Dylan Fisher

Today more than ever, practicing medicine is a business. Practices need to be run with the bottom line in mind, just like companies in any industry. One of the quickest ways to put a practice's bottom line in peril is by committing billing mistakes. Unfortunately, there are a handful of billing mistakes that are far too common in health care. 

Miscommunications between providers and coding professionals often lead to billing mistakes. These mistakes can become even more common when a practice decides to hire a third-party billing company as passing off the issue can breed further communication lapses, say experts.

Here's an in-depth look at some of the most common billing mistakes, how and when they occur, and what a practice can do to avoid them.

A common billing mistake, medical necessity cases, is becoming more and more common, according to Brian Bewley, JD, a health care attorney at Bass, Berry & Sims PLC in Nashville, Tenn. Medical necessity infractions occur when a patient's condition doesn't warrant the services a practice bills for. For example, if a patient presented with stomach pain and a clinician ordered images of his right foot, medical necessity may come into question.

"There's not only a review of what you billed for, [payers] look at the medical records and the underlying condition of patients to determine whether or not the [billed] services meet medical necessity," says Bewley.
Another common billing mistake is the misuse of modifiers while coding, according to Michael Fossum, CEO of Nobility RCM, a Chandler, Ariz.-based company helping practices with financials.

A modifier is a code that physicians use to indicate that a service or procedure has been performed and altered by a specific circumstance, but has not changed in its definition.

"If the proper separation modifier is not put in place, or a discriminate procedure modifier is not put in place, the insurance company will recognize that multiple procedures were produced on one claim," says Fossum.
Modifiers, and coding in general, can be particularly tricky for small practices lacking the resources to hire a third-party billing company. Hiring a partner to perform billing and coding services is something Fossum says is strongly in due to the complicated nature of the process.

"It is such a time intensive and knowledge intensive process, you have to spend a lot of time on the billing and coding aspects of a practice," says Fossum.

A third common billing mistake that practices make has to do with up-coding (billing too much for the service provided), or under-coding (not billing enough).

"A lot of people think that if they over code or up-code, it's the worst thing they can do. But, under-coding is just as bad," says P.J. Cloud-Moulds, a practice consultant and head of Turnaround Medical AR Recovery in Sioux Falls, S.D.

Under-coding happens when a practice fails to accurately code for all services they performed during a visit. This can leave valuable dollars on the table and cause incorrect reimbursement. The thing that makes under-coding so dangerous is that it's impossible to catch without an audit, and by that time "a small practice could have already shut down," says Cloud-Moulds.  

Why do practices continually make the same billing mistakes? It all starts with a lack of understanding, according to Cloud-Moulds. "Some physicians are consistently coding 'office visit, office visit, office visit.' But if you're doing something else during the visit, you need to code for it," she says.

Physicians go to medical school, not coding school, so a lack of knowledge can always be a factor, she adds. 

Bewley points to the fact that health care laws are constantly changing and overly complex as to why billing mistakes are made over and over again. "Most physicians and practices that I work with are well intentioned. They aren't trying to do something fraudulent. But because there's so much scrutiny of billing and reimbursement, even unintentional errors can lead to a need to refund money to payers, and false claims act cases," says Bewley.

With health care regulations constantly changing, physicians not equipped with the latest information can find themselves in hot water. Physicians don't have a lot of free time to begin with, so setting time aside to keep up with coding and billing regulations can add to the 

Outsourcing the billing and coding to a third party can take pressure off a practice, but it can also lead to unintentional error through communication breakdowns. Any time work is passed off, the chance of miscommunications become larger.

Elderly physicians may have a harder time adopting new regulations, as old habits are often hard to break, Fossum says. When a doctor has been in practice for many years, they sometimes stick to the billing codes they typically do in the office, he adds.

"A doctor who has been around 10 to 15 years still may have an encounter form or billing sheet and they just check off that they have done that procedure even though in the room they may have done various analogs to that procedure or other procedures," says Fossum.

The government audits practices of all sizes, and thinking your practice is too small can lead to disaster, experts say.

Bewley spent part of his career with the Office of Inspector General for the Department of Health and Human Services, gaining insight on the ways the government views health care organizations. "As a former government [employee], I can say that the government doesn't have any criteria for audits or investigations, everyone is fair game."

Government regulators do spend more of their time auditing larger practices, according to Fossum, but that doesn't exclude them from pursuing small practices at the same time. "Nobody is out of the woods or sequestered from the [auditing] process. The government has put significant resources into looking into everybody."

There are certain actions, all of a sudden changing the way your practice consistently codes that will always trigger an audit, no matter the size of the practice, according to Cloud-Moulds. For example, "If you all of a sudden stop coding 'office visit, office visit, office visit,' you could trigger an audit," she says.

When it comes to being audited, it's all about a practice’s documentation. "If Medicare can come see your chart notes, and they see detailed documentation, they will move on. Without good documentation, Medicare is going to see a problem and want to look at more charts. Size doesn't matter," says Cloud-Moulds.

Bewley suggests practices engage in their own in-house auditing and catch errors before they gain steam.  "Audit both the services you're providing and how you are billing for those services. You want to have some semblance of a compliance program. Unless you're checking on your own practice, you won't know [of errors] until someone else tells you," says Bewley.

Often, especially in small practices, physicians paying more attention to the billing and coding process would go a long way towards cutting down billing errors, according to Fossum.

"Most physicians think their piece of the practice management pie is the patient care. Altruistically, that is where their intentions should lie…you can't stick your head in the sand as a practice owner or a physician who needs to pay attention to those business pieces of the practice," says Fossum.

Cloud-Moulds says education is the only way for practices to stay on top of billing and coding regulations, suggesting webinars from Medicare as a good place to start. She also says having billing and coding in-house is an advantage.

"If you don't have a conscientious billing department they will just let a denied code sit as an error and not teach you. If you have an in-house billing department that is involved with the education with the practitioners, that's where your advantage is," says Cloud-Moulds.  

Furthermore, practices should always pay attention to the mail they receive from payers, even if it appears to be a simple postcard. "That little postcard is the payer's requirement to let practices know of a change they made in the provider network or the provider directory. Something could have changed that could affect the way you are coding and/or billing," says Cloud-Moulds.

Articles

An in-depth look at some of the most common billing mistakes in health care and what practices can do to avoid them.

Make Medical Billing Mistakes Less Common 

, our weekly column exploring what's being covered in the larger world of health care.

 found that 80 percent of Americans believe drug prices are too high, while only 39 percent have faith in the Trump Administration to fix it. According to the poll, lowering prescription drug prices was at the very top of the public's priority list, above infrastructure, solving the opioid epidemic, immigration reform, repealing the ACA or building a border wall.


The poll found that more than half of the public (52 percent) believe passing legislation to bring down drug prices should be a top priority for the administration, despite low expectations of seeing that come to fruition. Twenty-one percent of respondents reported they didn't trust either party to lower prices, up from 12 percent in 2016.


Furthermore, 72 percent of the respondents say pharmaceutical companies have "too much influence" in Washington, according to the poll. The poll also found that six in ten people (59 percent) are in favor of a national health plan, where Americans would receive insurance from a single government plan. Support for a national health plan rose to 75 percent when posed as an option among others for Americans to choose from. 


Researchers at the University of Colorado Anschutz Medical Campus are developing prediction models to better forecast which patients will be prescribed opioid medications long term after being discharged from a health care facility. The researchers hope this information will help identify patients with higher risk of future opioid addiction.

, the researchers noted that while opioids are commonly prescribed for pain, little is known about which patients will receive chronic opioid therapy (COT) following discharge from a medical facility.


To develop the prediction model, the researchers used data from the EHR from Denver Health Medical Center, an urban hospital located in Denver, Colo. Researchers identified patient-specific variables which were associated with the progression to COT. Variables included having a history of substance use disorder, a recent receipt of a benzodiazepine, an opioid medication or a non-opioid analgesic, receipt of an opioid at hospital discharge, and high opioid requirements during hospitalization.


The model the researchers came up with correctly predicted chronic opioid therapy in 79 percent of the patients and no COT correctly in 78 percent of the patients. The prediction needs further evaluation before moving forward, according to the researchers.

EHR Data Identifies Undiagnosed Genetic Diseases


A new EHR data mining technique developed by researchers at Vanderbilt University Medical Center found that undiagnosed genetic diseases may be more prevalent in the general population than previously assumed.

 and reveal that patients diagnosed with heart failure, stroke, or infertility, among other conditions, could be suffering from undiagnosed genetic diseases.


To come up with the data mining technique, researchers mapped the clinical features of more than 1,200 Mendelian diseases into phenotypes captured from the EHR. They summarized this evidence as phenotype risk scores to find patterns of symptoms that may be caused by an underlying genetic variant, according to the study.


The developer of the technique, Josh Denny, MD, professor of biomedical informatics and medicine and director of the Center for Precision Medicine, says EHRs have a lot of unused data that can be helpful for diagnosis. "…we're using the fact that the electronic health record has a lot of diseases and phenotypes tracked in it, and we can mine those and assess them in a rapid way," Denny told 

Creating Personal Space is Important for Physicians


"Interestingly, when I find myself in an unusually un-hectic day, I find it easier to continue that pace when I get home. We have developed a culture in which this type of [personal] space is a luxury, when in reality it is a necessity."

Jennifer Frank, MD, on the importance of physicians creating personal space

A recent poll found that 80 percent of Americans believe drug prices are too high, while only 39 percent have faith in it being fixed.

Americans Appalled over Drug Costs, Not Hopeful for Fix

Americans Get Less for More in Health Care

, Americans pay more than any other country for health care and get inferior results. The study, done by researchers at Harvard University, revealed despite spending the most on health care, Americans experience shorter life expectancy, higher obesity rates, and a higher rate of infant death.

So where is all of the money going? One of the main drivers of America's high health care cost is brand name prescription drugs, according to the study. In the U.S., people spend nearly double ($1,443) on pharmaceutical drugs compared to the average of other countries ($749).

Another takeaway from the study is that although the U.S. spends more on health care, fewer people are covered. In 2016, about 90 percent of the population had health care coverage in the U.S. But we spent about 18 percent of our GDP on healthcare. Other countries spent much less of their GDP on health care, ranging from 9 percent in Australia to 12 percent in Switzerland, while having more than 99 percent of the population covered.

Study: NPs, Physicians Face Similar Liability Risks

, the growing need for primary-care providers will be filled by nurse practitioners (NPs), not primary care physicians. NPs are growing in care responsibilities and expected to represent nearly one third of the family practice workforce by 2025, according to the study.

The study, published by The Doctors Company, the nation's largest physician-owned medical malpractice insurer, identifies the top risk management issues faced by NPs. The majority of these issues derive from clinical and administrative mistakes such as absence of written protocols or a failure to adhere to nurse practitioner scope of practice.

For the study, the Doctors Company looked at NP medical malpractice claims over a six-year period and compared them to claims against primary-care physicians to identify risk management issues that may be unique to nurse practitioners. The study also found that while top NP risk areas are fairly equivalent to those of physicians and can be addressed by similar strategies, many risk factors can be addressed if physicians understand NP laws and regulations within their state, while supporting NPs in providing care within the practice.

FDA Announces Plan to Cut Nicotine in Cigarettes

On Thursday, the Food and Drug Administration (FDA) announced a plan to reduce smoking rates by lowering nicotine in cigarettes to minimally or non-addictive levels. Lowering nicotine in cigarettes would strip them of all or most of their addictive power, which could lead to 5 million adults quitting smoking within a year of the plan going into place, according to analysis published in 

Furthermore, the analysis includes the potential for another 8 million people to quit smoking within five years of the plan being put into place. By 2100, the plan would prevent 33 million people who are now children or young adults from ever taking up tobacco, saving 8 million lives.

Because the tobacco industry is likely to fight these proposals, it could be eight to 10 years before reduced-nicotine cigarettes become a reality, according Erika Sward, assistant vice president of national advocacy for the American Lung Association.

Negotiating Favorable Value-Based Contracts with Payers

"We have an entire generation of providers, an entire health care delivery system that was literally formed [around the concept] that our job is to take care of sick people. In the course of the decade, the message is changing and we're now telling people we need to take care of people in a way that they never get sick."

Tamm Kritzer on the challenge of switching to value-based contracts

Despite spending the most on health care, Americans experience shorter life expectancy, higher obesity rates, and a higher rate of infant death.

Americans Pay More, Get Less from Health Care 

With numerous payment models in healthcare and each one focused on value, clinicians are often called upon to be part of the cost-saving equation. A problem arises when clinicians don’t know what they are looking for to achieve that outcome. This is where cost transparency becomes necessary.


Greg Hall, MD, serves as chief medical information officer at the New Hanover Regional Medical Center in Wilmington, N.C., an organization spearheading the cost transparency movement by making it possible to display costs to clinicians via their EHR through its Price Transparency Project.


At the Healthcare Information and Management Systems Society (HIMSS) Annual Conference in Las Vegas, Hall spoke about how having price information at the point of care is helpful in allowing physicians to practice cost consciously.


Currently, some clinicians are ordering therapies and medicine while being unaware of cost. According to Hall, this is because cost saving measures are not part of their workflow. "You can put out newsletters, hang posters, and send emails, but if it's not right in front of the doctor, it's not going to happen," said Hall.
Besides incorporating cost saving strategies into a practice’s workflow, Hall cited the importance for practices to utilize a scalable approach, require minimal education, and be sure to not come off as mandating choices to physicians.


"Doctors don’t like being told what to do. If you show a provider something is cheaper, they will take that into consideration," said Hall.
Practices must determine how physicians order medications and identify them as necessary. Some examples Hall gave were order sets, preference lists, and "one-off" orders.


A custom preference list is easy to use and offers physicians limited choices based on cost effectiveness. The list organizes medications by disease state, rather than in general. A preference list also recommends the dose, frequency, and formula information. "We use custom preference lists to almost trap [clinicians] into choosing the right thing," said Hall.


For "one-off" orders, the cost display shows the facility cost rather than the cost to the patient, to demonstrate the implications for the practice.


To show the importance of cost saving to physicians and other members of a practice, Hall recommends looking closely at the cost impact of expensive and less expensive medications. "The small drugs can do a lot of damage to your hospitals budget. Don't always focus on the stampeding elephants; the army of ants can eat away at you," said Hall.


One example Hall used was if a practice chooses to administer 4mg of ondansetron through an IV, it costs $2.25. That same medication in tab form costs $0.50. To better point this out to practice staff, Hall recommends showing them numbers, not just relative cost.


Hall recommends displaying this information at the point of care by adding a "daily cost estimate" column to the EHR, while also displaying the cost options in order. "Providers want to do the right thing, but they also want to do the easy thing. If you can move something up to the top of a list, they will do that," said Hall.

Healthcare organizations are always looking to save money, but physicians rarely know the effect of their treatments or medications. Here's how to change that.

Author | Dylan Fisher

Articles