Medicare Compliance & Reimbursement

With your Medicare margins getting squeezed tighter and tighter, you need to work twice as hard to find efficiencies in your home health agency. Your back office billing department is an area that's likely ripe for an efficiency overhaul.

Use these tips from billing expert Melinda Gaboury to help you get the most out of your staff and processes:

1. Eliminate duplication. One of your biggest money-savers may not be an easy step to take. "There's so much duplication going on" in many HHAs, Gaboury said in her presentation at the National Association for Home Care & Hospice annual meeting in Las Vegas that drew about 5,000 participants. That's particularly true for "hard core paper agencies" Gaboury said in her standing room only Oct. 3 presentation, "Achieving Efficiencies in Back Office Staffing & Structure."

Eliminating the duplication will require a thorough study of your paperwork flow from intake to discharge, she advised. And don't expect a transition to electronic medical records to fix your duplication problems. "Those same problems translate into a point of care system," she cautions.

2. Clean out "the junk." When you identify the duplication and otherwise inefficient processes in your billing system, you need to get rid of them even when staff say "it's the way we've always done it," Gaboury urged. You're likely to meet resistance from staff who don't want to change, but it's necessary to improve your billing performance -- and keep your agency operating in the black.

3. Figure out what your staff are really doing. Along with a paperwork flow study, you should interview staff about their paper vs. real-world job descriptions and duties, Gaboury counseled.

For example: You may feel you have enough staffing to bill properly, but then will discover one of your billers is actually spending half her time helping the intake department get authorization for visits, Gaboury offered. That will explain why billing collections are going undone and your accounts receivable is creeping up. Billing staff should have a copy of their official job descriptions and understand what they are responsible for, she urged. Once staffers are doing what they're supposed to be doing, you can determine whether you are over- or understaffed.

Bottom line: You can't hold staff responsible for their performance if they -- or you -- don't know what their job duties really are, Gaboury stressed to attendees.

4. Restructure your billing department. Your biller(s) must be held accountable, Gaboury emphasized. To do that, they need to report to a management-level supervisor. If your agency is big enough to have its own billing manager, that's great, she said. But they have to "truly manage the department," she cautions. That means reviewing key performance statistics. If your billing department reports to an outside manager, make sure the manager is providing adequate supervision, Gaboury cautioned.

5. Use billing benchmarks. Just like on your clinical side, your billing staff need to meet productivity and performance benchmarks, Gaboury advised. Be sure to set reasonable goals, then hold staff to them. Review the measures in team meetings, she urged. Your billing department should have team meetings just like any other department.

Reward your high performers with perks such as bonuses, days off, gift cards, etc., Gaboury suggested in response to an attendee question. But you also have to deal with your low-performing staff members. For example, you need to set a time limit for how long staff are allowed to perform below benchmark levels.

6. Educate billers. Everyone knows clinical staff need in-services and other forms of professional education. But what about billers? Billers need education too, Gaboury stressed. They should receive every-other month, or at least quarterly education sessions. And you should make sure they receive adequate training on any software you purchase, even when you have to pay for it.

7. Use software correctly. You are throwing thousands of dollars down the drain if you don't use your software the way it's intended. "You've got to have control of the process of implementing software," Gaboury warned.

For example: Scheduling systems often have a requirement that won't let visits be scheduled without orders in the system. But if you let staff override that because they swear they'll do it later, you're wasting your software's capabilities, Gaboury stressed.

Another example: Gaboury helped an agency whose biller was doing all their billing using an Excel spreadsheet, when she had a pricey software system at her disposal. Why? Because she had stepped into the role of biller unexpectedly and never received training on the software.

8. Conduct pre-billing audits. While you want to use your software to its fullest, don't believe developers' claims that it will eliminate your need for pre-billing audits. "You can't just leave it up to EMR," said Michael Horsley, owner of HHA All Coast Therapy Services Inc. in Lady Lake, Fla.

"Do not trust that your software system is 100 percent protecting you," Gaboury warned. You should conduct pre-billing audits on 100 percent of your claims, she advised. The audits will help you catch billing problems, compliance issues, and will cut down on your denials.

You should check to make sure there's a note for every visit, a plan of care signed and dated by the physician, supplemental orders back signed and dated, and that all visits are covered by orders, counseled Horsley in the presentation. Checking for orders is particularly important because the entire episode will be denied without them, Horsley stressed. And missing orders can put you at risk for fraud and/or survey problems.

Money-savers: You don't need to conduct the pre-billing audit until the end of the episode, Gaboury offered. And the audit can be conducted by billing or clerical staff, it's not a clinical review.

9. Track orders. Because you can't bill your final Medicare claim until the POC is back, missing orders can significantly delay your billing. But many HHAs let unreturned POCs slip through the cracks. You should track physicians' orders electronically, Gaboury said. If the POC isn't back within 15 days, it's time to resend. If you allow four or five months to go by before you ask the physician to sign again, then you can expect it to take four or five months to get orders going forward, she cautioned.

10. Tackle F2F documentation. A new wrinkle creating headaches for billers is Medicare's face-to-face physician encounter requirement, Gaboury related. It's important to read the F2F documentation when it comes back from the doctor, she said.

For example: One agency found the physician wrote "patient not homebound" for the narrative, Gaboury said. Other agencies are seeing that the F2F documentation has a totally blank narrative or is lacking a signature or date.

Remember: Under Medicare rules, you are no longer allowed to date stamp signatures. Docs must provide the date themselves.