From Physicians Practice, Inc. Q: We've been seeing a Medicare patient for about a year. She pays the required copays/deductibles out of her pocket. Well, she just informed us that she also has another insurance carrier. She wants us to go back, rebill all her claims with this payer, then refund for what she paid out of pocket. Do we have to do this? Can we charge her for doing it? It'll take quite a bit of time.
A: Honestly, I would ask the patient to submit the claims herself. Filing any claim is a courtesy we give our patients. It's her money. It will cost you to do the research and paperwork, and Medicare will frown on you charging her.
You can offer to help her find and understand the right forms, but she'll need to fill them out and send them in herself. The payer can reimburse her directly. Q: How many billing staff do I need?
A: Here is what Physicians Practice recommends for billing staffing, by claims volume:
* Billing full-time employees (FTEs) per 100,000 claims: 10.45. (Claims are the basic work unit of a billing staff member, just like work RVUs are for a provider.)
* Payment posting/cash management FTEs per 100,000 claims: 1.9
* Credit resolution FTEs per 100,000 claims: 0.40
* Insurance denial and follow-up FTEs per 100,000 claims: 3.1
* Patient follow-up and inquiry FTEs per 100,000 claims: 1.8
One biller per 10,000 claims may seem a bit low, but if the claims are clean, then no billing staff intervention is needed at all. Therefore, the ratio is not just a reflection of how good the biller is, but how good the process is.
A biller is defined as anyone who touches the process from the time a charge becomes a claim until the claim is fully paid. Q: We've seen benchmark data that says payroll should consume about 30 percent of a pediatric practice's revenue. When these percentages are tabulated, do they include benefits? Does that include vacation time or just insurance-type benefits?
A: It depends on which benchmarks you are using -- it's important to compare apples to apples.
The MGMA's Cost Survey found that for pediatric practices, median total support staff costs equal 27.08 percent of total medical revenue.
This includes benefits -- defined as FICA, payroll taxes, employee health and life insurance, and retirement. It does not include paid vacation.
Don't include in the staff count revenue-producing staff such as nonphysician providers who see patients themselves and bill for it. Q: Does dictation sent out nightly to a transcription service need to be checked and initialed by the physician prior to filing to the patient's chart?
A: Yes, physicians should review and initial or sign the notes.
There is no federal requirement to have a signature on every note, though some hospitals do. In any case, it is a good idea for risk-management purposes. A signature shows that the physician read the transcribed notes and approved them. However, if physicians simply sign the notes without reading them, your risk is higher, not lower. Physicians who do this cannot claim that the notes inaccurately represent what happened.
Also, some managed-care plans and some Medicaid programs may require physician signatures on progress notes. If ancillary personnel provide services, state laws regarding their services may require signatures to demonstrate appropriate physician supervision.
Under any circumstances, the notes should demonstrate clearly who provided the service, with or without a physician signature. Q: Is there is a time limit for insurance companies to request refunds from providers?
A: Refunds are a contractual issue. Look at your payer contract for limits on "recoupment." If there is no time limit, they can seek refunds for as far back as they like. Many physicians try to address this issue when it comes time to make or renew contracts. Also, some states impose some limits. For example, according to the Texas Medical Association, "state-regulated insurers and HMOs (which account for 20 percent of the market) [in Texas] may recoup overpayments only for those claims paid 180 days prior to the refund request. |
