Incorrect Reimbursements—Is This Your Practice?

Imagine you have received a remittance for patient John Doe for charge 99214 in the amount of $69.89. Your billing staff reconciles the money and updates the account. Would you consider this a successful reimbursement? If so, it may surprise you to know you have just been underpaid by $20 because the correct fee schedule was $89.89.

In 2008, the American Medical Association reported that claims were reimbursed incorrectly at least 29% of the time for private carriers and 2% of the time from Medicare. Adding this amount to the 14% of fees physicians spend trying to collect the reimbursement in the first place could financially devastate a practice.

A well-run practice should include supporting staff who have full knowledge of what your top payers are contracted to pay. In today’s world it is no longer good enough to just know the rules and regulations of coding and reimbursement. It is now extremely important to quickly verify that reimbursements are correct because some carriers have deadlines regarding claim appeals—even if there are errors.

Another example of an incorrect reimbursement from a payer is incorrect bundling of charges (e.g., bundling an office visit with a procedure or combining the reimbursement for drugs with a procedure). In addition, some carriers down-code evaluations and management codes automatically, and it is left up to the practice’s billing staff to appeal the change. To ensure you are being correctly reimbursed, your billing staff should:

• Keep contracts of your largest carriers readily available to your billing manager;
• Run scheduled audits of accounts receivable;
• Closely review all explanations of benefits;
• When dealing with coordination of benefits, be aware for what each carrier is liable;
• Identify the payer’s responsibility and member’s liability for each contract; and
• Know your payer’s timely filing guidelines in case a charge has to be appealed.

A rheumatology practice should never rely on outside entities to make sure it is correctly reimbursed. This is not only your practice, but also your business and livelihood. Ensuring correct reimbursements will contribute to a financially healthy practice.

If you have any questions or concerns on this matter, you may contact Melesia Tillman, CCP, CPC, at (404) 633-3777, ext. 820, or [email protected].

Are Your HR Files in Order?

Do you know if your practice is in legal compliance with the many employment rules and regulations business owners must follow? Protecting your business from human resources (HR) liability can be overwhelming—particularly when the physician, as practice owner or partner, must act as an HR manager. However every practice, regardless of its size and location, must deal with HR issues in one way or another, and understanding what is expected of you is half the battle.

Many times, the best place to begin working on HR is paperwork—and this also happens to be an area where many small-business owners are lacking. Employment files are of primary concern in managing and mitigating risk relating to HR. Separate and up-to-date personnel files should be kept for every employee—regardless of hours worked or length of employment—to decrease the chances of becoming involved in legal actions relating to hiring, supervision, or firing. Generally, an employee record should contain all important information relating to the employee and the job that he or she performs. When considering what should be kept in a file, it is important to remember that, in the legal system, if it isn’t documented, it didn’t happen.

Employers are responsible for the implementation of an organized system of maintaining employee records, and must be able to produce records on demand for employees, union representatives, or government agencies. Employee files are confidential documents and should be kept in a secure, locked location where access is controlled by the employer. No information should ever be released without written consent of the employee or without a court order. Failure to keep an employee’s file confidential can result in a lawsuit against the employer for invasion of privacy.

Employee data should be divided into three separate files: I-9 forms, personnel, and a separate confidential file. Here is information on all of these files.

Form I-9: All employers are responsible for the completion and retention of Form I-9 for each individual they hire for employment in the United States—this includes citizens and noncitizens. On the I-9 form, the employer must verify employment eligibility and identity documents presented by the employee, and record the document information on the form. For privacy reasons, all I-9 forms should be kept in one file, separate from individual employee files.

Personnel File: The personnel file holds every important document related to an employee’s job. This file should include all applicable job descriptions, application documents, new hire paperwork, performance records, attendance records, and employment history. Additions to the personnel file can be made at the employer’s discretion. A personnel file should always be complete and up to date, but available for review by the employee at any time, because he or she has the right to view this file at any time, without advance notice. Because of this, it is advisable to keep any sensitive information in a separate file.

Confidential Files: The confidential file should be separate from all other files and have limited access. This file should contain insurance, medical information, medical work restrictions, reasonable accommodation, credit, background-check results, drug and alcohol testing, workers compensation, benefits, and personal family information.

Payroll information should also be held in a confidential file. The payroll file should hold a record of the employee’s name, address, date of birth, job title, pay rate, and the dates of applicable pay changes, along with documentation of employment wage-per-hour data, tax and payroll data, garnishments, and documentation of wages earned and taxes paid for each pay period and for the calendar year.

Each of these files should be kept and maintained for the length of time required by law in easily identifiable files that contain all material required by law and company policy. The files should be periodically reviewed as part of a more rigorous HR audit to ensure that they are current, accurate, and complete.

Remember, your HR files are only a small part of your overall HR system. To further protect your practice from human resources liability, a regular HR assessment should be scheduled to evaluate all aspects of HR management, including recruitment and retention, policies and procedures, compensation and benefits, and legal compliance. The U.S. Department of Labor provides free information and access to employment advisors on their recently introduced e-laws Web site, www.dol.gov/elaws. E-laws has Web-based tools available that determine which federal employment laws apply to individual business owners and provides a customized guide on the basic provisions of these laws. Employment laws and their application are specific to your industry and the state where you operate your business. For the best counsel, contact a labor attorney in your area for more information specific to your practice.

For more information on protecting yourself from HR risk and conducting your own in-office HR audit, contact Itara Barnes at [email protected] or (404) 633-3777, ext. 819.