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countability. When we accept the concept that a $25 co-pay is no big deal, the rest of us end up paying in increased costs. This article in no way can cover each and every aspect of medical revenue recovery. I will try to steer you in a direction that will assist you in accounts receivable as well as help the medical community by trying to hold those responsible for medical debt accountable. Did you know medical collection activities save each of us about $600-$800 per year in medical costs?


INSURANCE CONTRACTS: Are there terms that govern what my recoveries will be? If you are contracted with an insurance carrier this answer is a simple, “yes.” I have handled many calls from physicians regarding whether a carrier can or can’t do something. I ask to see a copy of the contract and the response is they can’t find a copy. First, you need to know the identities of the health insurance carriers with whom you are contracted. All of your practice’s contracts with health insurers should be kept in a safe place and copies should be made available to the person(s) doing your billing. Addendums/changes should be attached to the originals and copies provided to update your biller. If you are “in network” with an insurer, you will be compensated based on the terms of that contract. If you have been doing business with certain health insurers and can’t find your contract, request a copy to update your records. If you run into problems, Sandie Becker, your physician advocate, for SCCMA-MCMS (408) 9988850 Ext. 3007 is a valuable resource and SCCMA-MCMS member benefit. Let’s face it, sometimes even when you have all of your contracts accounted for, and various product lines of insurance are understood by your staff/biller, there will still be issues raised about timely claims, improper coding, etc. That is why you need a strong advocate in your biller to appeal and question the insurers as to why claims were paid at less than contracted or not at all. OUT OF NETWORK/UNCONTRACTED SERVICES: The patient is usually responsible directly to the physician for services rendered where there is no contractual relationship between the insurer and doctor. It is possible for a doctor to verify benefits beforehand with a carrier and to accept the representation of payment of a certain amount. Caution: Always get authorizations and confirmations backed up in writing. The carrier will usually have provisions in their contract with their insured to pay a reduced amount or nothing at all for “going out of network.” What is my remuneration if I am not contracted with a particular insurer? If you have a written contract with the patient, the terms of the contract will dictate. If there isn’t a written contract, a doctor is entitled to “quantum meruit” which is the implied promise to pay the reasonable value for services rendered. This is determined by what is considered usual, customary, and

reasonable (UCR). This is determined by many elements including what other physicians in your geographical location are billing for this same service, your experience level and specialty, what you normally bill for this procedure or service, and as well as other factors. My experience in court is that if the procedure is one that you routinely perform, and you have a good idea what will be charged, you should advise the patient of same prior to rendering services. Otherwise, the doctor repairing knees on a 49er football player will likely get the same fee as other physicians in the area performing the same procedure for less. Most of our trauma surgeons are well aware of the problems emergent care poses with an insured patient. These emergency services should be paid on the basis of what is usual, reasonable, and customary (UCR); however, often times the carrier will only pay the lower rate they pay their contracted physicians. The doctor providing emergent care then has the ability to go after the insurance carrier for the balance. In this scenario, where no actual contract exists between the parties, case law has established an implied at law contractual relationship between physician and health insurer. You may legally pursue the patient for patient responsibility items such as co-pays, deductibles, etc. HOWEVER, USE CAUTION. In the case of HMOs and some PPOs, you may not “balance bill” the patient for the difference.

AFTER YOU HAVE IDENTIFIED THE SOURCE OF PAYMENT WHETHER IT IS INSURER, PATIENT, OR A COMBINATION OF BOTH: THE NEXT STEP IS BILLING Your office may employ persons in-house to handle your billing or you may employ an outside billing company. If you utilize a billing company, the average charge for services ranges from 5%-10% of the claims made or paid, depending on your agreement. As they are retained on a fairly low commission basis, their goal is to bill as many accounts as possible with the goal of getting it right the first time so additional time isn’t spent on appeals, etc., that are costly to a billing company. The physician should be certain his/her notes in the charts specifically match the CPT codes so claims are not rejected. Your biller should be comparing the claims with payments received to be certain the appropriate amount has been paid and, if not, why not. Your biller should be intimately familiar with your practice and the common CPT codes and modifiers you use daily. If you are presently having office staff conduct your billing and/or you are looking for a new billing company, to be certain you are maximizing your phase 1 (billing) of revenue recovery, we recommend you contact the newest sponsored partner of SCCMA and MCMS, ProMed Billing; they are located locally in Los Gatos. Their contact information: Adam Salinger at (408) 680-0000 or A good biller knows when to move the account onto the next Continued on page 14 MARCH / APRIL 2015 | THE BULLETIN | 13

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