It’s Not (Just) About the Billing Office:
Reimbursement Resources for Your Entire Staff
Reimbursement Resources for Your Entire Staff
July 2010 Issue
"It doesn't matter who the provider is, big or small, O&P businesses should always be looking for ways to improve their performance and efficiency and to maximize their reimbursement. Especially as insurance carriers keep cutting payments, you have to find ways to make sure that you are being reimbursed for everything you are entitled to."
-Lisa Lake-Salmon, president of Acc-Q-Data, Boca Raton, Florida
The process of O&P reimbursement is in the midst of a massive upswing in complexity. National healthcare-reform law, accreditation requirements, Medicare and Medicaid changes, payer audits and foot-dragging, and a slumped economy all mean that garnering the reimbursements that make patient care possible may never again be the sole purview of an O&P facility's billing staff. Clinicians, administrators, and even researchers and educators now all have practical roles in the day-to-day business of getting O&P businesses paid. Thankfully, there are resources that can teach people in every area of the profession to streamline the reimbursement process, setting the stage for optimal compensation before the bills go out, and fielding potential problems when they come to the fore.
Know Your Enemy
Understanding the problem is the first task, according to Lisa Lake-Salmon, president of Acc-Q-Data, Boca Raton, Florida. "The average O&P business is a one- or two-person setup," she says. "I'm not going to say that billing can't be done right in that kind of office, and I'm not saying that it can't be done profitably-of course it can...but you're not paying people $150,000 a year to do billing, and you can't really expect them to know every state law, every rule and regulation, and all the changes that Medicare and other payers make." The consequences of not knowing these details can be serious. Terry Supan, CPO, FAAOP, FISPO, owner of Supan Prosthetic Orthotic Consultations, Rochester, Illinois, says that improper documentation can be seen as fraud, bringing fines as large as $10,000 per count for either the clinician or the facility judged to be at fault, with a risk of losing one's national provider identification (NPI) number and license to practice. At the same time that payers are demanding more scrupulous documentation from every stage of care, some are being caught making slow payments, arbitrary denials, and short-payment of contracts.
"We see this all the time," Lake-Salmon says. "I have a provider right now that has a contract with Humana, and for three years [Humana] neglected to pay them correctly. I put together a spreadsheet showing how the payer was a little incorrect on payments here and there-$20 here, $10 there-and it may not seem like a lot, but over three years it's totaled over $60,000 that that provider was underpaid." Even when payers act in good faith and public reimbursement levels remain steady, it doesn't mean O&P businesses are in calm waters. If inflation and documentation workload increase while payments remain stagnant, the effect mimics payment cutbacks.
Associations Get It Right
Developing the knowledge and business policies to thrive under such conditions can be complex, but using a wide variety of resources, some from nontraditional fields, can help. The resources most recommended by the experts interviewed for this article were the learning modules provided by professional associations.
Supan notes, "In the private sector, people get so busy providing care that when they go to the Academy or AOPA meeting, they concentrate on the clinical lectures-but someone in the company needs to be attending the business lectures."
The American Academy of Orthotists and Prosthetists (the Academy) offers a wealth of tools for developing denial-resistant justification. Its Online Learning Center (OLC), for example, includes tools accessible to members and non-members throughout the United States, Canada, and internationally. It includes more than 125 clinical education modules, including state-of-the-science conference findings and courses derived from the Journal of Prosthetics & Orthotics (JPO), the Academy TODAY, suppliers, and annual meetings. The Academy also offers certificate programs for professional development in evidence-based practice. They range in price from free to a few hundred dollars, and many address reimbursement specifically.
Similarly, the Center for Orthotics and Prosthetics Learning & Outcomes/Evidence-Based Practice (COPL) focuses on developing the evidence base as an instrument for reimbursement and offers members access to a wealth of journals, conference presentations, and other tools. "Virtually everyone in O&P has had the experience of an insurer refusing to pay because you couldn't demonstrate that a specific device is more effective than some other treatments," its website claims. "We recognize that O&P is playing catch-up to other fields in having outcomes research and evidence-based guidelines/research to support what we do."
The American Orthotic & Prosthetic Association (AOPA) also offers its members a variety of tools. Its "Ask the Coding & Billing Expert" service allows users to call advisors Joe McTernan and Devon Bernard with questions. AOPA also offers members access to the website www.lcodesearch.com which lets users look up L-Codes by code, manufacturer, or category to help staff with coding and reimbursement questions. AOPA's Coding & Billing Seminar offers many take-home tools, and members can also purchase coding and billing products from the association, including CDs of clinical and business forms. Its "AOPAversity" listings include reimbursement-fundamentals courses, enlightening users through titles such as "How to File Claims," "Administrative Documentation," and "EOB Use and ABNs."
O&P groups aren't the only valuable information source for O&P businesses. Robert Rhodes, CO, FAAOP, director of the O&P programs at Eastern Michigan University, Ypsilanti, draws insight into practice management from experiences in a variety of fields, including retail sales. He sees customer-service basics, such as developing a rapport and building trust with patients, as a key to repeat business, and he steers colleagues toward the book How to Sell Anything to Anybody by Joe Girard, one of the nation's top salesmen. The U.S. Small Business Administration (SBA) offers business owners a variety of tools, including its SCORE program, which connects users with free advice from experienced business mentors.
For those who want more specialized insight, hiring an O&P business consultant can be highly efficient. Googling "prosthetics consultant" brings up a long list of professionals, and many, such as Supan, offer employee-education services that directly address a facility's most troubling reimbursement inefficiencies.
Educators Point the Way
Perhaps the most potent sources for reimbursement-related education lie in the university-based O&P programs. Though the average practitioner who doesn't want a master's or doctoral degree isn't likely to take advantage of such programs, a look at curricula offers valuable information about tools and concepts that support reimbursement.
At the University of Texas Southwestern (UTS), Dallas, for example, the instructional team led by Susan Kapp, CPO, FAAOP, stresses that "the practitioner is ultimately responsible for claims even though an office billing coordinator will frequently take care of insurance preauthorization, the prescription, and claims submission." For some class projects and coding exercises, UTS students use the AOPA Quick Coders, lcodesearch.com, and EPIC-brand electronic medical record and billing software.
"Detailed documentation of services provided and patient education is important to the continuity of care and for successful outcomes," Kapp's team says, adding that UTS students' documentation must justify each L-Code they bill and follow Medicare formatting and rules.
At Northwestern University, Chicago, Illinois, Program Director Thomas Karolewski, CP, FAAOP, and instructor Robert Lipschutz, CP, emphasize to students that the future of reimbursement is not going to be easy. "Dealing with insurance companies is only going to get rougher," Karolewski says. Northwestern students participate in journal clubs and hear guest lectures on a variety of topics, including use of the Amputee Mobility Predictor, OPIE software, and other tools. Lipschutz teaches a business module that covers topics that can impact a business' bottom line, including liability issues and facility accreditation.
At California State University Dominguez Hills (CSU DH), program instructor Mark Muller, CPO, FAAOP, says, "We teach our students how to ethically code and bill. We also spend a great deal of time teaching students to decipher the marketing hype in what manufacturers suggest for codes. When we go over new products and ask them what benefits they see in a particular product, we ask what the manufacturer is suggesting for the L-Code, and would the students be confident standing up in court under threat of a $20,000 fine, saying, 'Yes, I chose that L-Code because the product has this particular feature that treats this particular diagnosis.'" They also dissect coding that falls into ethical gray areas. Program Director Scott Hornbeak, CPO, adds that at CSU DH, students take AOPAversity modules and are required to evaluate the cost of devices compared to their reimbursement from payers.
Eastern Michigan University (EMU), Ypsilanti, offers a full course in O&P facility administration that includes 45 instructional hours, plus exercises that develop reimbursement skills throughout most other courses. According to Rhodes, EMU's program emphasizes rigorous documentation, fundamentals, and versatility. "If we went into a lot of detail about billing and specifically what codes are now, that might change next year," he says. "The principle behind what we teach is that students have to document what they've delivered, and their billing has to match the documentation because if it doesn't, they're going to wind up in a world of trouble."
At the Georgia Institute of Technology (Georgia Tech), Atlanta, the School of Applied Physiology master of science in prosthetics and orthotics (MSPO) program director, Christopher Hovorka, MS, CPO, FAAOP, agrees that in many cases, best practices for reimbursement are a pedagogical moving target. Because of this, he says, his program employs common instructional tools and methods, including didactic lectures and an emphasis on documentation development. Students then participate in a variety of off-campus clinical rotation sites. "That's where we try to give students exposure to the complications of the system-where the procedures are utilized in reality."
Perhaps most important, Hovorka says, is that Georgia Tech faculty members make it clear that students are "the pioneers." Students' future careers, he says, shouldn't be about "getting around the current system but about engaging people who can influence changes to the current system...of reimbursement. The people who make change are policy influencers at the state, regional, and federal levels. It's not an easy task to reach people like legislators and lobbyists, but we certainly encourage students to take a role in that."
Hovorka concludes, "Fundamentally, reimbursement comes down to evidence. We've kind of been stuck as a profession with an outdated billing system that reflects practice from decades ago...but in order to document what it is that we do that is relevant and appropriate and truly makes a change, we have to add to the body of knowledge.... We need more robust and appropriate research to document what we do, and that's only going to come through the schools and O&P profession working together."
This attitude, says Dan Cahoon, vice president of sales at PacWare, Sacramento, California, may help readjust the focus of healthcare. "Payers want to make healthcare about dollars and cents," he says, "but every O&P practice will tell you that healthcare is about humanity. Money plays a role, but when you deal with it with common sense, it becomes what it should be-secondary."
Morgan Stanfield can be reached at
Editor's note: The O&P EDGE does not endorse any company, product, or educational resource. Companies, products, and educational programs and resources mentioned in this article are for reader information only. Space does not allow for complete coverage of all products and educational programs and resources available to O&P professionals.
Practice Management Software
Top Updates to Four Popular Systems
According to Dan Cahoon, vice president of sales at PacWare, Sacramento, California, the rule of thumb in healthcare information technology (IT) is that it runs ten to 15 years behind the rest of the world's IT. If that's true, O&P practice-management software providers are working steadily to catch up. Acc-Q-Data, Futura International, OPIE Software, and PacWare are just a few of the many O&P software providers on the market, and representatives from each company spoke to The O&P EDGE about some of their latest updates.
At Acc-Q-Data Management Systems (AMS), according to Lisa Lake-Salmon, company president, one of users' favorite updates is a tool that provides online verification of benefits from private payers, Medicare, and Medicaid during appointment scheduling. Extensive new profit-and-loss reporting and work in progress (WIP) reporting has also been popular, as have enhancements to the company's automatic EOB-submission process, which can electronically submit primary and secondary claims from Medicare, Medicaid, and private payers.
At Futura International, reports company President Marshall Fryman, the theme is "automation, automation, automation." Many functions that formerly were handled in reports, such as matching ICD-9 (and, soon, ICD-10) information to Healthcare Common Procedure Coding System (HCPCS) codes, now happen automatically in case files. Futura software also now integrates support for the Compas [Computerized Prosthetic Alignment System] by Orthocare Innovations, and direct ordering through SPS and PEL Supply Company. Instant lookup and form population of NPI number and Provider Enrollment, Chain, and Ownership System (PECOS) information helps eliminate more errors, and coming soon is an automated appointment-reminder system.
Jonathan Shinn, chief operations officer of OPIE and oandp.com, says that OPIE users receive near-constant updates that are driven by user requests. Popular updates include improved dashboards, which allow users to spot any files that require attention without needing to drill down into them, PECOS lookup, automated ordering, automated faxing, and automated dictation. ZirMed, which handles OPIE users' electronic claims submission, also focuses on providing regular interface updates, and ZirMed Vice President of Sales Rich Flaherty says the company is already prepared for the rollout of ICD-10.
PacWare, according to Cahoon, has improved not only its practice management elements but also its point-of-sale system, which can support durable medical equipment (DME) and pharmacy sales. The PacWare package now includes digital signature capture and an autodialing system to remind patients about appointments and ordering of recurring supplies.
Editor's note: The O&P EDGE does not endorse any company or product. Companies and products mentioned above are for reader information only as a representative sample of software products on the market today. Space does not allow for complete coverage of all software providers.