Myth one: You need to bill the same amount to everyone
The fact is, you cannot bill your Medicare patients more than you do all your other patients. If your practice maintains various fee schedules (Source "http://www.supercoder.com/coding-tools/fee-schedules"), the government payers should be the lowest-priced among the group.
But then as long as you're following a contract or have consistent non-discriminatory billing policies in writing, billing may differ within your practice. But then, practically speaking, you should keep your billing policies consistent to stay away from accusations or discrimination.
Myth two: You have to send three bills before you write something off
Well, you have to make a reasonable attempt at gathering the co-pay, deductible, and when applicable, the balance of the bill; however that does not necessarily mean sending three bills.
Waiving deductibles and copayments regularly can violate several federal laws and regulations, including the Federal False Claims Act, anti-kickback statutes, and compliance guidelines for individual and small group physician practices. In the Federal False Claims Act, the OIG identifies three criteria that can end up in a violation: The waivers are routine, the waiver is given without regard to the individual's financial hardship, and the provider fails to pass on to the payer its proportional share of the discount.
Be careful: OIG regulations are not your only concern as far as collecting copays is concerned. Take a look at your payer contracts as well. Many contracts require that copays are collected during the time of service. A provider can lose participating status if they fail to toe the guidelines.
One reason you may be able to write off a patient's copay, deductible or balance is if the patient meets the criteria of financial hardship. In order for your practice to accept financial hardship as terms for a debt-off, the patient needs to be able to prove he's unable to pay. In case you cannot establish financial hardship, CMS requires that you make a reasonable endeavor to collect money from a patient. This might comprise sending three bills, followed by two phone calls, and a final notice. That cycle is at your practice's discretion. If you cannot collect it ultimately, be sure to document your efforts.
Myth three: You can bill only a single diagnosis code per claim
Well, you should bill as many diagnosis codes as you need to establish medical necessity for the services you are billing. Some payers' computer systems used to be able to read only one diagnosis code per line. However, now you should always be able to report all relevant diagnoses for each visit, and link the proper diagnoses to each service on each line.
This will become important when ICD-10 codes go into effect in 2013 at which point diagnosis coding will expand considerably.
Myth Four: E/M codes are assigned only by the level of medical decision-making (MDM).
Medical decision-making (MDM) is only one of three important components, depending on the category of the code. However you should always think about the nature of the patient's presenting problem when figuring out which code is most accurate.
Myth Five: If you are a Medicaid provider, you have to accept all Medicaid patients partly state-funded and state-designed, it's hard to give a general rule. Many states will allow some flexibility allowing you to limit new admits to your patient mix.
Some states may allow you to limit the number of Medicaid patients that you see. Most Medicaids recognize that you can go broke minus the ability to keep a viable patient mix.
Check with your state: If you are not clear regarding whether your state allows limitation of Medicaid patients, get in touch with your state's Department of Health and Human Services rather than contacting your payer.
Myth six: Medicare HMOs have to toe the same rules as Medicare
Medicare HMOs have a set of guidelines that they must follow; what's more, they've to cover everything Medicare would cover. However, they can also opt to cover other things, and they can require referrals, authorizations, and other things that Medicare would not need.
Myth seven: Secondary insurance always pays what Medicare does not
Well, secondary insurance is more likely to pick up what Medicare does not pay. However, secondary insurance does not have to pay for everything that Medicare does not. Oftentimes, secondary payers will only pay up to a certain amount and if Medicare has already shelled out that amount, they will not pay any more. Supplemental insurance will only pay Medicare's copays and deductibles, not everything else Medicare does not reimburse.
The fact is, you cannot bill your Medicare patients more than you do all your other patients. If your practice maintains various fee schedules (Source "http://www.supercoder.com/coding-tools/fee-schedules"), the government payers should be the lowest-priced among the group.
But then as long as you're following a contract or have consistent non-discriminatory billing policies in writing, billing may differ within your practice. But then, practically speaking, you should keep your billing policies consistent to stay away from accusations or discrimination.
Myth two: You have to send three bills before you write something off
Well, you have to make a reasonable attempt at gathering the co-pay, deductible, and when applicable, the balance of the bill; however that does not necessarily mean sending three bills.
Waiving deductibles and copayments regularly can violate several federal laws and regulations, including the Federal False Claims Act, anti-kickback statutes, and compliance guidelines for individual and small group physician practices. In the Federal False Claims Act, the OIG identifies three criteria that can end up in a violation: The waivers are routine, the waiver is given without regard to the individual's financial hardship, and the provider fails to pass on to the payer its proportional share of the discount.
Be careful: OIG regulations are not your only concern as far as collecting copays is concerned. Take a look at your payer contracts as well. Many contracts require that copays are collected during the time of service. A provider can lose participating status if they fail to toe the guidelines.
One reason you may be able to write off a patient's copay, deductible or balance is if the patient meets the criteria of financial hardship. In order for your practice to accept financial hardship as terms for a debt-off, the patient needs to be able to prove he's unable to pay. In case you cannot establish financial hardship, CMS requires that you make a reasonable endeavor to collect money from a patient. This might comprise sending three bills, followed by two phone calls, and a final notice. That cycle is at your practice's discretion. If you cannot collect it ultimately, be sure to document your efforts.
Myth three: You can bill only a single diagnosis code per claim
Well, you should bill as many diagnosis codes as you need to establish medical necessity for the services you are billing. Some payers' computer systems used to be able to read only one diagnosis code per line. However, now you should always be able to report all relevant diagnoses for each visit, and link the proper diagnoses to each service on each line.
This will become important when ICD-10 codes go into effect in 2013 at which point diagnosis coding will expand considerably.
Myth Four: E/M codes are assigned only by the level of medical decision-making (MDM).
Medical decision-making (MDM) is only one of three important components, depending on the category of the code. However you should always think about the nature of the patient's presenting problem when figuring out which code is most accurate.
Myth Five: If you are a Medicaid provider, you have to accept all Medicaid patients partly state-funded and state-designed, it's hard to give a general rule. Many states will allow some flexibility allowing you to limit new admits to your patient mix.
Some states may allow you to limit the number of Medicaid patients that you see. Most Medicaids recognize that you can go broke minus the ability to keep a viable patient mix.
Check with your state: If you are not clear regarding whether your state allows limitation of Medicaid patients, get in touch with your state's Department of Health and Human Services rather than contacting your payer.
Myth six: Medicare HMOs have to toe the same rules as Medicare
Medicare HMOs have a set of guidelines that they must follow; what's more, they've to cover everything Medicare would cover. However, they can also opt to cover other things, and they can require referrals, authorizations, and other things that Medicare would not need.
Myth seven: Secondary insurance always pays what Medicare does not
Well, secondary insurance is more likely to pick up what Medicare does not pay. However, secondary insurance does not have to pay for everything that Medicare does not. Oftentimes, secondary payers will only pay up to a certain amount and if Medicare has already shelled out that amount, they will not pay any more. Supplemental insurance will only pay Medicare's copays and deductibles, not everything else Medicare does not reimburse.
