Practice Management Alert

Billing Every Charge Every Time Is Best

Question: If I know a payer is going to deny a certain charge, do I need to bill it at all? Since I am familiar with which payers reimburse for certain charges and which ones don't, is there any reason why I shouldn't be billing payer-specific to save time and effort?
   
- Ohio Subscriber

Answer: "You should not treat anyone differently," says Donna Rachunas of Health Claim Services Inc., a billing service in Haddonfield, N.J.

"There should be a protocol that you follow," she says. Bill every charge and then administer the contract when you get the payment and/or denial. This leaves less room for human error, since you won't have to remember which things to bill, Rachunas says. Billing everything provides you with a clear record of what each of your carriers is doing for you.

It might seem as if you could save yourself a lot of effort by not billing certain charges, but that's probably not the case. Billing for everything saves you the mental energy of determining the exact status of your charges billed, Rachunas says. 

If the claim comes back noncovered, nonbillable, then you know to write it off. If it comes back noncovered but the patient is responsible, then you release the bill to the patient. Without the payer determining these things for you, you're forced to choose. That means the possibility of mistakes and losing revenue.

You also need to remember that carrier policies change all the time, Rachunas says. Payers might change what charges they cover, but unless you're billing them you'll never know.

The only exception to billing everything is with Medicare. You should not bill Medicare for anything that you know to be noncovered without first notifying the patient, Rachunas says.




Know What to Bill for Consolidated Billing

Question: Would you clarify the details of consolidated billing for SNF stays? For example, what qualifies a patient as an SNF resident and what services are excluded from the consolidated billing?

- Nebraska Subscriber

Answer: A skilled nursing facility (SNF) resident "is defined as a beneficiary who is admitted to a Medicare-participating SNF, or to the nonparticipating portion of a nursing home that also includes a Medicare-participating SNF, regardless of whether Part A covers the stay," according to the Centers for Medicare and Medicaid Services. 

Consolidated billing (CB) requires an SNF to bill Medicare for the entire package of care that its residents receive. The SNF collects any deductibles or coinsurances from its beneficiaries, and outside providers of any service or supplies must bill the SNF for payment, not the beneficiary or the Medicare carrier.

Services included in CB:

- all care that Part A residents receive
- technical components of physician services for Part A residents
- physical, occupational, and speech therapy services for Part B residents.

There are limited services that are specifically excluded from CB. For a detailed list of these exclusions, visit CMS' Web site for the SNF Prospective Payment System at http://www.cms. gov/providers/snfpps/default.asp.




Use Caution With Waivers

Question: We all know that doctors are going to continue offering professional courtesies, even with it on the OIG's Work Plan. Would it be a good idea, therefore, for me to write a formal policy regarding the waiver of co-pays, deductibles, etc.?

- Louisiana Subscriber

Answer: Experts agree -  A formal policy on waivers and professional courtesies is NOT a good idea. This would be a red flag for investigators that your practice is clearly noncompliant. Ideally, you should treat all your patients the same, says Donna Rachunas of Health Claim Services Inc., a billing service in Haddonfield, N.J.

If a doctor really wants to make exceptions, he should decide on an individual patient basis, Rachunas says.  Any type of blanketed rule on waivers is a big no-no; stick to a case-by-case approach, if anything.  

Tip: Protect yourself from liability by having the physician sign off on each case that he makes an exception.

Discounts for patients with financial hardship are a slightly different matter. Patients who can't afford a payment should address the problem in writing (including proof such as W2 forms and bank statements) so the doctor can make a consideration for financial hardship. For these situations, your office needs to have a set guideline identifying a back-up fee schedule that you will use to adjust the bill. Example: "In such an event, we will adjust the bill to the Medicare fee schedule based on its reimbursement." 

It's important to have this guideline in place and follow it consistently to keep out of jeopardy with your insurance carriers and Medicare, Rachunas says. Most payer contracts state that if you give a discount to a patient, you must give the same discount to the payer. If a carrier finds out you adjusted a patient fee without a set back-up fee schedule, they may have the right to demand you adjust your fee to them as well. Medicare considers any inconsistent discounting as fraud, and is also the most likely entity to use legal enforcement.

Bottom Line: Tread very carefully when dealing with waivers or discounts of any kind. Make sure your doctors realize the risks involved, and seek a legal opinion if you have any question as to the proper course of action.