IBC Audits

On August 12th, 2010, posted in: Industry News by

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IBC is at it again. Recently we have become aware of IBC performing audits on office consult codes. Although there was documentation from the PCP in the form of a script in the specialist chart, the service performed and a letter sent back to the PCP indicating findings, the audit department at IBC has determined this did not qualify as a consultation. When questioned as to why, we were told they considered this a ‘referral’ and a request for consultation should clearly state the word ‘consultation’ on the request from the referring physician.

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July 15, 2010, Health Net released a statement that a computer disk drive involving unencrypted personal information with provider’s names and social security numbers was missing. They state “the files on the missing drive were not saved in a format that can be easily accessible and therefore, they believe the risk to you is low.”

To ensure the integrity of your personal information, health Net has arranged for you to receive identity protection under the Debix Identity Protection Network, available for two years at no cost to you. Once you register, Debix will enroll you in their OnCall Credit Monitoring and you will receive OnCall Credit Alerts regarding changes in your credit file.

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Effective May 17, 2010
E/M codes, when billed with a ‘25’ modifier (indicating the office visit was for a distinct reason other than another service/procedure performed, same day) will be paid at 50% of the allowed amount.

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CMS, in transmittal 112, has spelled out documentation requirements for inpatient rehab facilities (floors):

  1. A qualified clinician must complete a preadmission screening no more than 48 hours before an IRF admission; (see below)
  2. The physician must generate admission orders for the patient’s care at the time of admission;
  3. A rehab physician must perform a post-admission evaluation no later than 24 hours after the IRF admission;
  4. The physician must complete an overall plan of care with an estimated length of stay within the first four days of an IRF admission;
  5. You must include the IRF patient assessment instrument (IRF-PAI) form in the patient’s medical record;
  6. CMS requires documented visits from the rehab physician at least three times a week; and
  7. Documentation must include notes once-a-week from interdisciplinary team conferences including the physician’s concurrence with all decisions made at the meeting.

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By Charles Fiegl on Apr 29, 2010
Washington Post blogger Ezra Klein opined on Rep. Paul Ryan’s (R-Wis.) April 28 comments regarding a permanent Medicare doc fix and the costs associated with health care reform.

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The legislation makes a number of changes to the Medicare program that will impact your practice over the next several years.  Some examples:

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Greater cash flow, lower A/R days and access to experts are just a few of the ways this surgery center profited from the switch.

The primary argument against outsourcing billing services is its cost. It’s no secret that billing companies make money by charging a percentage of what they collect. Depending on the vendor, that’s typically 4% to 10% of your gross – not a small expense – but it probably pales in comparison to the cost of hiring, training and providing benefits to a business office staff that isn’t billing and collecting everything that you’re due. We learned that the hard way. Early on we handled our own billing and coding, but quickly discovered that we were in over our heads and needed help.

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Your practice may benefit by outsourcing its medical billing

By Leigh Ann Simms , CCS-P, vice president and chief operating officer, doshealth, Columbus, Ohio

In too many medical practices, physicians remain naive about the complexities of medical billing. They fail to invest adequate resources in the department responsible for the organization’s financial success and legal compliance.

Medical billing requires constant attention to a plethora of regulations, publications, guidelines and laws. Entrusting its processes to unqualified staff is an irresponsible business practice. Practices purchase expensive hardware and software to fix medical billing problems, but the technology has limited value in the hands of untrained people.

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Financial difficulty is a discouraging fact of modern economic times. While you remain concerned about your patients’ well being, you also have to keep your practice financially stable.

When a patient hits a rough patch, it’s hard to resist the temptation to waive copay, deductibles or even write off balances. The problem, waiving deductibles and copayments can violate several federal laws, including the False Claims Act, anti-kickback statutes and compliance guidelines for practices. You may also violate payer contracts which could result in your removal from a provider panel.

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It’s difficult to say what carriers deem red flags in determining which services to audit. However it is true they use sophisticated tools to profile you. The most common red flags from an auditing eye are:

  • The same diagnosis for every visit. Each encounter must correlate to the patient’s chief complaint and the indication for the visit. It is unbelievable that the same diagnosis would be used for every visit from an auditing eye.
  • Billing the same CPT code over and over. Remember that bell curve…it still applies today. No practice or physician should be reporting all 99213’s for every patient.

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