All Entries in the "Access Q&A" Category
Follow ABN guidelines for noncovered outpatient procedures
Q: When a Medicare beneficiary presents for an outpatient procedure that we know is noncovered by Medicare, can we ask the patient for payment at the time of the service? If so, can we ask the patient to make a full payment? What about for a procedure that might not be covered and for which we deliver an advanced beneficiary notice (ABN)? Can we collect any payment at the time of service?
A: Medicare does not require providers to issue an ABN for services that are “statutorily excluded” (services that are never a Medicare benefit). However, you may still want the patient to sign a waiver of liability to ensure that they understand that they are responsible for the charges. For an excluded service, you can collect full payment for the services and, if it is your usual practice, you may request payment at the time of service.
If Medicare covers the service and the patient completes an ABN, you may collect payment from the patient at the time of service. If Medicare pays for the service, you must make the appropriate refund. If the service may be covered and you do not require the patient to complete an ABN, you cannot bill the patient.
Be sure to use any applicable condition codes and/or modifiers (e.g., -GA, -GX, -GZ) on the UB-92 or CMS-1500 form.
This question was answered by the APCs Weekly Monitor panel of experts.
Can you bill Managed Care the same way you bill Medicare for discontinued procedures?
Q: If we bill Medicare for a discontinued procedure, can we bill Managed Care the same way?
Some consultants are telling us that commercial insurance must follow Medicare guidelines. Other consultants are telling us that Medicare is allowing this billing practice to anyone who is paid under OPPS, that the ability to bill discontinued procedures is not a federal guideline that Managed Care must follow, but a contract with Medicare. Managed Care does not pay under OPPS so we would not be able to bill Managed Care for discontinued procedures. Instead, we must follow each particular contract.
A: The modifiers you cited are to be used in the Outpatient PPS system for “discontinued procedures”-outpatient surgical or diagnostic procedures that were started but discontinued by the physician due to “extenuating circumstances or to circumstances that threatened the well being of the patient”. Modifier 73 is used for a procedure that is discontinued AFTER the patient is prepared for the procedure but BEFORE anesthesia is administered or the procedure is started. Modifier 74 is used for a procedure that is discontinued AFTER the patient is prepared for the procedure and AFTER anesthesia is administered or the procedure is started. Medicare pays the provider for the costs incurred in preparing the patient, even though the procedure was not completed.
The modifiers for discontinued services MUST be used by providers billing the Medicare program for services to Medicare beneficiaries. In addition, payors offering Medicare Advantage or Medicare supplemental products with benefits that mirror Medicare coverage must provide payment for discontinued services. If the patient is not enrolled in a Medicare Advantage or Medicare supplemental product, the payor MAY accept the 73 or 74 modifier, but because the payor is not required to cover the same benefits as Medicare, it may not.
Whether this modifier would be accepted (and the discontinued procedure reimbursed) would depend on the terms of the patient’s insurance coverage and the terms of the contract between the provider and payor. Some payor contracts expressly refuse to pay for procedures discontinued for reasons which the payor deems to be inefficiency on the part of the provider or practitioner, such as scheduling conflicts for practitioners, equipment or procedure rooms, failure to properly prepare the patient, etc.
If the patient is NOT enrolled in a product providing Medicare coverage, you would need to determine the payor’s coverage policies for discontinued procedures. For more information on Medicare’s rules regarding Modifiers 73 & 74, click here.
Disclaimer: This question was answered by Robin Fisk, Esq, a lawyer from Ashland, NH. Please note that this response is an expression of opinion or informal guidance and is not intended as legal advice. Please consult with an attorney familiar with your specific circumstances.
How do I find benchmarking for staffing ratios?
Q: I manage the billing department of an infusion company that does both infusion and durable medical equipment billing. Are there any benchmarks for staffing ratios, such as how many staff I should have for a specific volume of accounts? Our DSO hovers around 115 and our staff tell me they’re “overworked,” but how do I know for sure if they are or aren’t?
A: Benchmarks for staffing ratios are best internally developed based on a combination of factors. The basic approach we use with our clients is to first identify and document the individual tasks associated with the billing function. If billing also includes follow-up and denial resolution, then those areas should also be listed. For each detail, the manager then needs to develop two measurements: the volume of work and the time needed to perform one unit of the work. Thereafter, it is simple math to calculate the amount of time needed to complete the specific volume of work. Next, determine the productive vs. non-productive hours paid, and use that information to determine the total number of FTE’s required.
The challenge is to obtain accurate time values. For example, if insurance verification is performed electronically, the time unit is typically very short-30 seconds or less per transaction. However, if verification is by website or telephone, then longer times will be the norm. It may be necessary to divide the volume of work for some tasks into electronic vs. manual processing, and calculate the different times accordingly.
Because each organization includes different tasks within a particular job category, external benchmarks can be misleading. We recommend the time and volume approach because it is geared to your specific environment and organization of work.
This question was answered by Sandy Wolkskill, FHFMA, president of Wolfskill & Associates in Chardon, OH.
Consider these strategies to bill non-qualifying inpatient
Q: If hospital staff perform a utilization review and the patient does not meet inpatient criteria, and also does not meet the standard to convert to observation through the use of condition code 44, what are a hospital’s billing options? Can it do any of the below?
A: Since the question does not state whether the patient is still in the hospital, there are two billing options, both of which depend on the patient’s current status:
1. When the patient is still in the hospital
When the patient is still in the hospital, but doesn’t meet inpatient criteria, a hospital cannot bill the claim as an inpatient. Because the patient does not qualify for observation, they are in essence an outpatient in a bed (OIB).
Many hospitals use this classification for patients as described in the above scenario. On an “OIB” claim, you can bill everything except for room and observation charges. Bill all ancillary and procedure charges as you would on an outpatient claim.
2. When the patient was admitted, then discharged
When a patient was admitted to your hospital and subsequently discharged, and it was later discovered he or she did not meet inpatient criteria, contact your fiscal intermediary and quality improvement organization. Various manual citations such as the Medicare Hospital Manual, Section 210, and the Medicare Intermediary Manual, Section 3110, support a hospital’s ability to submit a Part B-only inpatient claim showing the room charges in the noncovered only column of the claim.
Provide a disclosure with a paper claim or in the remarks field for an electronic claim. The disclosure should state that the inpatient admission is being billed as an outpatient service because, while services were medically necessary, the admission itself did not meet medical necessity for inpatient admission. This disclosure is a request that the FI pay for medically necessary services on an outpatient basis. Do not merely submit an inpatient claim or an OPPS claim, as this would not be appropriate.