2012 ASOPA Breakout Course

Transcription

1 2012 ASOPA Breakout Course The Challenges and Pearls of Surgical Billing and Appeals for the First Assistant David Bartczak, OPA-C, LSA, CSA, OTC Affiliations and Background Mederi Services, LLC (owner) TCOPA Past President, VP, Treasurer NBCOPA Parliamentarian / CME Committee 18 yrs experience in billing and coding that started while in the military Currently independent, OPA-C, LSA, CSA 1

2 Understand the Difference Not all assistants are the same Many states have different laws that apply to how an assistant can be used and billed Know your local laws Some states do license assistant that are non-md and non- PA-C, ie LSA, RSA As a general rule, if you can get credentialed to assistant then you should be able to bill for it. Introduction Discuss current techniques in billing Discuss current challenges for billing an assistant that is employed and independent Appeal or not to appeal and why What is that EOB really saying? Insurance appeal payment trends What does the future hold for assistants 2

3 Current Techniques in Billing CPT Modifier - AS represents a non MD First Assistant at surgery. CPT modifier -80 represents assistant at surgery by another physician. CPT modifier -81 represents minimal assistant at surgery by another physician. This assistant at surgery is providing minimal assistance to the primary surgeon. This modifier is not intended for use by non-physician assistants (e.g., RN, PA, OPA-C, LSA). CPT modifier -82 represents assistant at surgery by another physician when a qualified resident surgeon is not available to assist the primary surgeon. How Much to Bill for Services of an employed OPA-C or assistant Recommend Minimum of 50%; easier to calculate. Some Assistants do % Use your NPI and the Practice TID Most insurance companies now pay based on the TID number and if it is in network then you will be also BCBS will pay standard 14 % of allowed amounts for most cases at in-network rate Insurance companies out network rates are paid at a % of what is billed instead % of what is allowed Sample Joint Replacement charge of 6000 for the Surgeon, 3000 (50%) for the OPA-C. Paid at 35% equals $1050 or if we billed $1500 (25% as some recommend) then we would be paid only $525 which is a $980 loss. 3

4 How Much to Bill for Services of an Independent OPA-C or assistant Use your NPI, your company Type 2 NPI and your company EIN/ TID There is usually no standard methodology for Out of Network payments from most private insurance but some HMOs pay at the same rates for either It seems that Insurance companies out network rates are paid at a % of what is billed instead % of what is allowed Recommend 3x Medicare allowed for non-paying cases and 4 ½ - 6x Medicare allowed amounts, these rates generally line up with the middle and high rates of the Physician Fee Schedule guide Type of Denial Wording Seen Member Plans Covers Charges that are reasonable and appropriate as determined by "insurance Company". Means they don t want to pay any more. This has been paid following "Insurance Companies" guidelines for multiple procedures and services performed on the same date of Service. They are reducing payment because of multiple procedure (100 of 1 st, 50% of 2 nd and 25% for all others) Reimbursement for surgery includes elective services of assistant. Not saying one isn t needed, just that they aren t paying for them The prevailing reimbursement for this surgery includes any elective services of a surgeon or nurse assisting the operating surgeon. The charge for the assistant surgeon, co-surgeon, or surgical team is not covered under the members plan. Same as previous 4

5 Type of Denial Wording Seen (cont) Your Plan Does Not Permit Payment for this Type of Provider Yes you should be paid but this cheap policy / company won t be doing it J We are unable to locate a valid provider number on our system (BCBS) Their way of denying claim without discrimiating agaisnt you since they will not validate certain providers If you don't agree with our assessment, you may appeal on the member's behalf with signed authorization from the member. (UHC, BCBS, Cigna) You must get members authorization and send in with appeal before it can be considered. There is generally a time limit to appeal. Services by a provider who does not participate with Aetna are not covered unless the services of the on participating provider are pre certified. There is no way for non-md to be able to precert since they only precert hospitals and MD for surgery Charge exceeds the priced amount for this service. Services provided by a nonparticipating provider. Patient is responsible for charges over the priced amount. (BCBS) Means they do not agree with how much you charged and they want you to think you charged too much. 5

6 Appeal or Not to Appeal and Why? Plan to appeal everything if needed Make your appeals look professional and quote laws / statutes when possible to help Know whether claim should have been paid to begin with Identify amounts paid as fair, generally over 500 per case Remember, pigs get fat and hogs get slaughtered Appeals to Use for Insurance Companies Case Law supports refund requests by insurance companies (Appeal for refund requests) Most companies may dismiss if you appeal a refund three times (Cigna more persistent that most) If they take money back from future claim then just consider it an interest free loan Appeal ALL secondary insurance companies. Most will deny on first claim. (Appeal for them to act as primary) Appeal everything for medical necessity once if not paid Appeal if not paid at 100% of billed to see if they are paying in network or out of network. (Underpayment) Careful with Cigna and Medicare replacements Only send the information they request Workers Comp should be paying at least 17%, most states 6

7 Trends for payments to assistants Trends of insurance companies is either pay everyone as in network or no benefits allowed for out of network Have seen increase in Aetna considering services with surgeons payments or no payment unless you meet the definition of a physician or Needed pre cert Cigna polices starting to deny non license providers including LSAs, but appeals do sometimes work and see a lot of negotiated rates being offered Have seen a trend in the last 24 months that if the practice TID is in network then the assistant will be considered In-Network Trends for payments to assistants (cont) Plan appeals if paid as in network, but realize that if you shouldn t have been paid that it may bring attention to a claim that you don t want. Have seen increase in Request for Refunds but in the last 8 years I have never had any returned when appeal is done. Have seen more patient s with no Out of Network benefits Partial knee replacements assistants not payable (Aetna, Humana) 7

8 How Much Can an OPA-C Get Reimbursed for Assisting at Surgery Private Pay Insurance (Primary) BCBS C-Spine with hardware Billed 15K paid $3600 (CSA) (24%) ACL Recon Billed 2900 paid $2900 (CFA) (100%) Foot Nerve Decompressino Billed 5900 paid $5900 (CSA) (100%) THA Billed 6000 paid $4900 (LSA) (82%) THA Billed 6000 paid $5500 (OPA-C) (92%) Breast recon billed 9400 paid $5000 (LSA) (53%) Aetna C-spine with hardware Billed 11.4K paid $6300 (CSA) (55%) TKA Billed 5800 paid $3700 (OPA-C) (64%) Secondary Foot Nerve Decompressino Billed 6400 paid $6400 (CSA) (100%) Paid on appeal - initially paid $43 How Much Can an OPA-C Get Reimbursed for Assisting at Surgery (cont) Private Pay Insurance UHC - This year has been the best payer!! THA Billed 6800 paid $6800 (OPA-C) (100%) Shoulder (RTC, Decomp) Billed 11.3K $7900 (OPA-C) (70%) TKA Billed 6000 paid $4800 (LSA) (80%) paid on appeal initial paid $164 8

9 What Does the Future Hold for Assistants Obama Care License vs Certifications OPA-C School In Network vs Out of Network Employed vs Independent Alternative to Standard Office Settings for Employed Assistants Think about how to bring in extra revenue or reduce costs for your practice. The idea is to increase the revenue and not changing the work relationship or duties Become independent without changing your current situation Stay in the office with a reduced salary (i.e 50%) and continue all current duties Bill surgeries independently of the surgeon with your own company Bill as an out of network provider Generally better to use outside biller instead of office billers since they do not know or understand appeals Saves the surgeon/company money by reduction in salary plus reductions of the amount of taxes they would be paying on your behalf (+/ % of your salary) Surgeon / company would start a separate company that would hire you at a salary Stay at current salary (hopefully more) with the same duties Bill surgeries as an out of network company / assistant Also better to use outside billing company for same reasons as above Out of network billing generally pays much better than in network and this income would be filtered back to the surgeon / company 9

10 Summary OPA-C s can be reimbursed by private insurance There is legislation to support assistants, LSA There is Case Law to help with appeals OPA-C s and assistants can be reimbursed by secondary insurance OPA-C s can be profitable to a Orthopaedic Practice. Independent Assistants can be very profitable but not consistent. Where to Get More Information TCOPA Website (tcopa.org) Mederi Services Website mederiservices.com CPT / ICD 9 Book American College of Surgeons Survey Case Law TSBME Website Medicare Website Private Insurance Websites 10