Presentations from the 34th Clinical Meeting of the AAGL Advancing Minimally Invasive Gynecology Worldwide held November 2005 in Chicago, IL, USA
Reimbursement and Practice Administration
Considerations
Kristi Downey
Gynecologic Oncology of West Michigan
Thank you, I am going to speak on the practice administration side of all of this procedure.
I am approaching it from a decision point of view because it is a decision for you to make and your patient to make. We are going to go at it that way.
The first thing I am going to say, and I do not want you to flinch too much, but do you have protocols in your office for the use of this? Dr. Bertrand touched somewhat on that kind of approach. It does not have to be anything elaborate but it is a really good idea to do. You can have just a sheet of paper, a half sheet, these are the patients, these are the criteria that we are looking for, we have ruled out these co-morbidities, we can do this safely in our offices, etc. This is a tool that is going to help you with paper performance down the road. It is a quality assurance issue. Quality assurance needs to be prospective now, it used to be retrospective, and now your entire Q & A is going to need to be a prospective issue. And that is going to fold right in to outcomes management, paper performances, etc.
Insurances love a prospective quality assurance. So, it is going to help you with that issue. To develop clinical practice guidelines for the use of endometrial ablation in your office, that standardizes it for all of your practice partners. It is a quality assurance benefit, as I mentioned, and you can also communicate this to insurers.
The first decision you need to make is one of quality of care. Quality of care is an issue that is patient driven. What is the best medical choice for this patient? I think you have gotten a lot of information today to show that the office endometrial ablation can be an excellence choice for your patient. The first decision has got to be that this is the best medical decision, the best choice.
Then after that, the business focus comes in.
You and your patient made the decision to do this in your office, and what is next?
Is it a question of delivery of care, how to implement your treatment options? Some of the considerations that you are going to have are will it impact the quality of care? Some of the things we have seen in the past are that actually some of the hospital outpatient procedures can have a negative impact on quality of care because of problems with the whole system for the outpatient delivery in the hospital setting, or ASC setting. That can be a positive for you to do it in your office. It is certainly going to be a significant patient satisfaction issue for you. It will also impact your payment profile down the road, as you have seen.
Where the care is given is crucial. The office is patient preference and physician time management, which has already been touched upon. It is much easier for you to do this in the office than to try to carve it out of your OR surgical day. The reason you would do it in the hospital, as Dr. Bertrand mentioned earlier, is when co-morbidities require you to do it.
So, now we have made the decision to come in the office. I know that this statement was made that there is no pre-certification needed. But we have found, especially with new technologies and something new like the ablation being covered now for Medicare and Medicaid, with the global in the office, pre-certification tends to play more for us now. Why do you do it? How do you do it? When do you do it? Who does it? I am going to run through this fairly quickly because if it does not apply to you, you can ignore it. But, I think you will find it applying more and more, especially resulting for your reimbursement.
Pre-certification will not absolutely guarantee you payment, but it will give you the best chance to get payment. And without it sometimes you can get a denial. It is your best chance to maximize your payment, and your best chance to expedite that. Everyone would like to see a closer timeline between doing the procedure, billing for it, and actually getting paid for it. So that is one of the reasons in our area. Pre-certification has become something that we use pretty forcefully.
On-line pre-cert is the fastest. As you know, cell phone can take a while. Some of your insurances now are requiring fax and written ones. Those usually do not happen the same day.
When you start the pre-cert, if you need to do it, you do that as soon as your medical decision is made. You are going to bring these patients back. As soon as you have made the decision to do that, is when you want to start this process.
What do you pre-cert? Well, you pre-cert that they do indeed have insurance coverage. Just because they have that card and it has a date on it does not really mean that it is actually active at that moment. Confirm that this insurance is not going to stop it. That may sound fairly basic, but it is amazing what you can get tripped up on.
Confirm that outpatient in your office is covered. There are some policies out there that do not cover outpatient in the office, and these are not the endometrial biopsies stuff we are taking about. What they look at is more of an outpatient procedure, which endometrial ablation has been. Some policies do not cover that. So you need to know that.
Are there any further approvals needed? Usually you are going to be the PCP, and it is going to be okay for you to do that. But for some managed care plans, there is going to be some that will say "Yes, we will cover it but only if this person that we have against this patient in our plan signs off on it". You need to know that.
Okay, who does a pre-cert? This is very quick. A nurse can initiate it but do not let your nurse tie up her time very much in it. You should have your administrative staff do it, and it should be the biller and coder ideally because they are going to be translating the codes to the insurers. You would like to get that all in the record already so when that bill comes through, they are saying, "Yup, matches up" boom, boom, boom, all done.
The pre-cert approval: document that approval; get the approval number reference number, and the name of the person giving the okay if you can. We keep it in the medical record so that we always have it. We may note it in our computer records, but we keep it in the medical record.
What if they say, "Nope, we're not going to do it. We're not going to cover it"? You can get a signed ABN from the patient, if it is a Medicare patient, which I do not know how much your percentage would be, but that is an Advanced Beneficiary Notice and that is a specific CMS form, only for Medicare.
For other insurers you say, "Look, we're not going to be sure how much they're going to pay". You may have some payment for this and educate the patient. You will be surprised the number of patients that would prefer to have it done in an office, and not get the extra fees from the hospital, etc. They will say, "Okay, fine, thank you for telling me". Sign the form and you are all set.
Okay, it is approved, what do you do next? You want to be sure you bill the site of services, your office. That is 11. Actually we have had some offices for other issues that have billed the site of services, 22-Outpatient, because that is how they think of it as. But it is not, it is in your office, it needs to be billed as an 11. Bill your full fee; and your HCFA form, box 19, which you can do electronically. You just want to make a note that this is not an outpatient facility. This is an office, and it has been approved and you are all set. The global fees apply.
They asked me to speak on some issues that some people had when the insurances have not paid the full fee. They have carved out the practice expenses, said "Nope, we're not going to pay that to you". Well, they are not really allowed to do that. So, if they do not pay it fully, the first thing you need to know is why that has been denied?
One of the games that the insurances like to do is blame the computer. So they tell you that they cannot load two payment amounts for one code. You are not asking them to load two payment amounts; you are simply asking them to pay you the full amount when you do it in your office. So my response to that would be "Really"? You already do this for LEEP procedures because there is a different amount paid to you for LEEP if you do it in your office fee as opposed to an ASC, or the hospital, simple wide local excisions, things like that, they already have two values because they are deducting that office practice expense from your fee if you are doing it in the hospital setting. You are just asking them not to deduct it.
Another one is to blame the program. Insurance is using 2000 Medicare values, and your contract is tied to 135% of Medicare, or 150%, or whatever. This code was non-existent then. I find that very interesting. Because you know that they are paying for codes that have been added since 2000. I apologize for this being GYNOP codes, but that is what we do; 58954 is a complicated surgery for malignancy, and 57155 is tannin and ovoids and those have both been added in the last couple of years. And you know they are paying for those.
So, that is a really bogus argument if you get that back from your insurer.
There is no special price. We are not asking them. This is the problem with someone's Blue Cross Blue Shield. And they are told that Blue Cross Blue Shield does not special price individuals CPT codes. Again, we are not asking them to special price, you are asking them simply to acknowledge that you do have a practice expense with this and to pay it to you.
Now, they cannot take out the facility fee, when you did not use the facility is what it boils down to. If you are in the position where you have signed a managed care contract, and in that contract they have put a specific price on this procedure and you have signed it, then, you kind of have signed away your rights to complain about this. You need to check those contracts carefully. But for endometrial ablation in your office there is absolutely no reason they should not be paying you the full amount.
They are telling you that an ambulatory surgical center and your office are the same thing. Well, they are not, as we have already said. If you are doing it in your office, you are entitled to the equipment reimbursement, the practice expense reimbursement, your whole overhead, etc., which is all what is rolled into that practice expense.
So under RBRVS, as I believe Dr. Anderson showed you, you have the physician management amount, you have the practice expense, and you have the malpractice, those are all multiplied times your GPCI, which is your Geographic Practice Cost Indicator and then that is all deployed x the conversion factor.
You cannot treat these things as the same. Same insurance in this state was paying other people in the state correctly. So then it is an issue, why isn't yours loaded correctly? Is it a managed care contract? Is it somebody who does not know what they are doing, who happens to handle your billing and processing for that insurer? That is something you would have to look into and see what the root cause is for that.
Another insurer, United Health Care, said that the 2005 codes were not loaded, and they would not be till 2006. Why is that? Okay? I will bet you that United Health Care is paying Medicare supplemental because they are a big Medicare supplemental payer. Well, then they got those 2005 codes in there to pay the Medicare supplemental. So this is another argument I find totally bogus. I pretty much get into their face pretty quickly about it.
So, how are you paying your other fees, your Medicare supplemental, etc? It is a system problem you need to correct would be my response to that. And, are they going to pay interest? Most contracts have for clean claims a payment parameter time. If they are not making full, appropriate payment within that parameter, I would tell them I am going to invoke my own timely payment clause, which means you are going to pay me X percent interest. Again, the argument is you already paying these codes for the Medicare supplements time so I know you've got the codes in the system. You are just trying to avoid paying me.
The root, the bottom of this, is that almost all the insurers these days use the RBRVS system, which is developed by Medicare. So, if they are using that, which means they are using CCI edits, and I know you have all come up against the CCI edits, they are usually basing your payment on some percentage of Medicare, you cannot pick and choose what part of this system that you are going to use. If they are going to use RBRVS and CCI edit, etc., they must use the whole thing, and Medicare says that in-office endometrial ablation is entitled to the full fee, including the practice expense.
So, if you use any of that, as I said, you cannot pick and choose what you are using, and they have a legal requirement to follow that. There have been two losses. I am aware of one in upper New York State, and one either in Florida or Arizona, I do not recall which. It was not on this issue, but it was on insurance trying to invoke Medicare CCI edits and RBRVS limitations. But then are not following some of the other issues with Medicare; cases the courts ruled that they had to follow all of it.
If for some reason you do not get your payment, the first thing you do is appeal it. Use your normal channels, your contact person at your insurer, your provider relations person who is going to be more willing to listen to you usually than the person at the other end of the phone, upon just calling the insurance company cold. And you want to inform and involve your patient, "Hey, there's a problem here, and we are working on it, but you know you may need to do a little bit too".
The second step that we found very effective is to ask the patient to call their
human resources department. Most insurers really do not care if that patient is
happy, but they do care if that employer stays with you. So that employer is
representing to their patient, to their employee, your patient, that we have
very good insurance, we have excellent physicians; you have excellent access to
care. And you say, "Really? Well, they are denying this". Mostly, it takes about
one call from a human resources department upset about a patient's access to
care, etc. and you will be amazed at how quickly you get that check.
State Medical Societies and the plan's complaint or ombudsman regulations, a lot
of plans have that now. Your State Medical Societies are important in Michigan,
where I exist. Right now Blue Cross Blue Shield is being sued by the State
Ob/Gyn Society and the State Medical Society for this kind of thing with global
payments on OB's side.
Your third step is to write a letter to the Medical Director. You can cite the CMS regulatory language, other insurance reimbursements, and especially what that plan, that insurer, is paying other areas in your state or out-of-state. They are paying correctly, they are recognizing the full-fee with the practice expense, but in your area they are not. That really pretty much shoots the insurance out of the water. I would cc on this letter your insurance commissioner, whoever are the regulatory people in your state, I would cc it right there on the letter so the Medical Director sees where that is going.
Your final appeal unfortunately is trying to enforce the policy of the contract, which is usually going to boil down to something out of legal remedies. This is going to be an issue. If you are having this kind of a problem with an insurer, you are not just having it over endometrial ablation; you are having it over other issues as well too. If it gets to that point you are really going to have to go head to head with them.
You want to track your insurances to know your problem ones. If you have success with one insurer take that tactic, take that policy; use it with the next one. Your admin people should be doing all this. You are going to have to be persistent and relentless, which you probably already know, especially with some of the big plans like, Blue Cross Blue Shield and United Health Care. Engage you local and state medical societies because they will help you.
This is my email address if anybody wants it. Thank you very much. [gynonc@mac.com]