DEVELOPING CRITICAL THINKING SKILLS: ANALYZING PROBLEMS AND MAKING DECISIONS

Chapter 14


DEVELOPING CRITICAL THINKING SKILLS: ANALYZING PROBLEMS AND MAKING DECISIONS



Objectives


After completing this chapter, you should be able to:


image List at least three examples of payor contract provisions that influence scheduling, billing, or collections


image Discuss potential situations and make decisions concerning confidentiality and patient rights


image Discuss potential situations and make decisions concerning payor collections


image Discuss potential situations and make decisions concerning patient collections


image Discuss potential situations and make decisions concerning provider compliance with laws


image Discuss legal responsibilities related to each issue



Key Terms



collections agency


an outside resource option to collect delinquent payments from patients.


comment period


the time during which everyone may review proposed rules and requirements developed by the Secretary of Health and Human Services to meet a specific law. Anyone may submit comments and suggestions during this time.


compliance deadline


the date when a “final rule” developed by the Secretary of Health and Human Services to meet a specific law becomes mandatory and is strictly enforced.


conversion number


the dollar value assigned to each RVU (relative value unit) to find the allowed fee in an RBRVS (resource-based relative value system) fee schedule.


curriculum vitae


an expansive résumé that documents credentials, education, work history, and specific accomplishments, such as research projects, speaking engagements, and published works.


delinquent payment or account


a payment or account that is overdue.


False Claims Act


a law that makes it illegal to submit a false or an inaccurate claim to the government for payment. This law covers all types of government payments, not just medical claims.


final rule


the official release of new rules or standards developed by the Secretary of Health and Human Services to meet a specific law. Once a final rule is officially released, you may begin using the rule. After an implementation period, a compliance deadline is established.


gag clause


prohibits a physician from discussing with a patient the treatment options the payor does not cover, such as experimental treatments or treatments that are expensive, even when one of these treatments represents the best course of action for the patient.


proposed standard


the first draft of new rules or standards developed by the Secretary of Health and Human Services to meet a specific law. After a public comment period, a final rule is developed.


Qui Tam


a provision of the False Claims Act designed to allow ordinary citizens to report violations without repercussions.


relator


the person who reports a violation under the False Claims Act. A whistleblower.


Stark laws


laws that regulate many activities relating to consultations and referrals. They prevent physicians and other providers from profiting from the consultations and referrals they give out. They are often called the anti-kickback laws.


whistleblower


a relator in a Qui Tam action; the person who reports a violation of the False Claims Act.



Introduction


In Chapters 1 through 13, you learned about medical plans, how to work together as a team to gather claim information, how to complete and file claim forms, and how to achieve reimbursement success. However, in the real world things are not always textbook perfect. Laws change and new rules are implemented nearly every year. Even when everything is done correctly, unexpected problems can and do arise.


In Chapters 1 through 13, you learned about medical plans, how to work together as a team to gather claim information, how to complete and file claim forms, and how to achieve reimbursement success. However, in the real world things are not always textbook perfect. Laws change and new rules are implemented nearly every year. Even when everything is done correctly, unexpected problems can and do arise.


When you know the fundamentals about how medical insurance and reimbursement function and you know what changes to look for in the future, you are better equipped to resolve medical insurance and reimbursement problems encountered in a working medical practice.


Each of the topics discussed in this chapter has been either introduced or discussed in detail in another chapter. The purpose of this chapter is to give you a sample of what can go wrong and why. Many of the topics are explained in more detail in this chapter because your knowledge level is greater now than it was when the topic was first introduced. When you finish this chapter, you will be able to analyze some of the most common problems encountered in medical practices and make appropriate decisions.



Health Insurance Portability and Accountability Act of


The Health Insurance Portability and Accountability Act of 1996 (HIPAA) set many deadlines for the gradual introduction and implementation of certain requirements of the law. These HIPAA requirements influence how medical entities (physician offices, hospitals, medical plans, claim clearinghouses, etc.) conduct business.


The Health Insurance Portability and Accountability Act of 1996 (HIPAA) set many deadlines for the gradual introduction and implementation of certain requirements of the law. These HIPAA requirements influence how medical entities (physician offices, hospitals, medical plans, claim clearinghouses, etc.) conduct business.


The Secretary of the Department of Health and Human Services was given the responsibility of proposing standards, each of which has specific rules, to meet the requirements of the “Administrative Simplification” section of HIPAA. Proposed standards are subject to change before the final rule is published. When a standard is first proposed, there is a specified comment period during which everyone nationwide may review the standard and its rules and submit opinions and suggestions. After the comment period is closed, the opinions and suggestions are evaluated and a final rule is developed.


Once a final rule is published, you may begin using the standard. By the compliance deadline, you are required to use the standard. The compliance deadline also is subject to change. The period between the date the final rule is published and the date that compliance becomes mandatory is commonly called the implementation phase. You are expected to learn how to use the standard during this time. When a final rule is very complex, providers are given a longer period to learn to use the standard.


Final HIPAA standards are expected to follow the compliance schedule that appears in Table 14-1. The compliance dates are estimates, as published on the official government websites for HIPAA.



The standard for “Transactions and Code Sets” is intended to provide one set of codebooks and one set of rules that every payor and every medical provider will be required to follow. This standard was developed to ease the burden that physicians and hospitals faced of trying to meet hundreds of different sets of rules, since every payor wrote its own rules to augment or replace national rules. It also is intended to make the electronic transmission of claims easier by standardizing the claim transmission format. Currently, clearinghouses are needed to translate claims into the hundreds of electronic formats created by payors.


The “National Provider Identifier” (NPI) standard is intended to replace the collection of ID numbers given to each physician with one number per physician that is valid nationwide and that is recognized by all payors. Historically each payor issued ID numbers, and some issued different ID numbers for use with referrals or when rendering care, with a different set of ID numbers for each physician in each office location.


The “National Employer Identifier” standard is intended to replace the collection of ID numbers given to each facility, each incorporated solo physician, and each group practice with one ID number that is valid nationwide and is recognized by all payors. The employer identification number (EIN) used for tax purposes has now been named as the national employer identifier.


The “Security” standard is intended to close loopholes in laws by defining what security measures must be taken to prevent illegal access to medical information that is stored on a computer or that is transmitted electronically. It also defines punishment when unauthorized persons gain illegal access.


The “Privacy” standard is intended to revise the rules governing who may gain access to an individual’s medical records and revise the steps that are required before access is granted. The rule makes it easier for payors to obtain records needed to make payment decisions. It also makes it easier for patients to acquire copies of their medical records and enables patients to learn who has received copies of their medical records. The privacy law adds several new record-keeping requirements for all medical entities.


Some standards are still in development. When they are officially proposed, a comment period is announced. You should begin to learn the requirements when the standard is first proposed, but you will not begin to use them until a final rule is published. Every comment submitted during the comment period is taken into consideration as the final rule is drafted. The final rule usually has modifications and is not identical to the proposed rule. All the dates are estimates and are subject to change. By the compliance date, the new standard becomes mandatory.


When you begin using a standard at the time that the final rule is first published, you can become proficient by the date of mandatory compliance. Those who wait until the standard is mandatory before they begin implementation risk penalties and sanctions as they learn the rules.


HIPAA standards that are still in development are expected to follow the schedule in Table 14-2. Sometimes it takes longer than expected to write a final rule. The final rule usually has modifications and is not identical to the proposed standard.



The “National Health Plan Identifier” standard is expected to make it easier for physicians and hospitals to identify payors and send claims to the correct payor address the first time.


The “Claims Attachments” standard is expected to provide a standardized secure method for attaching medical records, operative reports, diagnostic imaging, etc., to claims that are transmitted electronically.


As the various deadlines for implementing each phase of HIPAA draw near, you must be ready to help your practice meet the new requirements. It is essential for you to join professional organizations to keep abreast of these changes as they occur. Medical assistants, medical billers, medical coders, medical records specialists, medical office managers, medical compliance officers, and medical financial officers each have professional organizations. Each organization takes steps to keep members informed of important laws and how they apply to you personally as well as professionally. Many of these organizations are listed by name in Chapter 2.


If you have time to do the research yourself, most of this information is available on the Internet. The CMS website (http://cms.hhs.gov) and the website for the Department of Health and Human Services (http://www.hhs.gov) are good places to begin when searching for items about HIPAA and the status of proposed “Administrative Simplification” standards.



MEDICAL OFFICE CONFIDENTIALITY REQUIREMENTS


The privacy and security of patient information are closely intertwined. However, HIPAA treats privacy and security as separate issues. The final rule for the Health Information Security Act, proposed in August 1998, was released in May 2003. It redefines the way in which medical offices must handle the security of individually identifiable patient information if any information for that patient is ever placed in a computer or transmitted electronically. The proposed electronic security rules also govern hard copies of electronic documents and hard copies of other documents for every patient who has electronic documents on file. The compliance date is an estimate released by the government and may be subject to change.


Since October 16, 2003, Medicare has required claims to be sent electronically. There are a few exceptions for companies that truly are unable to send electronic claims, but you must complete an application to be granted an exception and you must have a compelling reason to get approval to send paper claims.


If your medical office uses a computer or if any patient information is ever entered in a computer, including when your billing company uses a computer to send claims, security within the physician’s office must prevent a patient or a visitor from seeing any individually identifiable patient information. Individually identifiable information is a concept borrowed from the Privacy Act and is discussed in more detail there. Many offices use a divider or a screen to prevent unauthorized people from viewing computer monitors or viewing hard copies of documents currently in use by employees.


The Security Act also requires each medical entity to take reasonable measures to prevent an unauthorized person from accessing patient information using the Internet. If your office has Internet access, you can meet this requirement by purchasing and installing a good quality computer program called a firewall. A firewall prevents unauthorized access to your system when you are online. A person skilled in using computers to steal information, commonly called a hacker, might be able to get around even the best firewall. However, having a firewall is considered a reasonable measure to meet the law because the average person online cannot gain access and the average computer hacker is not skilled enough to get around a good quality firewall.


If your practice does not own a computer and all patient documents, including billing documents, are completed without the use of a computer or a word processing typewriter that uses a computer chip, the proposed Health Information Security Act does not apply to your practice.


The final rule for the privacy standard, first proposed in October 1998, was released February 20, 2003. The final rule took many people by surprise because the scope was greatly expanded from the proposed rule.


Key provisions of the final rule for the privacy standard are:



image Access: People are given the right to see and copy their own medical records. Some states did not grant people this right of access, even when the patient paid the entire bill for the medical care. The only exception is for mental health. In mental health, the provider (a psychiatrist or a psychologist) may refuse to give a patient access to his or her own record if the provider determines that doing so could be detrimental to the patient.


image Privacy: The proposed rules pertained only to records stored on a computer, but the final rule pertains to all patient information, including that stored on a computer, all forms of hard-copy records, and spoken information. The inclusion of spoken information was the biggest surprise in the final rule, and spoken information is the most difficult to control. You must make a reasonable effort to avoid eavesdropping. Lower your voice and face a corner when speaking on the telephone. Do not discuss patients in public parts of your office or facility, such as elevators, hallways, and waiting rooms. Keep a partition (usually Plexiglas) between the waiting room and the receptionist.


Originally, the Privacy Act would have made patient sign-in sheets illegal, and you would not have been able to call a patient by name when you were ready for them. However, a clarification was issued 2 months after the final rule was published. The clarification clearly allows for a sign-in sheet and allows patients to be called by name.


In addition, in the final rule, business associates who require access to patient information must sign a “business associates agreement” in which they also agree to keep patient information confidential. When such an agreement is in place, the business associate can be held accountable for any breaches he or she creates.




Note, however, that under this standard, whoever pays for medical care may see the medical record entries related to the care paid for without first obtaining consent from the patient. This not only includes payors, it also includes banks and credit card companies. The only exception to this disclosure with or without consent when related to paying for medical care is psychotherapy notes. Then the patient must sign a specific consent for each individual entry that is disclosed.


In addition, patients may now ask to see a list of each disclosure of individually identifiable patient information from his or her records, including but not limited to who received information, what information was sent, and the date it was sent. This has greatly increased the record-keeping burden for the medical office. Please see Appendix D for more information about the provisions for disclosure.




image Patient rights: Under this rule, all businesses, not just medical businesses, must inform people of their business policies for handling individually identifiable information, and the person’s rights regarding that information. Each business must disclose who they share information with on either a routine or occasional basis, and they must give people the option of being excluded when this information is shared. Individually identifiable information is clearly spelled out in the privacy act. It includes demographics, such as name, address, phone number, birth date, and medical record number, as well as any information that would cause someone to identify a specific individual. The final rule included the example of a small town where only one or two hip surgeries might be performed on a given day or even in a given week or month. If you then refer to just the procedure and the date or time of the procedure (the hip case from Thursday morning), most of the people in the town would be able to identify the exact person who had received the surgery. In that situation, it would be a violation of privacy even though the patient’s name and demographics were not mentioned.


image Research: Under this rule, the patient is not given the right of access to his or her own medical records related to participation in a research project. Nor are they guaranteed access to the results of any research projects they participate in, even if the anticipated results did not occur and, most surprising of all, not even when a high percentage of the participants are dying. There is already controversy about this rule, so watch for changes.


image Penalties: Health care providers, payors, and clearinghouses would be subject to civil and criminal penalties (up to $25,000 per year and 10 years in jail) for violating the law. Yet, HIPAA prevents the Secretary of the Department of Health and Human Services from including a private right of action for individuals to sue for violations of the law.


image Preemption: In the final rule, federal regulations would not preempt or override stronger state laws. Instead, they would set a baseline of minimum protections to which the states could add additional provisions to better protect their citizens. A July 1999 report issued by the Health Privacy Project found that while few states have health privacy laws that protect all medical data, most states have enacted legislation to protect sensitive information, such as information pertaining to mental health, communicable diseases, and genetic testing. Please see Appendix D for more information about protected health information (PHI).


To protect patient confidentiality (both privacy and security), unauthorized people must not be given access to private medical records. Although the physical medical record is the property of the physician, the information in the record belongs to the patient. Therefore a patient must be given access to his or her medical record and may have a copy of his or her medical record, except as noted above, but the physician owns the medical record.



WHO MAY SEE PATIENT RECORDS


Rendering physicians and select employees may see a patient’s medical records on a need-to-know basis. Patient consent is not required in this instance because it falls under the clause pertaining to treatment, payment, and operations (TPO).


Patients may see their own medical records except when a mental health provider denies access to specific mental health records. Parents of minor children and legal guardians may see the applicable medical records. However, spouses do not have the right to see each other’s medical records or to be told individually identifiable medical information without a written consent from the patient.


Use of the patient’s medical record is strictly regulated. It may not be used for any purposes other than those stated in current laws. Under the new privacy standard, when a payor pays a claim for a service, permission from the patient is not required for the payor to gain access to the medical record entry for the service. The exception to this rule is psychotherapy notes. Psychotherapy notes cannot be released to a payor without the patient’s express, limited permission.


If you allow an unauthorized person access to a medical record and the information is misused, you and the person who misused the information may both be held liable for civil and criminal penalties. Under both the privacy and the security standards, the civil penalties are increased up to $25,000 per year and criminal penalties are increased to up to 10 years in prison.



PATIENT PROTECTION LAWS


The patient protection policies and procedures used in your practice must mirror current state and federal laws. You must become familiar with current laws and pending legislation so you can adapt your practice to meet the new laws as they take effect. You are not required to meet pending legislation, but you should be prepared to explain the issues to patients when they ask.


Internet search engines can help you learn about both current and pending legislation. However, it would be wise to consult the medical attorney for your practice to verify current laws before changing office policies based on an Internet search.


Many states have state-specific legislation detailing patient rights and responsibilities. To find out if additional “patient rights” legislation exists in your state, contact the insurance commissioner or the Department of Insurance. If your state has patient rights legislation, ask the insurance commissioner’s office to send you a copy of the rights or see if a copy is available on the Internet. Contact information for the Department of Insurance for each state can be found in Appendix B and can be verified at Medicare’s website: www.medicare.gov.



Payor Contracts


Payor contracts often play a key role in the prevention and resolution of reimbursement problems. Unfortunately, many physicians do not have their contracts professionally reviewed before they sign them, and many do not inform their employees about contract provisions. In addition, sometimes physicians do not make a photocopy of each contract before returning the signed contract to the payor. You cannot effectively meet contract requirements you do not know exist.


Problems arise when contract provisions are not followed. Additional problems arise if the physician did not seek the advice of a medical attorney and/or a medical CPA, and, as a result, unfavorable contract provisions were not identified before the contract was signed.


Most payors will not readily share specific contract provisions when you call to ask about contract requirements. They typically claim it is too difficult because they maintain multiple standard contracts as well as numerous customized contracts with literally thousands of physicians and other providers for each of their hundreds of medical plans. It is interesting that the claim adjustors employed by these same payors can readily find every contract-specific requirement when it is time to impose penalties.


It is critical for medical office employees to have access to the clauses in payor contracts that pertain to scheduling, billing, and collections. Physician substitution coverage is an example of an issue that pertains to all three: scheduling the patient when the attending physician is not available and then billing and collecting the fee when someone else provided the service. When you learn and follow payorspecific contract requirements, many reimbursement problems are prevented.


When you work as a billing manager or an office manager, you are responsible for knowing and meeting contract requirements and for sharing them with other employees on a need-to-know basis. When you work in another position in the medical office, understanding these issues will enhance your ability to meet the responsibilities of your position. In addition, this kind of knowledge can enhance opportunities for advancement.


So the key question is: How do you persuade a physician to share this critical information? When you can demonstrate that you are knowledgeable, that you understand contract confidentiality, and that you understand how and when you may use contract information, you have taken the first step toward winning the confidence of the physician.


Remember, physicians have a high level of education and special medical skills, but they seldom have time to also become experts in business. Physicians generally hire employees to handle business issues for them. Payor contracts and medical reimbursement are among the business functions in the medical office.


You can become one of the people physicians turn to for assistance when they negotiate payor contracts. Begin by learning as much as you can about payor contracts: the purpose, how to use the information, how and when contract information may be shared, and how to help physicians meet payor contract requirements. These topics are introduced in this book, and additional courses are available if you want to learn more than is offered here.



PROVIDER ENROLLMENT, CREDENTIALING, AND CONFIDENTIALITY


As a side effect of the many laws regulating payor contracts, the process of becoming an authorized provider for a medical plan has become much more complex than merely signing a contract.


Each physician must complete a long application form and attach documents to prove current licensure, educational background, clinical background, and areas of expertise. Gathering these documents and compiling the required information is more time consuming than merely updating the physician’s curriculum vitae. A curriculum vitae is an expansive résumé that documents the physician’s credentials, educational history, and work history as well as specific accomplishments, such as research projects, speaking engagements, and published works.


The payor uses this information for credentialing. Credentialing is the process of verifying credentials to establish that a person has not misrepresented accomplishments, that licensure remains current, and that the person has not been excluded from participation in federal medical plans. Even if the physician has already been credentialed by the medical plan and is merely changing practice affiliations (changing partners or opening a solo practice), credentialing can take several months. The physician is not considered an authorized provider until credentialing is complete. Often a payor-specific provider number is issued when credentialing is complete.


In the flurry of application paperwork, it is easy to forget to read the actual contract, especially if the physician has previously been a provider for the medical plan. Physicians often do not realize fees can be negotiated, and many physicians miss the fine print that advises making a copy of the contract. The original contract is returned to the payor with the application paperwork. The payor does not routinely send the physician another copy of the entire contract; often the payor only returns a copy of the signed signature page. Staff members are then informed, “Now we accept Aetna,” or whatever contract was just signed.


Antitrust laws prohibit physicians from discussing their payor contracts and fee schedules with other physicians. The intent of the legislation is to prevent large physician organizations from engaging in price fixing. Antitrust laws do not prohibit physicians from discussing contract provisions and fee schedules with employees. Payor contracts can be shared on a need-to-know basis with anyone who has a legitimate reason to see the information. This includes medical attorneys, medical CPAs, and medical business consultants, as well as practice employees. Some medical offices now require a signed confidentiality agreement from each person or company that will view any portion of any contract(s).


Physicians may overemphasize the confidentiality of payor contracts because they do not fully understand the complexities of the antitrust laws, but often it can be to avoid the problems they need to face when copies of their contracts are not in their files and they cannot argue the fee schedule and other contract provisions. If you suspect this is the situation, use diplomacy to resolve it without embarrassing or upsetting the physician. This is a common issue. Physicians are highly educated professionals. Remember to always treat them with the utmost respect.


One acceptable course of action is to ask the physician for permission to get an updated copy of each contract so you will have current fee schedules to use in the billing and collections department. With the physician’s permission, you may then call provider services at each medical plan and ask for an updated copy of the contract with the current-year fee schedule attached. When it arrives, you may respectfully ask the physician for permission to review the entire contract so you can find and summarize the clauses that pertain to scheduling, billing, and collections.


The payor will probably look at the physician’s claim preparation history and can make an educated guess about whether the physician or his employees are properly applying the contract. If the payor is saving a lot of money through penalties and by downcoding billed services that do not meet contract requirements, the payor is not going to be very eager to send you an updated copy of the contract.


Payors know most medical offices are not persistent. When the payor fails to respond to the first request, very few medical offices make a second request. However, the squeaky wheel almost always gets the oil. Sometimes you have to be persistent and request a contract copy from the payor more than once. Remain polite and courteous each time you talk with the payor’s provider representative, but keep asking until you receive the updated contract with a current fee schedule. Then remember to call and thank the provider representative for the help you have received.



FEE SCHEDULES


Contract law is a serious matter. In February 2000, the courts ruled in favor of the payor when a hospital system wanted to exercise the right to cancel a particular payor contract without cause, as was allowed in the contract. The payor successfully argued that the hospital actually wanted to negotiate better fees before the expiration of the existing contract, and the judge agreed with the payor.


This case set a legal precedent that has become very difficult for physicians and other medical entities to overcome. To avoid facing problems such as this, ask your physician(s) to obtain the assistance of a medical CPA to negotiate realistic fees and a medical attorney to find and remove any other unfavorable contract provisions before each contract is signed or renewed.


Payor contracts discuss fees in a variety of ways. Many of them are designed to make you work to find the fee schedule, and a few are cleverly worded, which can easily mislead you about the true fee schedule.


Some payors use the resource-based relative value system (RBRVS) to calculate fees. RBRVS was introduced in Chapter 10. The payor gives a conversion number in the contract and tells which version of RBRVS to use when calculating the fee. The conversion number is the dollar value per relative value unit (RVU). The most common version of RBRVS is Medicare’s RBRVS fee schedule, but other publishers such as McGraw-Hill and Ingenix also publish RBRVS fee schedules. These other publishers usually assign RVUs to every CPT procedure code. Medicare only assigns RVUs to the procedures that are “covered services” for Medicare.


When Medicaid uses RBRVS, they usually use Medicare’s RBRVS fee schedule and assign a Medicaid conversion number (dollar value per RVU). Only Medicaid may have a conversion number lower than Medicare’s conversion number.


Workers’ compensation often has a unique RBRVS scale. When someone refers to the state’s RBRVS rate, they usually mean the state’s workers’ compensation RBRVS fee schedule. The “state” RBRVS usually applies only to workers’ compensation claims.


Some payors assign one conversion number (dollar value per RVU) for some services and another conversion number for other services. For example, one payor contract might assign the following conversion numbers: Medical services: 48.00, surgical services: 58.00, OB/GYN services: 54.00.


The medical office is expected to obtain a copy of the specified version of RBRVS, look up each procedure code, find the total number of RVUs assigned to each procedure code, and perform the mathematical calculations to determine each fee. Most RBRVS books have multiple columns. Separate columns show the breakdown between the work RVUs, the overhead (practice expense) RVUs, and the malpractice (risk) RVUs assigned to each procedure code both alone and with a specific modifier attached. Some RBRVS books include a column to show the assigned global periods for procedures that have global periods. Usually one of the columns gives the total number of RVUs for the procedure code or procedure code plus modifier.


The geographic practice site indicator (GPSI—pronounced “gypsy”) allows for regional cost differences and expenses that are common to a given region. The RVUs and the GPSI are stable numbers within a given region. The variable is the conversion factor identified in each payor contract.


First you multiply each of the work, overhead, and malpractice RVUs by the GPSI for each factor and then add them together to get the adjusted RVUs. Then you multiply the adjusted RVUs by the conversion factor (CF) (dollar value per RVU) to find the fee for each item [adjusted RVUs: (work RVU × work GPSI) plus (overhead RVU × overhead GPSI) plus (malpractice RVU × malpractice GPSI)] × CF = $. Use a calculator and double-check each of your numbers!




Because the law states you cannot bill Medicare a higher fee than you accept elsewhere for the same service,you must be sure the conversion factor in each of your contracts is higher than Medicare’s conversion factor. In 2005, Medicare’s conversion factor was 37.8975.




Medicare also publishes a fee schedule in which the RBRVS mathematical calculations have already been applied. It is listed each fall in the Federal Register, and it is often available on the Internet website for a state Medicare carrier. The only thing not yet applied is the GPSI. Medicare also will send a fee schedule with all the math, including the GPSI, to specific physicians upon request.


Very few other payors who use RBRVS offer that courtesy. You should take the time to do the math and create a fee schedule for each of your major payors that use RBRVS to use as a reference when you post payments.


The following illustration shows how to compare the fees for multiple conversion numbers. Each conversion number can represent a different payor, or it can represent a different specialty for the same payor. Add a column on the left for the correlating procedure code, and you also have a usable fee schedule comparison chart.


CF = conversion factor


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May 25, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on DEVELOPING CRITICAL THINKING SKILLS: ANALYZING PROBLEMS AND MAKING DECISIONS

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