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Gulf Coast Pain Management
Lynne Carr Columbus, DO
Know Your
Medicare Carrier
How to Stay On Top of Ever-Changing Policies
By Theresa Defino
Lynne Carr Columbus, DO, has more reasons than most to keep up
with edicts and
policies of her Medicare carrier in Palm Harbor, Fla. Columbus was once
on the wrong side
of FBI investigators probing fraud allegations in the practice she
joined just after completing
her residency.
Columbus, a pain management specialist, did nothing wrong — in fact, she
was fired
for refusing
to engage in the fraud, which took the form of unbundling claims,
and
later gave testimony against
her former partners. But the experience taught her
to be as unerring as
possible in her dealings
with BlueCross BlueShield of Florida,
the insurance carrier that
processes her Part B Medicare
claims for the Centers
for Medicare & Medicaid Services (CMS).
The other reason Columbus is careful is that Medicare makes up 80
percent of her revenues.
Both Columbus and her billing manager, Terry Bush, follow a number of
strategies to stay
involved in Medicare issues and up-to-date with carrier policies, and
their efforts seem
to be working: Columbus estimates 98 percent of her Medicare claims are
paid the first time
they're submitted. Because she is a solo practitioner, Columbus is still
permitted to bill Medicare
on paper; other larger offices must convert to a new electronic format,
which is causing some
of them difficulty.
"When I sat down with the FBI ... I understood what they were looking
for.
It taught me not to do creative billing. Another lesson I learned was
staying informed.
As a physician you have to realize that you have to be up on all these
guidelines,"
whether for government or private payers, says Columbus.
Bush built her own knowledge after 13 years of doing Medicare billings.
She reads
her carrier's newsletter closely, checks its Web site for information
and makes a point
of attending at least two conferences per year on Medicare-related
issues, which are
given by the carrier, the pain management association, or by private
coding companies.
For her part, Columbus also attends Medicare conferences and serves on
the Medicare
committee of her state medical society. She also finds it helpful to
consult an attorney when
questions arise about submitting claims or appealing denials.
"I think it's really important that offices establish a good
relationship with a healthcare attorney.
I run a lot of things by attorneys," she says, pointing out that most
offices may be able to turn
to the same attorney they use to review contracts or conduct other legal
business for them.
In addition, Columbus eschews the hands-off approach some physicians
might have when
it comes to billing issues. "I sit down personally with Terry. "You
really want to have a hand
in the billing," she says.
Working with
your carrier
As Columbus' example
shows, the key to working effectively with a Medicare carrier is simple,
says Alan Morris, MD: Be educated and know how to advocate for yourself
or your peers.
"When you can't negotiate the amount, you can understand and know the
process,"
says Morris, former chairman of the American Academy of Orthopedic
Surgeons'
Council on Health Policy and Practice.
Keeping up with coverage decisions is important because they sometimes
are modified
or reversed based on clinical evidence of efficacy, or lack of it.
Morris recounts the recent
example of CMS imposing limitations on coverage of arthroscopic surgery,
deciding to pay
for it only in "mild to moderate" cases after research was published
showing it was no better
than a placebo in patients with severe osteoarthritis. He notes that it
is up to the local carrier
to interpret what mild and moderate mean.
During his 34 years of practice in St. Louis before retiring in 2001,
Morris became quite familiar
with his local carrier and with federal Medicare officials. Each
Medicare carrier is required
to have a group that includes physicians who offer input, called the
Carrier Advisory Committee
(CAC). In addition, carriers employ a medical director to assist
physicians. In each instance
there is an opportunity for the physician to be better informed and to
volunteer, Morris says.
Morris not only served on his local CAC, but he also was a member of a
national committee
impaneled by the American Medical Association, called the Relative Value
Scale Update
(known as RUC), which advises CMS on increases to Medicare payments. In
his case,
the RUC he served on in 1997 had a real impact, says Morris, resulting
in an increase
in physical payment for office visits.
For six years, Gerald Rogan, MD, was the medical director for National
Heritage Insurance
Company (NHIC), California's carrier, which encompassed 2.5 million
beneficiaries, the largest
region in the nation. While in that position, which he held until July
2003, Rogan stressed
to physicians that, "Medicare coverage decisions at the local level are
interactive.
Doctors have a voice."
Off-label use of drugs, uses of new tests such as sleep studies, and
policies that govern
when established tests are reasonable and necessary, such as MRIs for
low back pain,
are examples of issues about which carriers might issue local coverage
decisions,
says Rogan, who was in private practice for 25 years before he joined
NHIC.
All of these may be of interest to physicians, who Rogan encourages to
join their
carrier's CAC.
CMS'
authority limited
One of Medicare's top
physicians agrees that providers can take steps to be better
informed.
Since he was named director of CMS' Physicians' Regulatory Issues Team
in October of 2002,
William Rogers, MD, has traversed the country meeting with providers.
The emergency medicine
physician senses that while most understand the channels to
communicate
with their carriers
and receive information, he's been surprised by how
many have basic
misconceptions about
coverage and payment decisions.
"When I talk to doctors, the deficiencies I see in their understanding
of the Medicare program
mostly have to do with coverage and payment," two big issues, he
acknowledges.
He says many assume the CMS decides what it will pay for — and how much;
neither is true.
The agency is permitted to pay only for services or items that meet the
definition contained
in the original Medicare legislation, namely those that are "reasonable
and necessary for the
diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member."
In addition, payment is possible for services that fall into benefit
categories that have
been added
by Congress; screening procedures were generally not covered until
recently,
for example.
"Physicians didn't understand why we couldn't pay for screening. Doctors
always think it's that
the Medicare officials are too dumb to care about this" type of care,
when they were powerless
to cover it, Rogers says.
"The other thing they don't understand is that for doctors' payments,
Congress created
RBRVS
(Resource-Based Relative Value Scale)," he adds. "Every year [CMS has]
a
pool of money
to pay Part B, and we have to allocate that pool between X-ray, lab,
and
physicians,
and the amount we pay is based on the RUC." For information and
assistance,
Rogers recommends that physicians start with their carrier's Web site.
Like Morris,
he encourages physicians to contact their carrier's medical director,
and to use all avenues
open to make their concerns heard, even beyond the carrier level.
"If a physician felt a local coverage decision was inappropriate or
wasn't able to change it,
that doctor should ask CMS for a national coverage decision," Rogers
says. "Anybody can
request a national coverage decision. You can force the whole agency to
respond to you
just by writing a one-page letter."
Practicing physicians might disagree about exactly how responsive
Medicare is, but it's
worth knowing that national review is an option.
HIPAA
complications
Six billing staff,
including two coders, support the eight-physician Women's clinic
in Boise, Idaho, and like Columbus' office, they take steps to keep
up-to-date
on the carrier's policies and procedures, says Cathy Treadway, clinic
administrator.
The office handles 2,900 patient visits per month, filing close to 4,000
claims per month
to an amazing 1,300 different payers, including Medicare. While Medicare
billings make
up less than 10 percent of the practice's total, they nonetheless want
to be able to collect
all they are owed.
"[The coders] are very involved in the Idaho Medical Association, which
has done a good
job of sponsoring 10 to 12 audio conferences a year," Treadway says. "On
top of that we
really encourage continuing education. We use publications to help [such
as those sold
by Medicode] and we get an e-mail newsletter [from the local Medicare
carrier]
that comes once a month. There is a local coders group that they go to
monthly.
The combination of readings and seminars keep them in tune with what's
going on."
Treadway herself has testified before Congress about compliance with the
Health Insurance Portability and Accountability Act (HIPAA).
And her staff's efforts had been paying off. The office was getting
"clean" claims
(submitted electronically) paid in 10 days.
More recently, that success has been hindered by HIPAA. She's had to
work
through a clearinghouse — at an additional per-claim fee — to be able to
send
the new claims format electronically, even to Medicare. The office's
practice management
software vendor was not able to upgrade its systems to continue direct
billing to
Women's clinic payers.
"We are seeing more rejections; each [payer] has a little different
interpretation of what
is required. It is a constant battle. We've had some really rough months
of collection,"
says Treadway.
For dealing with large Medicare issues like HIPAA compliance, Morris
suggests
contacting the Washington, D.C., office of a medical society; most
associations maintain
some presence in the capital so they can lobby for changes. "Find out
who's involved in
advocacy with CMS and Congress," he advises. "That's another avenue for
being involved
in the process." Don't be shy about asking for help or even offering to
testify before
Congress
or meet with federal officials as Treadway did, he adds.
Theresa Defino is a freelance medical writer with 15 years'
experience covering b
economic,
legislative, and clinical aspects of healthcare issues. She has written
for WebMD
and edited such publications as Managed Care Week, Medicare
and
Managed Care Strategies, and Practical Guidance on HIPAA and
E-Health for the Physician Practice.
She can be reached at
editor@physicianspractice.com.
This article originally
appeared in the May 2004 issue of Physicians Practice.
More Articles About Gulf Coast Pain Management
Dr.
Lynne Carr Columbus, D.O.
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