Has this happened to you?
You have carefully coded all your visits to close any gaps, document all chronic conditions, and added all those pesky HCPCSII codes and there they are again on a report from the carrier as if nothing ever happened. It is infuriating. Wasted time you, the provider spent on countless seminars, webinars, in-person training, and you do everything right and your score still does not reflect it. What is going on? It could be as simple as your biller. She is still in a fee-for-service mentality. And it is costing you dearly. Not only in aggravation, but in real dollars. Things could change though with a value based payment system.
Let’s take the example of Dr. Weissbren, MD. An internal med physician with a fairly large full-risk population.
Dr. Weissbren was not yet ready to give up his fee-for-service population altogether, and with the help of a PA maintained a juggling act. His first year at full-risk was – naturally – financially a catastrophe. Which was why he congratulated himself to keeping the robust fee-for-service business. And his very competent biller. She was, by all accounts a very aggressive and competent coder, biller, and collector, and his outstanding AR usually looked pretty good. Nevertheless, he committed to improving in his second year and diligently learned all about MRA scores, proper diagnosis coding, chronic conditions, HEDIS star ratings, and all that went with it. He worked long hours and implemented his newfound knowledge.
Still, at the half year mark, his scores did not improve. The medical director and coding experts visited and explained. No change. Only towards the end of the year did someone notice that Dr. Weissbren’s notes had all the proper codes, but miraculously, the claims did not. It took another month for someone to connect the dots and realize the biller was deliberately removing diagnosis codes, changing them or deleting them from the claim. A massive audit of all encounters for the entire year revealed this to be the case for all visits. She had applied her fee-for service logic to a managed care world. What worked before now had almost cost the practice two stars and $104,000.
This is not an isolated incident.
All too often we see that billers in a practice are left out of the training cycle. They themselves do not consider the material covered as relevant to their job, because “it only affects the capitated plans anyway.” The idea, that ‘’billing’’ is not in any way connected to encounters or alternative payment systems is deeply ingrained. And could not be further from the truth. As the example shows, we desperately need to shift our perception from “bonus” to “quality based payment”. A payment that is, indeed, responsibility of the billing department. We can no longer separate the regular billing and the “capitated” billing. Alternative payment systems are exactly that, part of the payment structure without which no independent practice can survive.
Billing, the revenue cycle as a whole must encompass all sources of payments.
And that must include every staff member. Billing is not an isolated event, performed in a backroom with bad lighting. It is part of an intricate mechanism of interconnected parts; all of which must be equally trained, updated and have access to information.
Are you considering switching to a value based payment system?