coping with regulatory and payer demands to practice pm&r bruce m. gans, md

PHYSICIAN PAYMENTS: MEDICARE, OTHER PAYERS

AND RECENT CHANGESCoping with Regulatory and Payer

Demands to Practice PM&R

Bruce M. Gans, MD

It is not getting any easier to practice or get paid for your work

Payers are seeking ways to avoid payment, shift responsibility, and minimize their exposure to all providers, including physicians

How to Increase the Chances of Getting Paid

Do the right things clinically Document them well Code accurately and completely Inform the patient of their liability for paying for

your services before you provide them Collect co-pays at the time and site of service when

possible Review your insurance plan participation regularly Review your collections regularly Understand your contractual allowance rates

How to keep what you were paid

Audit your records yourself for documentation and coding accuracy

Cross-audit your charts with other providers Engage external auditors to review, critique, and

educate yourself and your staff

How to recover what was taken away after you were paid

Appeal everything Follow the rules meticulously Engage professional help Track your success Learn from your mistakes or failures to win

Working with Institutions

Medical Administrative Roles Employment Independent Contractor On-call arrangements

Risks to be avoided Review the contract carefully Document your work if you must invoice for payment Do the work you invoice for Make sure your payment rate is truly fair market value

Working with Institutions (continued)

Clinical Roles Incorporating Medicare documentation requirements for

inpatient rehab care into your practice Separating or commingling administrative and clinical

services Gym rounds Team meetings with patients

Use of extenders

Overarching Needs

Patients come first Balance your obligation to your patient with the

responsibility to show reasonable restraint in how you provide care and authorize/prescribe drugs, goods and services

Work in close alignment with others involved in the care of your patients

You are looked to as a leader, so lead with wisdom, grace and integrity

MEDICARE AUDIT AND APPEALS DEVELOPMENTS

Peter W. Thomas

Update on new RAC contracts and future audits

Existing RACs continue to audit certain claims RAC legal challenge delays awards of new round of

RACs Changes to RAC contracts that benefit providers

Physician-specific ADR limits

Additional Documentation Request limits by provider group

“Related” claims linking physician and facility claims for payment

New authority for CMS contractors to deny related claims

Specific rules governing denial of related claims

Two-Year ALJ hearing assignment delay and response from/impact on providers

Extent of ALJ hearing backlog AHA Lawsuit to challenge ALJ delay FAIR Fund Amicus brief to demonstrate harm to

providers 68% Settlement offer for acute care hospitals re:

short day stays Impact of developments on appeals process Pointers on challenging denials of claims, including

recoupment and interest

Congressional developments involving reforms to lessen impact on legitimate providers

Series of Congressional hearings exposing burden on providers

GAO Report on Medicare Audit Contractors Senate Special Committee on Aging Report on

Audits and Appeals Pending legislative efforts on Medicare audits and

appeals

Physician-specific Considerations involving Medicare Claims

Physician documentation of prosthetic/orthotic claims

Status of Physician documentation “template” being developed by CMS

Prior Authorization of certain DMEPOS Regulatory changes involving Off-the-Shelf

Orthotics

Competitive bidding of DME

Round II and the future of Medicare competitive acquisition of DME

National pricing based on competitive bidding Impact of coding on access to DMEPOS care

QUESTIONS AND DISCUSSION