REIMBURSEMENT IN THE FSEC WORLD. Everyone is jumping on!
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- Lydia Gray
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1 REIMBURSEMENT IN THE FSEC WORLD Everyone is jumping on!
2 OPPORTUNITY Rapidly growing industry Everyone wants in Emergency Physicians Hospitals Non-ER Physicians Nurses Pharmacists Architects Real Estate Developers Venture Capitalists
3 WHO ON YOUR TEAM IS AN FSED REIMBURSEMENT EXPERT?
4 CURRENT ENVIRONMENT What we are seeing Explosive growth and regional saturation Mixed media & patient reviews Payer push back Legislative push back Tepid reactions on a national scale Innovative partnerships
5 FUTURE ENVIRONMENT What we anticipate Further legislation Consolidation National expansion Continued pushback from payers Adoption of EDIS systems and EMRs CMS recognition of the independent model
6 FSED REIMBURSEMENT IS IMPACTED BY
7 FSED MODELS Independent Owned by individual or corporation not hospital Must be licensed by state Structurally separate from hospital CMS does not recognize nor pay Most adopt out of network strategy Utilization of services is identical to hospital Admission rates range from 5% to 10%
8 FSED MODELS HOPD (Hospital Outpatient Department) Operate under hospital license CMS recognizes & pays In network with hospital contracts Has the advantage of hospital name & branding
9 IT TAKES 2
10 PROFESSIONAL COMPONENT Represent skills of physician Documentation must support E/M level Modifiers are important so services not bundled PA & facility levels may not always match POS is required on physician claims
11 FACILITY COMPONENT Resource based billing (must support medical necessity) Modifiers are important (carrier specific) Appeals usually prompted by non-emergent diagnosis No different than hospital facility billing Trends Prudent lay person definition becoming difficult to win Plans are writing into their policies that non-emergent diagnosis are not covered Provisions of the plan prevail
12 ALL ABOUT THE $$$
13 COLLECTIONS Copay & deductibles Historically high Up to $500 on copay Easily $5,000 to $10,000 for deductible Copay may be the only money you collect Cannot routinely waive copays Obligated to bill for and collect deductible if in network
14 IN AND OUT OF NETWORK
15 OUT OF NETWORK Negotiable Much higher appeal rate Require more billing resources Non-emergent diagnosis much harder to get paid Most are paying percentage of Medicare (100 to 150%) Usual & customary (not defined no standard) Balance billing (choice) Patient left with higher out of pocket responsibility Longer revenue cycle
16 IN NETWORK Case rate Level driven Paid according to contracted rate Usually paid in a timely manner Requires less billing resources In network rejections Phone call or corrected claim Requires accreditation (Joint Commission, COLA) Placement on plan websites & books Does not necessarily drive volume Cannot discount bill or reduce deductible Shorter revenue cycle
17 CONTRACT MANAGEMENT Guidelines for credentialing Licensed Joint Commission or equivalent CLIA / COLA certification Transfer agreements with hospital Insurance requirements Credentialing can take 30 to 45 days Case rate negotiations all inclusive 30 to 45 days to become effective All in could be 120 days or more Most will not contract with FSED without physician group
18 STRATEGIC REVENUE PARTNERS
19 CLAIM DENIALS Incorrect or incomplete insurance and demographics Non emergent diagnosis Modifiers & Ecodes (missing / incorrect) Multiple appeals may be required
20 CODER Coding gets claim paid Emergent diagnosis is key Tells story in codes (ICD9) Procedures & labs (CPT), supplies & drugs (HCPCS) Within the guidelines (PA only) (95 & 97) Consistent to not prompt audits Bill aggressive but within guidelines to maximize $$$
21 SMALL THINGS INCREASE YOUR REIMBURSEMENT OPPORTUNITIES
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30 FRONT DESK First & last contact with patient Face of your company Must be a pleasant experience Verify eligibility Must utilize encounter to inform PT of financial responsibility Must not mislead the patient Paperwork with disclosures Data entry drives the claim
31 PATIENT PERCEPTIONS Do not understand difference urgent care / ER Do not understand ER bills (facility fee) PTs do not understand their benefits Co-pay is all I have to pay Deductible Charges applied against deductible Co-insurance Short visit does not warrant charges for services provided Very happy with visit & experience until they receive EOB Sticker shock
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33 EDUCATION Every encounter is opportunity Paperwork Front desk Nurse Doctor Radiology tech Verbiage matters (clinic, office) Website Social media You need a FSED reimbursement expert to educate the payors on your behalf
34 PRESENTED BY: Juli Forde (972) Rhonda Sandel (832) Nancy Dumas (281)
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