Practice Tips

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Important Practice Information and forms

• Overtime Pay Requirements

Q&A

Your Practice Questions Answered!

Q:  Our office has been submitting Medicare claims containing both the NPI and legacy identifiers, and these claims have been paid. What is our next step? Are there any upcoming implementation dates we should be made aware of?

A.  Once your claims with both the NPI and legacy identifier have been paid, Medicare urges you to send a small batch of claims with only the NPI. If the results are positive, begin increasing the number of claims in each batch.

May 23, 2008, is a critical upcoming NPI date. As of May 23, only the NPI will be accepted on all HIPAA electronic transactions and paper claims.  Reporting a legacy identifier will result in the rejection of the transaction. 

If you are still including legacy identifiers on Medicare claims, in anticipation of the May 23 deadline, you should begin testing claims with ONLY the NPI in the primary provider field immediately to ensure that your office continues to be properly paid.

Q:  Our office recently received a request for copies of a patient’s records. I know we are required to make copies, but what are we allowed to charge? 

A:  According to Michigan law, if a patient or authorized representative makes a request for a copy of all or part of his or her medical records, the health care provider to which the request is directed may charge the patient a fee that is not more than the following amounts:

• An initial fee of $20 per request for a copy of the record

• Paper copies as follows:

  • One dollar ($1) per page for the first 20 pages

  • Fifty cents per page for pages 21 through 50

  • Twenty cents for pages 51 and over

• If the medical record is in some form or medium other than paper (for example, X-Rays), the actual cost of preparing a duplicate

• Any postage or shipping costs incurred by the health care provider in providing the copies

• Any actual costs incurred by the health care provider in retrieving medical records that are seven years old or older and not maintained or accessible on-site

The law further states that a health care provider may refuse to retrieve or copy all or part of a medical record until the applicable fee is paid. However, it further states that a health care provider must waive these fees for an indigent individual. The provider may, however, require the patient or authorized representative to provide proof that the patient is indigent. An indigent patient is entitled to one set of copies per health care provider. Any additional requests for the same records from the same health care provider are subject to the fees outlined above.

Special Note: Physician offices may not hold copies of medical records “ransom” for nonpayment of bills. If a patient requests copies of his or her records, physicians must comply, regardless of whether or not the patient owes the physician for services rendered.

Q:  I understand that Medicare has released its fee schedule for 2008, reflecting a congressional fix that prevented a huge decrease. But, I have heard that this fix is only good through the end of June. Is this true? What can we do to ensure Congress makes this fix apply for the entire year?

A:  It is true that at the end of the 2007 Congressional session, the U.S. House and Senate acted to suspend the 10 percent Medicare physician fee cut scheduled to go into effect on January 1, but only for six months. The 10 percent cut will go into effect on July 1, 2008, unless Congress again acts to postpone the mandatory fee reduction.

Under Medicare’s Sustainable Growth Rate (SGR) formula, cuts in physician payments are mandated whenever growth in these expenditures exceeds growth in Gross Domestic Product. In addition to the temporarily postponed 2008 cut, another 5 percent cut is scheduled for January 1, 2009. In previous years, as happened in 2007, Congress stepped in at the last minute to postpone the cuts.

The ACA and ICA are both working hard on the national level to ensure that these cuts do not take effect. You, too, can make a difference by contacting Senators Levin and Stabenow and your U.S. Representative and asking them to:

1. Look critically at Medicare physician reimbursement and work for a policy solution to address the current approach, which is highly problematic.

2. Be sure that any such policy solution takes into consideration the status of all providers in the healthcare community, including non-MD practitioners.

To contact these lawmakers, go to the ACA Legislative Action Center on the ACA website (www.acatoday.org). The site contains a form letter explaining the situation.

Q:  My office manager is expecting her first child in a few months. Yesterday she informed me that she is thinking of exercising her rights under the Family and Medical Leave Act. She is a valuable employee, and I’m happy for her, but with a small practice (myself and two employees) I don’t know what this means and if I can afford it. What are my obligations under this law?

A:  Congratulations to your CA! Raising children may be one of the most important accomplishments in life. Your CA sounds like she wants to spend the first few critical months concentrating on being a good parent. However, the Family and Medical Leave Act (FMLA) will not apply in this situation.

FMLA is a federal act that provides eligible employees of covered employers the right to take up to 12 work-weeks of unpaid leave in a 12-month period for the birth of a child, for placement of a child for adoption or foster care, to care for a close family member (spouse, parent, son, or daughter) with a serious health condition, or when the employee’s own serious health condition makes the employee unable to perform his or her job. A “covered employer” is defined as a private employer with 50 or more employees or any public employers. As you do not have 50 employees, FMLA does not apply, and your CA does not have any rights under this act.

I would suggest that you sit down with your CA and try to work out an arrangement with her. You mentioned that she was a valuable employee, and given the problems with finding good employees and the cost of training new staff, I’m sure you will want to work out an arrangement that is good for both of you. Best of luck to you and your CA!

Q:  Last year my insurance biller resigned. By the time I hired a new assistant, taught them the job, and asked them to begin to catch up on my billing backlog, several months had passed. Recently, I received a rejection form an auto no-fault insurer, stating that they will not pay because it is over one year from the date of service. The real kicker is that the insurance company had been sitting on my bill for months. The auto insurer says the law is on their side. What kind of nonsense is this?

A:  Unfortunately, as a result of several recent Michigan Supreme Court rulings, the insurer is right. Following are three one-year statutes of limitations all providers need to be familiar with:

• A person injured in an auto-related accident has one year after the accident to make a claim to the responsible auto insurer (MCL 500.3145). The Supreme Court has ruled that there are no exceptions to this rule, and even overturned a long-standing ruling that allowed for certain exceptions, such as under age children and mentally incompetent people.
• A health care provider must bill for a covered service within one-year from the time the service was incurred. The question of when an expense is incurred, when the service is provided, or when the bill is sent, is currently before the court. So, a safe way to proceed is to make sure you bill within one year of providing the service.
• If a person injured in an auto-related accident, or a health care provider, finds it necessary to bring legal action against an auto insurer, the legal action must be commenced at any time within one year after the most recent allowable expense…has been incurred. Any legal action undertaken can only include claims that go back one year.

Q:  I have a few different questions for you.

1. I recently attended the Advanced Decompression Therapy seminar sponsored by the MAC and need some advice on the most appropriate ways to get paid by insurance companies for this service. Can you help?

2. Our office also has a new water massage/traction therapy table. Can we bill it out as mechanical traction?

3. Do we automatically accept assignment when we send a claim or is there a formal agreement that needs to be signed? I am trying to get a clearer understanding of when we can bill the patient for the portion of the services that the insurance company does not cover.

A:  According to the ACA, the best code for spinal decompression is 97012 (Mechanical Traction). However, there is a temporary level II HCPCS procedure code that you can use: S9090 (Vertebral Axial Decompression, Per Session (Dr. Randy Reed, who taught the recent seminar on decompression uses this code.). Most payers will reject this code as not payable or experimental, which allows you to bill the patient at the rate your office sets.

Unless this water table is different from any I have seen in the past, it does not meet the definition of traction. Nor does it meet the definition of massage, since massage consists of provider-patient contact. The ACA (which participates in the committees that define and value CPT codes) believes that the proper code is 97799 (Unlisted Physical Medicine/Rehabilitation Service or Procedure). Unfortunately, this code is often rejected, meaning that the patient must pay out-of-pocket.

Generally speaking, to hold you to a fee schedule, a company must have you under contract. Some entities, such as PPOM, will sign you up as part of their network and then “sell” you to different carriers. Through your PPOM contract you must accept this new carrier’s fee schedule. There are several exceptions to this – BCBSM, Medicare, and Workers’ Compensation.

Michigan law governing Blue Cross includes a provision that basically states that if a provider accepts assignment, they are participating with BCBSM for that year (though they will still be out-of-network). As such, the provider is held to the BCBSM fee schedule. Medicare and Workers’ Comp have fee schedules set by law and you cannot collect more than their fee schedules.