pt Resp

Appeal

Regence / Care Core

Use of Member Consent Form

�Services requiring pre-authorization cannot be

billed to patient even if…

�Patient signs a waiver/consent/ABN form


7 Areas of Impact to Consider

1. Case Presentation / ROF modification

� 30 day tx plans will work best

� Re-submit 7 days prior to end to continue care


7 Areas of Impact to Consider

2. PRN patient paperwork hassles

� >30 lapse will force restart

3. Double Duty patients (chiro & massage)

� Visit approvals will not match

4. Secondary Slap

� Watch Double Denial


5. Staffing – do we have time?

� Consider outsourcing

� Consider “down-sourcing”

6. Documentation

� Prompt

� Detailed

7. Diagnosis Coding

� Hierarchy

� Updates


Participation Considerations

1. Demand to see how many DC’s in each tier

2. Appeal your Tier Level early

3. Use the Trial Period to test system

4. Examine 1099 to see impact

5. Opt Out Before Kicked Out or Downgraded


Navigating Pre-Authorization Programs DVD Tutorial

• Billing/Coding

• Documentation

• Staff Management

• Business Strategies

Specific to Regence/Care Core

The Future

� Do the Math & Take Action

� Develop Multiple Streams

� Monitor Money

� Educate to Excel

� Focus on patients,

not paper

� DC’s are still thriving!

Work Smarter, Not Harder

www.StrategicDC.com

Services

• Blog articles-

www.strategicdc.com

• Seminars & Webinars

• Audit Assistance

• Private Consulting

• One Day Intensive

7 mistakes dc’s can’t afford to makestrategicdc.com/wp-content/uploads/2013/12/wsca-7... · 7...

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