Billing and Reimbursement

Early Career Practitioners

Association of Surgical Assistants

Orlando 2014

Luis F. Aragon

Washington

OregonIdaho

California

Nevada Utah

Arizona New Mexico

Colorado

Wyoming

Montana

North Dakota

South Dakota

Nebraska

Kansas

Oklahoma

Texas

Arkansas

Louis

iana

Missouri

Iowa

Wisconsin

Michigan

Illinois

India

na

Ohio

Pennsylvania

New York

Ve

rmo

nt

Minnesota

New

Ham

psh

ire

Maine

Kentucky

WestVirginia

Virginia

North CarolinaTennessee

SouthCarolina

Georgia

Ala

bam

a

Mis

sis

sip

pi

Florida

Massachusetts

Con

ne

cticu

t

Rhode Island

New

Je

rse

y

Maryland

D.C.Delaware

State oversight for CSFA, CSA, SA-C

Legislation for RNFAs

States with restrictions for CSFA, CSA, SA-C

Next session ?

Luis F. Aragon

Determining success

Surgeon preference

Volume

Specialty

Payer mix

Hospital relationship (Stipend)

Personality (Risk aversion)

State and legislature

Luis F. Aragon

Surgical assisting is 80% attitude and personality;

10% skills and 10% knowledge.

- L. Aragon

Luis F. Aragon

A National Provider Identifier or NPI is a unique

10-digit identification number issued to health care

providers in the United States by the Centers for

Medicare and Medicaid Services (CMS).

NPI

https://nppes.cms.hhs.gov/NPPES/Welcome.do

Taxonomy code

A unique ten character alphanumeric code that

enables providers to identify their specialty at

the claim level.

Designed to categorize the type, classification,

and/or specialization of health care providers.

Administered by the National Uniform Claim

Committee which is chaired by the AMA with a

critical partnership with CMS.

Luis F. Aragon

Luis F. Aragon

http://www.nucc.org/index.php?option=com_content&view=article&id=97&catid=18&Itemid=128

Luis F. Aragon

Luis F. Aragon

http://www.nucc.org/index.php?option=com_content&view=article&id=98&catid=18&Itemid=128

Luis F. Aragon

Third Party Billing

Luis F. Aragon

In Network or Out of Network?

Out Of Network Potential for higher reimbursement

Delayed Payment

UCR uncertain

Requires continued, extensive

training and education. Reputation

can be damaged after a procedure

the patient receives what they might

think is an enormous bill, but it could

simply be the Explanation of Benefits

(EOB). Patients must be educated so

that they understand what the EOB is

and the process and responsibilities

associated with payment.

Assignment of Benefits

In Network Reimbursement is lower

Rates are negotiated upfront

Payment is usually prompt

Billing patients for their responsibility

is mandatory and does not have the

flexibility that being OON has in terms

to the issue.

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Out of Network

It refers to a provider that does not have a contract

with an insurance carrier.

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Life Cycle of an Insurance Claim

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Clean Claim

Luis F. Aragon

Luis F. Aragon

In House billing

Learning curve

Software

Time consuming

Not recommended for small practices

Outsourced billing

Familiarity with the industry

Trust

Not recommended for large practices

Hybrid / Leased options

Self-starters

Time available

Willingness to learn the process

Billing options

Luis F. Aragon

Practice Management Solution Specifically

Designed for Surgical Assistants

Store, track, and electronically transmit credentials to

facilities

Schedule cases and sync all schedules to any mobile

device

Improve coding and billing workflow with custom charts

and templates that keep communication consistent

Electronically submit all insurance claims to payers with

real time feedback and a powerful appeals system

Customized reporting to help practices grow

Choosing a billing company

Familiarity with the industry

Time doing business

Better Business Bureau rating

American Medical Billing Association

American Association of Professional Coders

Professional Association of Healthcare Coding

Specialists

Request a Business Associate Agreement (BAA)

Request references from current clients and trade

organizations

Luis F. Aragon

Luis F. Aragon

Any entity that handles protected health information (PHI) needs to be

HIPAA compliant.

Covered Entities and their Business Associates need to protect the

privacy and security of protected health information (PHI).

There are 4 rules that you will need to dissect. HIPAA Privacy Rule

HIPAA Security Rule

HIPAA Enforcement Rule

HIPAA Breach Notification Rule

http://www.ihs.gov/hipaa/documents/ihs_hipaa_security_checklist.pdf

Secure texting

http://www.spok.com/solutions/mobile_communications/hipaa-compliant_texting

HIPAA Compliance

Luis F. Aragon

http://www.ama-assn.org/ama/pub/advocacy/topics/administrative-simplification-initiatives/national-health-insurer-report-card/denials.page

Claims denials

Luis F. Aragon

In the first quarter of 2013, 32.5% of persons under age

65 with private health insurance were enrolled in high

deductible health plans.

The average per-person deductible increased 117%

between 2003 and 2011 (from $518 to $1,123) and that

the average family deductible increased by 106%

during the same time period.

72 percent of practices anticipate declining to negative

profitability in 2014 due to diminishing reimbursements

and underutilized or inefficient billing and records

technology.

71 percent of practices are considering a combination

of new software and outsourcing services to improve

their RCM systems

Important facts to know

Source: 2013 Black Book Practice Management –Revenue Cycle Management EHR Software Top Vendors Report

Obamacare’s Failing Cost Control (10/14/2014)http://online.wsj.com/articles/obamacares-failing-cost-control-1413758684

An accountable care organization (ACO) is a healthcare organization characterized by a payment and care delivery

model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned

population of patients.

http://online.wsj.com/news/articles/SB10001424052970204720204577128901714576054

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Insurance Exchanges

Luis F. Aragon

Routine waiver of deductibles and co-insurance

American Medical Association

Opinion 6.12 - Forgiveness or Waiver of Insurance Copaymentshttp://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion612.page?

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

HIPAA Section 242 (Public Law 104-191 104th Congress) Title II, Subtitle Ehttp://aspe.hhs.gov/admnsimp/pl104191.htm

Office of the Inspector Generalhttp://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html

http://oig.hhs.gov/fraud/docs/safeharborregulations/072991.htm

http://oig.hhs.gov/testimony/docs/2004/40624oig.pdf

Luis F. Aragon

Luis F. Aragon

Card Choice

Authorize.net

Luis F. Aragon

QUESTIONS?