Eyeworld

EW NEWS & OPINION 26 by Corinne Wohl, MHSA, COE and John B. Pinto To the point: Simple practice tune-ups for complex times Claims payment processes by large insurance companies are often inefficient and/or inaccurate. It can be frustrating to call an insurance company and get multiple answers from multiple representatives for the same question. And the days of having a local rep stop by to see how things are going is long gone. Error rates for insurance payments vary widely and are regionally de- pendent. The best plan is to promptly catch errors. Enforce policies that re- quire staff to utilize the spreadsheet tool. When payment errors arise, its preferable to address them directly from the EOB the very day they are posted, so they don't slip through the cracks. Assess whether the errors you find are random or a definitive trend. Contact the insurance com- pany for resubmissions or appeals for the faulty processing for each patient. A call to an assigned rep- resentative can be helpful, if one is available, if you do detect a trend. Getting to the root of the problem is more efficient than continuing to appeal each case. It's also important to note that not all errors are in the insurance Above is an example spread- sheet. Due to space limitations, there are only 2 insurance types list- ed. It would be common to include your top 10 insurers across the top of this form. We suggest you focus at least on the top 25 CPT codes your practice bills for, but you can make this list as long or short as you prefer. The spreadsheet's function is multi-fold: • For the administrator: It's an op- portunity to see for the first time, or to revisit at least annually, what each insurer is paying compara- tively by CPT code. It's also a good orienting tool as you prepare to renegotiate fees. • For the business office: It's a great tool for the staff posting the pay- ments. It provides a quick check to see if the insurer is paying per contractual agreement. It helps each payment poster observe trends for incorrect payments quickly, which means capturing revenue on time and less rework needed for appeals. Keep this spreadsheet on a shared drive so all staff that post payments have access and utilize it as a helpful tool. "It takes less time to do a thing right than to explain why you did it wrong." –Henry Wadsworth Longfellow W ithout putting too gentle a tenor on it, money is the blood flowing through the veins and arteries of your practice. When the mon- ey flows in, everything else can be healthy and thriving. Patients receive care. Facilities are supported. And doctors and staff earn a living. Billing work—"revenue cycle man- agement," or RCM to use the more modern term—is the beating heart of your practice. Most well-run practices focus harder on RCM than they do on any other business domain. They chart and code diligently. They secure window payments at check-out for patient-responsible amounts. They assure the shortest possible time lag between date of service and claims submission. They track receivables to assure that older receivables out more than 90 days are no more than 12% or so of the total. But all too often, the contrac- tual component of what is actually being paid by insurance companies is overlooked as a key performance indicator. Without this component of de- tailed review, you could be missing significant revenue opportunities. One way to keep easy track of what payers have agreed to pay, and subsequently to see if they are actu- ally doing so, is to keep an updated spreadsheet containing all the data details. In order to prepare this audit tool, collect these materials: • Excel or any spreadsheet program • Contractual agreements for each key payer including an updated fee schedule (which often has to be requested for the CPT codes specific to your practice) • Name and contact information for each payer's representative • Explanation of Benefits (EOBs) forms used for posting insurance payments • Some practices have one fee schedule; others have one for Medicare and a second for all oth- er insurers, for the purposes of A/R management. Be sure to include both, if applicable. Comparing contracted payments with actual payments received company's favor. Overpayments are as problematic as underpayments. Overpayments must be recognized and sent back to the insurer in a timely manner according to your contractual agreement. Proper revenue cycle manage- ment is multi-faceted and requires ongoing checks and balances to assure efficiency and accuracy. EW Ms. Wohl is president of Wohl Associates Inc., a practice management con- sulting firm. She earned her masters of health services administration degree at the George Washington University and has 30 years of hospital and physician practice management expertise. She can be contacted at czwohl@gmail.com or 609-410-2932. About the authors Mr. Pinto is president of J. Pinto & Associates, an ophthalmic practice management consulting firm established in 1979, with offices in San Diego. His latest ASOA•ASCRS book, Simple: The Inner Game of Ophthalmic Practice Success, is now available at www.asoa. org. He can be contacted at pintoinc@aol.com or 619-223-2233. June 2016 Representative/Contact Provider Services Amy Smith Phone Number 877-235-8073 877-235-2222 Insurance Company MEDICARE 2016 BCBS Code Procedure Charge Allowable Payment Allowable Payment 66761 PI YAG Laser (List the charges from your practice here) $308.28 (List payments for each contractual agreement here) 66821 YAG Capsulotomy Laser $342.41 66984 Phaco w/ IOL $656.87 66985 Secondary IOL Exchange $797.96 66986 IOL Exchange $945.98 67036 Pars Plana Vitrectomy $939.42 67800 Chalazion Excision $132.21 67850 Lesion Excision 1/2 cm $223.39 68761 Punctal Plugs $152.50 99213 Low Severity $75.19 99214 Moderate Severity $110.72 99215 High Severity $149.18 92014 Comprehensive $127.69 92012 Intermediate $87.10 92134 OCT (retina) $46.61 92133 OCT (glaucoma) $45.50 92235 IV Fluorescein Photos $114.00 92250 Fundus Photos $81.00 92083 Visual Field $66.56 Sample spreadsheet to keep track of payment agreements

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