TMA Payment Advocacy Earns Big Return on Dues Dollars

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Medical Economics Feature – November 2011


Tex Med. 2011;107(11):19-22.

By Ken Ortolon
Senior Editor

Pearsall family physician Daniel Schmidt, DO, says Texas Medical Association payment specialist Erin Gregorcyk Smith was a "guardian angel" for him earlier this year when he was having problems getting his Medicare payments. 

"They didn't pay us for six months while they were reviewing our credentials, and they didn't pay us for three months this summer when we had a simple mailing address change from our street address to a P.O. box number," Dr. Schmidt said. 

But Ms. Smith cut through the red tape and connected Dr. Schmidt to the right person at TrailBlazer Health Enterprises, the Medicare contractor for Texas, to resolve each problem quickly. 

In the end, Ms. Smith's efforts freed up nearly $15,000 in back payments to Dr. Schmidt that Medicare had held for months, seriously affecting his cash flow. 

Dr. Schmidt is among dozens of physicians for whom TMA's Payment Advocacy Department helped recover payments from Medicare and private health plans this year. In fact, as of the end of August, the department had helped secure more than $1 million in payments delayed by incorrectly processed claims, Medicare enrollment issues, and other problems. 

Plano family physician Christopher Crow, MD, chair of TMA's Council on Socioeconomic, says those results are a tremendous benefit of TMA membership. 

"What a great, tangible member benefit that so many physicians across the state obviously are making use of," he said. 

You may email TMA's reimbursement specialists for assistance. Visit the TMA website for more information on how the association can help you.


Persistence Pays

TMA's Payment Advocacy Department has worked closely for years with the health plans, Medicaid, and TrailBlazer to resolve problems physicians have getting their claims paid correctly. Dr. Crow says their persistence certainly paid off this year with more than $1 million recovered for TMA members. 

That money comes from resolving incorrectly processed claims, getting lost or delayed Medicare enrollment applications processed, educating physicians' office staff on how to resolve ongoing billing issues with health plans, and various other advocacy efforts. 

Genevieve Davis, director of the Payment Advocacy Department, says the problems often are just "weird system glitches" at the health plans that cause a large number of claims to be denied. 

Also, many physicians have had problems with Medicare enrollment applications this year. Dr. Crow says the ongoing switch to the new Medicare Provider Enrollment, Chain, and Ownership System could be responsible for that. 

"The transition to this new system went about how you would think it would go for any type of transition to new software for a government agency, which is extremely slow with a lot of hiccups, a lot of unintended delays, with not really anybody on the other end of the line to tell you when and how it's going to get fixed," he said. 

Ms. Davis says there also were problems with physicians continuing to submit paper enrollment applications, holding up payments for months. 

That was the case for Houston neurologist William Gilmer, MD, who attempted to reenroll in Medicare after creating a professional association and relocating his office. 

"It was just a very long, drawn-out ordeal," said Kathy Huggins of Account Management Services, who does Dr. Gilmer's billing. "The instructions are not real clear when enrolling in PECOS, and every time you call and speak with provider services, you get a different answer. So you're filling out forms over and over, and they shut you down." 

Ms. Huggins says Dr. Gilmer was waiting for more than $20,000 in Medicare payments when he turned to the TMA Payment Advocacy Department for help. The department cleared up the problem in two days, and Dr. Gilmer received his payments. 

Payment Advocacy staff also helped a four-physician Dallas oncology practice recover nearly $300,000 in claims that were tied up with enrollment issues. 

Nacogdoches dermatologist Travis Lynn Warthan, MD, says Payment Advocacy staff helped him resolve billing issues with Blue Cross and Blue Shield of Texas when he hired his daughter, Molly Warthan, MD, to work in his practice on a part-time basis.  

While other health plans and Medicare allowed him to bill for his daughter's services using his tax identification number, Blue Cross would not. TMA staff helped him figure out the best way to bill that carrier, he says. 

"They helped me wade through some of the different answers we got from Blue Cross," he said. "They were able to help guide me through the NPI [National Provider Identifier] regulations and figure out how to file claims where you have an employee but want to file claims under the employer's NPI number." 

But Payment Advocacy staff does more than just resolve individual physician claims or enrollment issues. Recently, TMA persuaded Blue Cross to suspend the Procedure Plus Evaluation and Management Service Reimbursement Methodology that was set to go into effect Sept. 1. This would have paid the evaluation and management service at 100 percent of the allowable amount, while any procedure performed at the same time would have been considered the secondary service and paid at 95 percent of the allowable amount. 

TMA officials say that the policy would have impacted multiple specialties and could have totaled several million dollars annually in lost payments for physicians. 


Getting the Hassle Out

Ms. Davis says many of the claims, enrollment, and other problems come to TMA's attention through its Hassle Factor Log program, emails to Payment Advocacy staff, or inquiries to the TMA Knowledge Center. Sometimes, she says, it's just "physicians reaching out" to TMA. 

"Even if it's just calling (512) 370-1300 and saying 'Please help me,' they are able to be routed appropriately within TMA to find somebody to help them resolve their issues," she said. 

More information on TMA's Hassle Factor Log program is on the TMA website online

Dr. Crow says the department staffers are able to aid physicians because of their extensive knowledge. 

"You don't get $1 million without a lot of hard work, a lot of expertise, and a lot of different things that had to be corrected," he said. "It's not like it was just one carrier on one type of surgery in one location in Texas. It's really from all comers, all payers, all specialties, and all regions of the state." 

Dr. Crow says Payment Advocacy staff members have the breadth and depth of knowledge to assist "with pretty much any situation. As a member, that's a great benefit. All of us at some time or another have those issues, and to have a resource like that is pretty incredible." 

And, Dr. Crow says the health plans maintain a very collegial relationship with TMA in attempting to resolve claims and other issues. 

In fact, Blue Cross officials say they created their Office of Physician Advocacy (OPA) specifically to work with TMA on resolving claims and other issues. 

"The Office of Physician Advocacy here at Blue Cross appreciates the opportunity to work with TMA's staff in resolving 'hassle factor' issues," said Dee Whittlesey, MD, Blue Cross vice president for OPA. "Because our OPA staff understands the importance of TMA's work, our turnover time for resolution of 'hassle factor' claims is 1.5 days." 

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.


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