Reduce costs, maximize efficiency, increase revenue

Key Points

"It's critically important for us to get on board and be considered an integral part of what's coming," said Jason R. Miller, OD, MBA, FAAO, who is in a partnership private practice here, and a consultant and lecturer on billing and coding issues.

One of the objectives of the various reform measures focuses on "pay for performance" to encourage coordination of information and higher reimbursement for better outcomes. The Physician Quality Reporting Initiative (PQRI) currently offers an incentive payment for satisfactory reporting as specified by the Centers for Medicare and Medicaid Services but is also the first step toward pay for performance, Dr. Miller said.

In addition, the government will be offering incentives to encourage implementation of electronic medical records (EMR) and electronic prescribing. Use of these tools will be communicated to the government via specific PQRI codes. For example, in 2010, if doctors code G8553 (which means that at least one prescription was generated during the encounter and it was transmitted electronically using a qualified system), at least 25 times during the year, they will qualify for a 2% bonus.

With so many upcoming changes, Dr. Miller encouraged physicians to stay on top of these codes; otherwise, they might encounter penalties in the form of reduced reimbursements in the future. He also noted that many new EMR systems have practice management modules that will prompt the provider to use the appropriate level code or specific add-on codes and suggested that providers strongly consider using resources that allow them to mange their time more efficiently.

"Billing and coding is an integral part of what we do every day and of being successful in the business aspect of what we do," he said. "We need to know what we're doing, why we bill at a certain level, and how we can maximize the success of our business. Obviously, taking care of eyes is what we all want to do, but we want to be able to remain in business and be paid appropriately for our time and expertise."

Because of the reform initiatives, increased competition within the healthcare industry, and a trend toward decreasing provider reimbursement, the need for accurate billing and up-to-date information is greater than ever, Dr. Miller said. He acknowledged that while few optometrists enjoy spending time on the billing and coding side of their practices, they need to know if it's being done properly.

Benchmark billing, coding

One of the strategies for success in billing and coding is to establish measurable ways to look at accounts receivable.

The clinician should review a monthly report from the practice billing manager or the billing agency to determine whether any insurance carriers should be dropped because of habitually slow reimbursement. A monthly self-audit can also ensure that proper documentation is being provided for codes.

Another strategy to reduce processing costs may be outsourcing the billing department. Most outsourcing companies are paid based on a percentage of what is collected and have an incentive to stay on top of denials and follow up on any unpaid claims.

"This may allow us to focus on what we do best, which is seeing patients," Dr. Miller said.