coping with regulatory and payer demands to practice pm&r bruce m. gans, md
TRANSCRIPT
PHYSICIAN PAYMENTS: MEDICARE, OTHER PAYERS
AND RECENT CHANGESCoping with Regulatory and Payer
Demands to Practice PM&R
Bruce M. Gans, MD
It is not getting any easier to practice or get paid for your work
Payers are seeking ways to avoid payment, shift responsibility, and minimize their exposure to all providers, including physicians
How to Increase the Chances of Getting Paid
Do the right things clinically Document them well Code accurately and completely Inform the patient of their liability for paying for
your services before you provide them Collect co-pays at the time and site of service when
possible Review your insurance plan participation regularly Review your collections regularly Understand your contractual allowance rates
How to keep what you were paid
Audit your records yourself for documentation and coding accuracy
Cross-audit your charts with other providers Engage external auditors to review, critique, and
educate yourself and your staff
How to recover what was taken away after you were paid
Appeal everything Follow the rules meticulously Engage professional help Track your success Learn from your mistakes or failures to win
Working with Institutions
Medical Administrative Roles Employment Independent Contractor On-call arrangements
Risks to be avoided Review the contract carefully Document your work if you must invoice for payment Do the work you invoice for Make sure your payment rate is truly fair market value
Working with Institutions (continued)
Clinical Roles Incorporating Medicare documentation requirements for
inpatient rehab care into your practice Separating or commingling administrative and clinical
services Gym rounds Team meetings with patients
Use of extenders
Overarching Needs
Patients come first Balance your obligation to your patient with the
responsibility to show reasonable restraint in how you provide care and authorize/prescribe drugs, goods and services
Work in close alignment with others involved in the care of your patients
You are looked to as a leader, so lead with wisdom, grace and integrity
MEDICARE AUDIT AND APPEALS DEVELOPMENTS
Peter W. Thomas
Update on new RAC contracts and future audits
Existing RACs continue to audit certain claims RAC legal challenge delays awards of new round of
RACs Changes to RAC contracts that benefit providers
Physician-specific ADR limits
Additional Documentation Request limits by provider group
“Related” claims linking physician and facility claims for payment
New authority for CMS contractors to deny related claims
Specific rules governing denial of related claims
Two-Year ALJ hearing assignment delay and response from/impact on providers
Extent of ALJ hearing backlog AHA Lawsuit to challenge ALJ delay FAIR Fund Amicus brief to demonstrate harm to
providers 68% Settlement offer for acute care hospitals re:
short day stays Impact of developments on appeals process Pointers on challenging denials of claims, including
recoupment and interest
Congressional developments involving reforms to lessen impact on legitimate providers
Series of Congressional hearings exposing burden on providers
GAO Report on Medicare Audit Contractors Senate Special Committee on Aging Report on
Audits and Appeals Pending legislative efforts on Medicare audits and
appeals
Physician-specific Considerations involving Medicare Claims
Physician documentation of prosthetic/orthotic claims
Status of Physician documentation “template” being developed by CMS
Prior Authorization of certain DMEPOS Regulatory changes involving Off-the-Shelf
Orthotics
Competitive bidding of DME
Round II and the future of Medicare competitive acquisition of DME
National pricing based on competitive bidding Impact of coding on access to DMEPOS care
QUESTIONS AND DISCUSSION