Traditionally, in our December article, we outline the issues in the final Medicare fee schedule for the next year. Unfortunately, the government shutdown has delayed publication of the schedule until Nov. 27, 23 days after its normal publication date. Go figure.
Therefore, for this year’s December column, we will shift focus and outline the issues that we know will be important in 2014 and discuss what we think might be implemented by Medicare for 2014.
New CPT code
There is one new CPT code: 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type]).
This code was added, as suggested by Medicare, because urologists billed the insertion of an indwelling ureteral stent with ureteroscopy/lithotripsy a high percentage of the time. We do not know the value of the combined code. A strong stance by the AUA may result in a value commensurate with current payments, but we will have to wait and see the Centers for Medicare & Medicaid Services’ final value. When codes are combined, the payment usually decreases.
Affordable Care Act-driven changes
At press time, the Affordable Care Act’s (ACA) personal insurance mandate is moving forward and there are many uncertainties. The rollout of the health care exchanges may multiply the problems we have with patients changing insurance. We think four things are very clear:
The insurance coverage for some of your patients will change on Jan. 1. As of Jan. 1, we recommend that you treat all of your patients as if you have no idea what their insurance coverage is. Reconfirm the eligibility of patients on every visit and verify their coverage for the services your office intends to provide. The insurance company may have changed, or it may just be the policy and/or the coverage that has changed. We won’t go so far as to say that you should throw out all of your insurance data and start anew, but we would recommend that you treat the old data as being suspect and insist that each patient’s insurance information be checked and compared to existing data.
Many of you have been exposed to our “wheel of fortune” (the detailed step-by-step description of documentation, billing, and collection for services in the physician office) and the role that accurate insurance information plays in submitting a clean claim. If you follow best practices in each step of the claims submission process, including collecting from the patient prior to service, then you will receive full payment for services rendered within 10 to 28 days for the majority of services. If a claim is rejected, requiring an appeal, payment from the insurance company will come within 45 to 60 days if at all. In addition, your in-house costs go up astronomically; it’s estimated that the average cost for an appealed claim is $30 to $45. The cost of submitting a clean claim is about $5 or $6. If you do not appeal, the costs are even higher. If you do not collect from the patient up front, your time to collection and write-offs will increase.
Patients will be paying a higher percentage of the total cost. We highly recommend that you fine-tune your patient collection process. Think about the consequences of not having an effective collection process. Using simple math, an average urology practice operating at 50% overhead cost means that a patient on a Bronze ACA plan with a 40% co-pay translates into 80% of physician take-home pay coming from the patient. (This does not include the deductible, which on average has also increased.) Although charity care is a part of every physician practice, you should make that decision prior to providing the service instead of having a non-collectable debt.
The databases, electronic solutions, and know-how are available for you to know/estimate the patient’s responsibility prior to providing a service. This will allow you to collect at the time of service, give a discount, set up a payment plan, or determine that you will provide the service free of charge. It is far cheaper to write a refund check than it is to bill and collect. Data clearly demonstrate that patients not paying after three statements will result in collections of only 10% of charges owed by the patient. If you cannot set this up in your office or don’t understand how to do so, ask for help now. Don’t wait until you have a problem. (Go to our website, www.prsnetwork.com, if you would like more information.)
Coverage for preventive care will increase. This part of the ACA is a double-edged sword. More services that you provide may be paid for by insurance; however, as patients are paying more of the cost for all other services, there may be pressure for you to label services as preventive care when in reality they constitute diagnosis and/or treatment. We strongly encourage you not to bend to patient pressure or the feeling of compassion for the patient. Bill accurately for the services you provide and avoid the audits and risk of “take backs” in the future.
More patients will be eligible for Medicaid. With increased federal subsidies, Medicaid may be a more viable payer in some states but the increase in covered lives will make it difficult for many plans to process the increased numbers. Each practice will have to carefully examine its state Medicaid plan and determine if and how much you are willing to participate in Medicaid in your state.