Today's insurance carriers — Medicare, Medicaid and others — are making it increasingly difficult for health care suppliers to get paid for their services. No matter what service or equipment is supplied, payers are limiting the amount of reimbursement or making it more challenging to get reimbursed at all. And when you do get paid, you never know if Medicare will later decide to recoup the money during a post-payment audit. Knowing that the Medicare Modernization Act will continue to create allowable reductions makes the pressure even more intense.
The situation is frustrating to be sure, but there are some things you can do to counteract the rigorous requirements that continue to pester the industry.
More for Less
From order intake to accounts receivable, it is clear you will need to learn to do more for less. What does this mean? Invariably, you will have to expect more of your staff as Medicare requirements become more demanding. For example, when Medicare requires proof that your diabetic patient has actually been testing, will you have access to that documentation? Or will you take the chance that the DMERC may not actually ask for this backup proof?
Are you corresponding with your sleep therapy patients to determine if they are using their CPAPs (continuous positive airway pressure devices) between days 61 and 90 of the rental period? Is this documented for proof during an audit? In this strict reimbursement environment, contact your rental patients at regular intervals to establish whether they are still using the equipment. It is your responsibility, according to Medicare, to ensure that the patient is actually using and has a clinical need for your equipment.
In an effort to hone in on costs, consider using an intern to make your calls. There are also companies that make these compliance calls by computer. Ironically, for customers who don't mind computer-generated calls, this tactic works well because it cuts down on costs and can generate additional revenue in accessory/add-on sales.
Minimizing expenditures while achieving outcomes can be accomplished if you explore alternative ways of handling mundane tasks.
For example, do you employ a quality control staff/employee to review your intake documents before releasing claims? If so, how many control checks do you require internally? More than ever, in an effort to submit clean claims, HME providers are adding quality control checks to review their already-reviewed documentation. This becomes superfluous if you have too many checks and too many hands touching the work.
Consider creating a control check before confirming the order, and perhaps a pre-billing edit check before submitting the claim. Other than that, at some point you have to trust your gut and release the claim. If there is a way to automate this function, do so. An edit or checklist that prints when information is missing may eliminate the need to employ staff for this function.
Having employees do like things together usually speeds up the process. Try a variety of methods to determine which way works best for you. Some companies are now using quality control staff as intake assistants. Instead of verifying insurance and ensuring that all the information is correct in the system, they are actually tying up loose ends after customer service completes the initial order. This pre-empts the need for the billers to do follow-up work on incomplete orders.
Realign Staff
Now is the time to focus on one of your biggest expenditures: wages and benefits. Contributing to the bottom line, both positively and negatively, staffing can make or break your company. Sometimes, middle management/supervisors are too weak to coach the staff. Other times, the staff is too weak to be coached. And in some cases, both are actually the main issue.
The cliché “You get what you pay for” may be relevant. Or, you can pay someone top dollar and still not get them to perform. It depends upon senior management and how they approach leadership, but holding people accountable for their performance is something that most HME providers don't do.
In order to get the most out of your staff, set goals and make them achievable so employees feel like they can be accomplished. Engage your staff in establishing the goals. If they are part of the goal-setting process, they are more likely to want to succeed.
If your employees are not functioning well as a whole or in part, you may decide to re-interview to determine whether staff members are in the right positions. There are several companies that help profile employees to see if they fit your mold. The expense is minimal, and potential to find a good employee is maximized.
Automate
In many HME companies, staff does not rely on software because they do not trust it; they feel as though the software doesn't really work for them. Although this may be true at times, it is also true that users often input corrupt data or do not fully understand the capabilities of their systems.
Try keeping a list of software issues, and call your vendor periodically to discuss them. If your staff doesn't know how to articulate the problem, help them present the issue in a way that the software vendor will comprehend. Either way, attempt to rely more on your computer system to give you what you would otherwise be doing manually.
Medical necessity documentation — the certificate of medical necessity, for example — should not only be generated from the computer but the software also should be able to track the documentation until it is signed and dated by the doctor. Many HMEs avoid using their software to handle this process because they feel it is easier to track manually. For the most part, this is untrue. The system should be able to track CMNs that are outstanding. Remember that the less manual work you do, the more time you have to retrieve the CMNs and reduce your days outstanding.
Another way to automate is to have your sales and marketing team (or respiratory therapists) take orders directly into a hand-held device, such as a BlackBerry. This will enable the intake staff to receive orders in a more timely way, allocate the workload more evenly, avoid loss and keep management abreast of orders that filter in to the company.
Another way to use automation in the operational process involves automated patient receivables management. As insurance companies continue to reduce their coverage percentages, patients are required to accept more of the fiscal burden. Currently, for instance, many insurance companies pay only 60 to 70 percent of the usual and customary charges rather than the 80 or 90 percent they used to pay a few years ago. This means that patients must pay the remaining 30 to 40 percent, or almost half, of the outstanding balance.
To get your money up front like the doctors do, investigate the use of an automated debiting system that allows patients to have the payment made directly from their bank. Of course this requires the patient's permission, but their portion of the bill can then be paid automatically each month (or week, if you prefer).
Such a system would work most effectively for rental patients (or large purchases that are paid over time), but it means that you could reduce the number of private-pay billing and collections staff. Having your money up front also will minimize the hassle for your patient. Neither you nor he will need to send or receive the invoice/statement or affix a stamp because no bills will actually be generated. The cost can be as nominal as $1.50 per transaction and should be a win-win situation for those who sign up.
Weigh Options
As we all know, changes to the HME industry are staggering and costly. The more you do to protect your interests, the more Medicare does to create additional paperwork. Although they make it taxing, you must stay ahead of the game and look for ways to ensure payment at minimal cost. This means that you should look for ways to do more work for less money by creating efficiencies inside your operation.
While I always advocate following Medicare protocol, I also believe that at a certain point you must let your claims go and relinquish them to the hands of the DMERC for payment. Generally speaking, to check a claim multiple times before submission means that you will likely lose your profit.
Further, as you employ staff, make sure you hire the best person for the position. Realign staff as necessary; don't simply add people to problems. Hold people accountable, and make the most of your employees. Finally, automate as much as possible. Don't assume your software can't do something. Ask your vendor how it might meet your needs, not if it can.
Finally, maintain perspective. Inevitably, some of your claims will be denied. Never compromise your integrity by deviating from the law or regulations. Strike a balance, think outside the box and continue to look for ways to improve in this often puzzling and mysterious atmosphere of HME under the MMA.
Miriam Lieber is president of Lieber Consulting, Sherman Oaks, Calif., specializing in operations management and reimbursement for the HME industry. She can be reached at 818/789-0670 or by e-mail at miriam@lieberconsulting.com.
