Medical Economics Feature - November 2007
By Ken Ortolon
Corinth Family Medicine and Pediatrics needed help. The two-physician practice in North Texas was bringing its billing back in house and needed a crash course in coding and billing.
"We were looking to change our billing practices, and we were just looking in all directions for advice," said family physician Adam McDowell, MD. "We also had been having some trouble getting some claims paid, and I wasn't sure how to go about getting that taken care of."
When Dr. McDowell learned the Texas Medical Association and the Denton County Medical Society were sponsoring a mini-consultation program in May, he and office manager Heather Purcell decided to attend. It was time well spent. Dr. McDowell and Ms. Purcell agree that TMA reimbursement specialist Genevieve Davis gave them the advice on general billing questions they needed and helped resolve their specific claims issues.
"I knew TMA had resources, but I wasn't sure what those resources were," Dr. McDowell said. "It [the mini-consult] was very helpful in all aspects, mainly just finding out what TMA has to offer. Now, I use my TMA benefits a lot more often than I did before the mini-consult because I didn't know what was available or how to access that help."
Bang for Your Dues Buck
TMA and the county societies have offered the Mini-Consult Program for more than a decade. The program gives TMA members and/or their office staff members a 30-minute, face-to-face consultation with reimbursement experts from TMA's Payment Advocacy Department. The best part is that the consults are a free benefit of membership for TMA members and their staff.
"Physicians need to know this program is a benefit to them; it's a benefit of their membership in TMA, and it's an opportunity for a one-on-one conversation with a TMA expert who can help them answer their questions about reimbursement, payment, coding, and billing problems," said Teresa Devine, director of the Payment Advocacy Department.
The mini-consults cover just about any type of physician billing, coding, or reimbursement issue. Frequently, physicians or their billing staff will attend simply to get a general overview of services TMA offers. Other times, they have specific questions or claims issues they want help to resolve.
"If they come in with specific issues, I'll sit down and look over claims with them, talk about why a particular claim was denied, or where they can find information on an insurance company's Web site," Ms. Davis said.
Many of the questions involve similar types of billing hassles frequently reported to TMA's Hassle Factor Log program. These include claim denials, refund requests, or questions about an insurance company's medical or reimbursement policies.
"People who are mini-consult savvy bring in a stack of EOBs [explanations of benefit]," Ms. Davis said. "Most of the time their questions require some research on my end, but occasionally I can give them an answer right then and there."
If she can't resolve a question at the mini-consult, Ms. Davis frequently asks the practice to send her additional information, so she can research the matter or take the complaint to the payer involved.
"It's not always the insurance company's fault," she said.
For example, a radiology practice took more than $25,000 worth of outstanding claims from one insurance company to a Corpus Christi mini-consult. While the claims initially appeared to be filed correctly, Ms. Davis talked to insurance company representatives and learned that a majority of them involved billing for an add-on code where no primary code was billed.
"Add-on codes, by their very definition, have to be billed with a primary code," Ms. Devine said.
While the radiology practice was not happy to learn the claims had been coded incorrectly, the insurance company said many could be resubmitted, Ms. Davis says.
Ms. Davis has extensive experience working in physician practices and in health care payment plan contracting. She has experience in physician office education and training physicians and staff in correct coding and billing practices. In her role as a TMA reimbursement specialist, she helps practices with issues affecting reimbursement.
Meeting a Demand
Ms. Davis does more than a dozen mini-consults each year across the state, usually sponsored in conjunction with local county medical societies. Occasionally, an independent practice association or large group practice cosponsors one.
The events usually last two to three days, depending on demand, and are held at county medical society offices, local hospitals, or other locations.
County medical society officials say the program is very popular with their members.
"It really is a truly valuable, tangible member benefit that people are very pleased to be able to access here locally," said Smith County Medical Society (CMS) Executive Director Angela Driggs.
Ms. Driggs says Smith CMS has participated in mini-consults from the beginning of the program and she rarely has trouble filling all the time slots.
"Because they've used the service before, they are anxious to have the one-on-one assistance with those problem situations, the ones that they can't get straightened out on their own. We have everybody from the solo doc to the folks from our larger health systems come. It really is a very broad spectrum of folks who take advantage of that."
Pat Harris, with Harris CMS, says Houston physicians also find the mini-consults valuable. Harris CMS sponsors mini-consults twice a year and finds high demand for the visits. In fact, society officials are thinking about adding an extra day to their next mini-consult program.
"We do two-and-a-half days, and sometimes it's not enough," Ms. Harris said. "Doctors seem to like it, and it lets us know if there are any trends going on in the area."
Both Ms. Driggs and Ms. Harris say mini-consults primarily draw physicians' office staff members, but the doctors occasionally show up to discuss a particular issue. But no matter who attends, they find the consultations valuable, Ms. Driggs says.
"Sometimes they'll come just for the general information, but more often they have specific issues they are having difficulty with -- something that has presented a particular frustration and they haven't been able to get it resolved," Ms. Driggs said. "To get the help and information they need to finally, once and for all, get that thing resolved is a great value to them."
Ms. Purcell of Corinth Family Medicine and Pediatrics says the mini-consult she attended helped her do her job better.
"My main concerns were Medicaid and Medicare and well-child claims and how to make sure they were clean and who they go to," she said. "I think it was very useful. It helped me understand a lot about what I am doing now. I feel confident and secure I'm doing my job right."
County medical societies or physicians interested in sponsoring a mini-consult in their community should call Ms. Davis at (800) 880-1300, ext. 1416, or (512) 370-1416, or email Payment Advocacy.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
Avoid Mistakes: Ask TMA
Given the complexity of billing and a lack of understanding about proper coding practices, physicians may not realize they're making mistakes until it's too late.
To help physicians avoid delayed and incorrect reimbursement, TMA Practice Consulting offers two types of reviews to determine whether a practice is following payers' guidelines for appropriate billing.
The first option is a baseline review, which provides a one-time analysis of a practice's coding and documentation habits and results in a report that practices can use to take improvement measures. The second is a quarterly review, including a baseline review, consultation, and follow-up audits.
A TMA consultant also can train physicians and staff members to understand documentation guidelines, inappropriate or inaccurate coding, and weaknesses in medical record documentation.
For more information, visit www.consulting.texmed.org, call (800) 523-8776, or email TMA Practice Consulting.
TMA's practice management services include the Hassle Factor Log, coding and billing hotline, and payment advocacy - all free to TMA members. Physicians can get answers to questions about correct coding, claims appeals, and other insurance matters. TMA also can intervene with an insurer or health care payment plan to help resolve a problem. Call (800) 880-1300, ext. 1632, to reach the Hassle Factor Log.
To aid physicians and their office staff members with tracking their Medicare billing and coding, TMA Payment Advocacy offers physician members a Medicare practice evaluation tool that details the frequency of evaluation and management (E&M) coding by specialty. A report from TrailBlazer Health Enterprises covers the E&M Service Distribution Report for January through June 2005, the latest data available.
TMA members can access the tool on the TMA Web site.
If you have questions about reimbursement, coding, billing, or collections, the TMA Reimbursement Community can help. It focuses on coding, billing, and collections. Community members can post questions, give answers, share experiences, and access hot topics, resources, and links. Community membership is free to TMA member physicians and their office staff.
The Reimbursement Community also is your one-stop shop for billing and collections resources. For example, once logged in, you can easily access TMA Hassle Factor Log forms to use when you need help with problem insurance claims and ongoing updates on payer policies and fee schedule changes and on Medicare Advantage plans.
If you have questions or need help logging in, contact the TMA Knowledge Center at (800) 880-7955 or email the TMA Knowledge Center.
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