It's important to determine the value of an insurer to your practice. Calculate the ratio for each contract to determine how the individual plan or company contributes to your overall financial success.
If one or two companies dominate this statistic, make sure you develop the best possible working relationship with them. If you have a particularly hard-to-work-with plan which is responsible for a small percentage of your practice revenue, consider the possibility of terminating your participation with that plan.
Payor Mix Ratio = Individual Payor Reciepts / Total Receipts
As an alternative to the Payor Mix Ratio, consider calculating the Payor Ratios. Replace receipts with adjusted charges. This ratio indicated what should you have received from various payors. When the actual collections differ significantly from what you should have collected, the problem often is the result of contractual write-offs.
August 20, 2016
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Gross Collections Ratio is a ratio that shows how much of what you bill is actually received. To make sense of this ratio you must compare it with the net collection ratio. This helps determine whether your fees are too high or low.
Gross Collections Ratio = Total Collections / Total Gross Charges
Net Collection Ratio takes into account your contractual adjustments with the insurance companies. The measure incorporates your contractual disallowances - how much of what you’ve agreed to be paid much how you've actually received. Be careful in calculating this. In posting disallowances (contractural write-downs) with each third-party payor’s reimbursement, don't assume that whatever has not been paid is a contractural disallowance. MCOs and other payors (including Medicare and the Blues) often disallow more than what was contracted.
Net Collection Ratio = Total Collections / Total Gross Charges April 1, 2016 _______________________________________
On April 15 of 2015, President Obama and the members of Congress passed the Medicare Access and Chip Authorization Act (MACRA), which included a permanent solution for repeated temporary fixes to the Medicare Sustainable Growth Rate (SGR) methodology used to pay doctors. Under the new law, from 2015 through 2018 physicians will see an automatic increase of 0.5% annually in Medicare payments. No automatic payment increase will be provided in 2019 as doctors transition to a Merit-Based Incentive Payment System (MIPS). Doctors participating in the MIPS track for reimbursement will have their Medicare fee schedule payments adjusted up or down based on performance measures on four weighted categories: quality, resource use, meaningful use of electronic health records, and clinical improvement. The MIPS model is scheduled to begin in 2019, but 2016 is a crucial year. A provider’s performance in quality reporting programs in 2016 will affect the final MIPS score.
MIPS, the merit-based incentive payment system, uses a score on a 100-point scale to grade your practice’s performance in four different categories. These performance categories include: • Meaningful Use (MU)
• The value-based modifier (VBM) payment system quality as determined by the Physician Quality Reporting System (PQRS) standards
• Use of VBM payment resources
• Your clinical practice improvement The points earned in each category will have a significant impact on the financial well-being of your practice.
The Centers for Medicare and Medicaid Services (CMS) has set a standard "performance threshold" of 50 points. You must satisfy at least 50 points to avoid paying a penalty. If your practice scores a 50, your payment adjustment will be 0 percent - generating neither penalty nor reward. However, if your practice scores a 51 or above, you might receive additional financial compensation.
March 8, 2016 _______________________________________
Podiatry Billing Services uses a clearinghouse to send claims to payers. Claims are processed electronically and are date and time stamped. The batch of claims is submitted to each insurance company for review and payment. If a claim is denied for timely filing and there is proof that the claim was timely filed, it should be appealed. The appeal should include the patient’s name, date of birth, date of service, policy number, ICD-10 Codes, charges, the date originally filed and accepted. Most payers take 30 to 90 days for review of appeals. Deadlines for timely-filing can vary by state. Below are examples of timely-filing deadlines for some of the larger payers:
• Medicare: 365 days from the date of service
• Blue Cross/Blue Shield: 6 months from the date of service
• Cigna: 90 days from the date of service
• Medicaid: 95 days from the date of service
• United Healthcare: 90 days from the date of service For more information about timely-filing visit the payer’s website and look under the provider section for timely filing deadline. It’s very important to know the deadlines for carriers in your state. Holding claims can result in non-payment due to timely filing.
February 13, 2016 _______________________________________
To measure the performance of your practice, there are 7 metrics you should monitor on a regular basis: Accounts Receivable, Age of Receivables, Average Daily Charges, Collection Percentages, Clean Claim Rate, Patient Collections, and Denials. The Accounts receivables measure reveals how quickly a practice turns receivables into cash. Ideally, organizations should be keeping this metric under 30 days. Age of Receivables shows how long your money has been outstanding. The longer a claim remains unpaid, the less likely it will be collectible. Organizations should examine those receivables past due over 90 days and determine whether there are preventable issues that can be addressed to shorten the payment time frame and prevent similar problems in the future. Average Daily Charges is a metric to track over time possible patterns which could reveal productivity issues or patient volume fluctuations. For example, by monitoring this measure a practice can pinpoint staff members who are underperforming and need additional training. It can highlight seasonal patient volume variations that may represent opportunities to temporarily augment staff to better manage cash flow. Collection Percentage compares the payments a practice receives with what it is supposed to receive for the services it provides. Clean Claim Rate should be high (near 100%) as claims scrubbers and other tools identify “dirty claims” prior to claims submission. A decline may indicate the need to change payment rules and algorithms, improve workflows or train staff. Using this measure shows how well the practice optimizes payer contracts and collects balances due from patients. Patient Collections is increasingly important With the advent of high deductible health plans. Providers can not be haphazard in collecting copayments, deductibles, and coinsurance. There is increasing pressure to fine-tune this process to prevent large revenue shortfalls. Practices that watch patient collection rates need to make sure their front line staff are asking for and collecting payments consistently and reliably. Outliers in this area can point to the need for staff training, patient education and standardized processes for soliciting payment. Denials help practices keep a close eye on rejections and denials which can highlight a wide array of problems i.e. staff errors, payer rule changes, or lack of eligibly verification. Practices that watch for denial trends can catch systemic issues and prevent future rejections.
January 27, 2016 _______________________________________
Due to contractual adjustments, you probably collect less than what you charge — making it more important than ever to actually collect all of what you are legally entitled to receive. Net Collections Ratio is used to assess contractual disallowance versus actual payments. Don't assume that what has been paid and disallowed is correct. MCOs and other payors (including Medicare and the Blues) often disallow more than contracted. Check your collections ratio. Net Collections Ratio = Total Collections / Total Gross Charges
January 15, 2016 _______________________________________
Along with the common seventh character extenders A and D, there is a seventh character extender used to report an injury. This seventh character S, for sequela, is described in ICD-10 as for use "for
complications or conditions that arise as a direct result of the condition such as a scar forming after a burn." This seventh
character extender is used only to describe the long-term after-effects of an injury. Aftercare codes beginning with the letter Z in the last chapter of the IDC-10 coding manual are not used to describe the aftercare injuries. The code for the initial injury is used changing the seventh character to S. In addition, the symptom or sequela, such as the scar or limping or pain are reported in the first position. For conditions arising after an injury, use the seventh character S. For help with ICD-10 Coding issues contact Podiatry Billing Services.
October 24, 2015 _______________________________________
When coding for a foot or ankle problem, it is necessary to specify the involved foot. Unspecified foot or ankle should not be used. Both the musculoskeletal chapter and the injury chapter contain laterality code descriptions. If the patient has pain in both feet and there isn't a bilateral code, report two codes, one for right foot pain and one for left foot pain. Having a bilateral diagnosis code doesn't change how we report the CPT code for procedures performed bilaterally. Continue to use modifier 50 on the CPT code and select a bilateral diagnosis code(s) or report the condition twice using the diagnosis code(s) for right and left. Using a bilateral diagnosis code doesn't change CPT reporting. For help with ICD-10 Coding issues contact Podiatry Billing Serivces.
October 10, 2015
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"A" is used for active treatment of an injury, not only the initial encounter. Injuries require a seventh character extender in ICD-10 that defines the
episode of care and, for fractures, the healing status of the fracture. The diagnosis code for the injury remains constant throughout the care of the injury, but the seventh character extender changes. When does initial care stop and subsequent care begin? Don't just use the seventh character solely on the first service with the patient; continue to use the "A" seventh character on follow-up visits while the patient is still receiving active treatment. Switch to "D" for subsequent care when the patient is receiving routine care in the healing or recovery phase. “A” in the 7th digit is for ”Active” not initial.
October 1, 2015
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The ICD-10 implementation began October 1, but for the first year of the code set Medicare will not deny claims solely based on the specificity of diagnosis codes as long as they are in the appropriate diagnostic family of codes. Physicians won’t be financially penalized because of a coding error. During the first year Medicare claims will not be audited based on the specificity of diagnosis codes if they are in the appropriate family of codes and Medicare Administrative Contractors including Recovery Audit Contractors will be required to follow the policy. _______________________________________ In February 2014, Nachimson Advisors released an updated report estimating the cost of ICD‐10 implementation for a small practice ranged from $56,639 to $226,105. This included an estimated cost of payment disruption after the compliance date. _______________________________________ Under the Affordable Care Act (ACA) there are multiple payment options. Options can include the healthcare EFT standard via ACH, credit and virtual card payments, and wire transfers. Each payment type has unique attributes and associated costs, and providers have the ability to choose the payment type that best suits the needs of their practice. According to a recent report by the Coalition for Affordable Quality Healthcare (CAQH), a nonprofit organization that helps streamline business processes, providers who do not use electronic claims submission and authorizations are loosing large sums of money. On a per-transaction basis, the report notes, the provider-facility cost is $1.56 lower for electronic than for manual claim submission, $3.39 lower for electronic eligibility and benefit verification, $2.02 lower for electronic claim status inquiries, $1.53 less for electronic funds transfer (EFT), and $1.53 less for electronic remittance advance (ERA). The cost of obtaining prior authorizations over the phone or by fax is $18.53, versus $5.20 for electronic approvals. That's a savings of $13.33 per transaction. _______________________________________Gross Collections Ratio
Merit-Based Incentive Payment System (MIPS)
Timely Filing of Insurance Claims
7 Metrics to a Successful Pratice
Net Collections Ratio
Sequela
Bilateral Diagnosis Codes
Treatment of Injury Coding
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