Physician Revenue Generation | Slideshare

Physician Revenue – Getting paid for the work you do from Slideshare

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  • 1. Understand
    • How physicians generate revenue
    • How medical billing works
    • Become familiar with
      • CPT coding 
      • ICD coding
  • 2. Dependent on adequate and appropriate medical documentation
  • 3. Document encounter Pertinent positive and negative findings in history and exam Differential diagnoses Treatment options Risks and benefits to patient of treatment options
  • 4. Rejected by Insurance
  • 5. Accepted 90% Rejected 10% Physicians Practice, 5 Common Medical Practice Denials, May 2014 http://www.physicianspractice.com/medical-billing-collections/5-common-medical-practice-denials-and-remedies-may-2014
  • 6. Physicians Practice, 5 Common Medical Practice Denials, May 2014 http://www.physicianspractice.com/medical-billing-collections/5-common-medical-practice-denials-and-remedies-may-2014    Duplicate Claim    Missing Required Information   Service Included In Service Previously Paid    Non-Covered Service     Late Claim Filing
  • 7. Rejected by Insurance
  • 8. High Rejection Rate Slow Submission Of Claims Inaccurate or Incomplete claims Delayed Coding Inaccuracy Slow approval Of claims Slow payment Audits Inadequate documentation
  • 9. Low Rejection Rate Fast Submission Of Claims Accurate and Complete Claims Prompt Coding Accuracy Good Documentation Timely Billing Prompt approval Prompt Payment
  • 10. Business in Medicine
  • 11.  Current Procedural Terminology (CPT) Codes    Code for services provided   Hospital admission  Follow up visit   Procedure    Code for level of service    Ranked 1-3 or 1-5 for some services    Higher levels result in higher payment
  • 12. = Service Codes
  • 13. Current Procedural Terminology (CPT) codes Developed by the American Medical Association Describe medical services   Patient visits   Procedures   Tests   Used by Medicare since 1978, other insurers quickly followed
  • 14. Medical documentation
    • H&P
    • Progress Note
    • Operative note
    • Order for a test or imaging study
    • Diagnosis (ICD) Codes
  • 15. = Diagnosis Codes
  • 16. Diagnosis codes!
    • International Classification of Diseases (ICD)
    • ICD-9 – 17,000 codes
    • ICD-10 – 155,000 codes
    • ICD-10 will be required starting in 2015
  • 17. Initial Inpatient Evaluation CPT Code Medicare Allowable Charge RVUs Level 3 99223 $204 3.86 Level 2 99222 $138 2.61 Level 1 99221 $102 1.92 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed Three levels for this service 1997 E&M Documentation Guidelines Used by physician to determine what level to bill
  • 18. Procedure CPT Code Medicare Allowable Charge Arthroplasty, knee, (TKA) 27447 $1,682 No levels for this service This is for the physician’s component of the service Hospital and device costs are billed separately
  • 19. OR Insurance Claim #1 Insurance Claim #2
  • 20. Initial Inpatient Evaluation CPT Code Medicare Allowable Charge RVUs Level 3 99223 $204 3.86 Level 2 99222 $138 2.61 Level 1 99221 $102 1.92 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed
  • 21. Initial Inpatient Evaluation CPT Code Medicare Allowable Charge RVUs Level 3 99223 $204 3.86 Level 2 99222 $138 2.61 Level 1 99221 $102 1.92 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed
  • 22. Medicare Alone Medicare + Supplemental Insurance Medicaid (IL) No Insurance Practice Charge $392 $392 $392 $392 Medicare Allowable Fee $204 $204 Medicare Responsibility $163 $163 Supplemental Responsibility $0 $41 Patient Responsibility $41 $0 $0 $392 Total Payment $204 $204 $67 ? 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014 Illinois Medicaid Fee Schedule, Accessed 7/29/2014
  • 23. Medicare Alone Medicare + Supplemental Insurance Medicaid (IL) No Insurance Practice Charge $392 $392 $392 $392 Medicare Allowable Fee $204 $204 Medicare Responsibility $163 $163 Supplemental Responsibility $0 $41 Patient Responsibility $41 $0 $0 $392 Total Payment $204 $204 $67 ? 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014 Illinois Medicaid Fee Schedule, Accessed 7/29/2014 The Medicare Allowable Charge may not cover the cost of providing the medical service and is independent of what a physician might charge (bill) for these services. Physicians are prohibited from collecting the difference between the charge and the Medicare Allowable Charge.
  • 24. Medicare Alone Medicare + Supplemental Insurance Medicaid (IL) No Insurance Practice Charge $392 $392 $392 $392 Medicare Allowable Fee $204 $204 Medicare Responsibility $163 $163 Supplemental Responsibility $0 $41 Patient Responsibility $41 $0 $0 $392 Total Payment $204 $204 $67 ? 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014 Illinois Medicaid Fee Schedule, Accessed 7/29/2014 Many practices report the cost of providing services to patients with Medicaid for healthcare coverage exceeds reimbursement. Payment from patients without insurance is variable, but they are charged at the highest rate.
  • 25. Rejected by Medicare Rejected by Supplemental Only Eligible for payment if Claim Accepted by Medicare 80% 20% Portion of Charges
  • 26. Complex and Lengthy Process
    • Influence factors you can control
    • Timeliness of coding
    • Accuracy of coding
    • CPT
    • ICD
    • Quality of medical documentation

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