Billing Practices Research Articles

What Is Left of Charity Care after Health Reform?

The passage of the Patient Protection and Affordable Care Act on March 23, 2010, significantly changes the health care landscape. But even with the considerable expansion of insurance, many people will still lack coverage. When fully implemented, the act is designed only to cover about thirty-two million of the forty-six million uninsured Americans. Illegal aliens are specifically excluded. For others, implementation is immediate; the so-called individual mandate, for example, does take effect until 2014, and there are exceptions for people for whom available policies are still too expensive, or who have religious objections. Once in effect, the mandate has limited penalties, and some people will choose to purchase coverage despite the legal requirements. Who will provide care for the remaining twenty million or more people who will still be uninsured? Nonprofit hospitals have long functioned as the safety-net in our health system, but the requirements for charity care seem to be evolving. (1) A 2007 Internal Revenue Service report stated that about half of nonprofit hospitals spent 3 percent or less of revenues on charity care. Nowadays, hospitals are bringing in large amounts of money, paying their CEOs record amounts of compensation, and engaging in aggressive debt recovery actions. Richard Scruggs, the high-profile attorney who spearheaded the litigation against the tobacco companies, has filed a class action lawsuit against nonprofit hospitals for their billing and collection practices. The Financial Accounting Standards Board announced in April 2010 that it was interested in comments on current practices of measuring charity care for accounting disclosure purposes. Senator Charles Grassley has proposed federal legislation to establish minimum charity care standards for hospitals. The Illinois Supreme Court recently upheld the revocation of Provena Hospitals' state property tax exemption in Urbana, on the basis that the property in question was put to a sufficiently under Illinois law. With many other state and local tax authorities scrutinizing nonprofit hospitals, this question has moved to the forefront of health law debates. What obligations should nonprofit hospitals have to provide charity care? According to the current benefit standard, nonprofit hospitals must meet certain requirements in order to maintain their federal tax-exempt status. The requirements, set out in Internal Revenue Ruling 69-545 (1969), do speak directly to the need for charity care, but rather highlight a series of criteria such as operating a full-time emergency room, providing nonemergency services to all who are able to pay, participating in Medicare and Medicaid, having a representative governing board, allowing staff privileges to all qualified applicants, and reinvesting surplus funds in operations. Interestingly, IRR 69-545 replaced the old of financial ability standard, which required hospitals to provide charity care to the best of their financial ability precisely because of hospitals' concern that the then-new federal health programs (that is, Medicare and Medicaid) would obviate the need for charitable services. The community benefit standard was designed to broaden the types of activities that would suffice for tax-exempt status. Ironically, hospitals and regulators have focused primarily on charity care expenditures in applying the standard over the last four decades. The new health reform legislation addresses some of the charity care issues. It states that hospitals can charge patients qualifying for financial assistance not more than the amounts generally billed to insured patients. This is to address the concern that uninsured patients might be charged amounts significantly above the rates paid by insured patients so as to make the amount of charity care provided by the hospital seem as high as possible. It limits the use of extraordinary collection actions until a hospital has made reasonable efforts to determine whether the patient in question is eligible for financial assistance. …

Documentation Improves Your Efficiency

Documentation Improves Your Efficiency

Hospital supplements in Belgium: Price variation and regulation

Although there is a comprehensive public health insurance system in Belgium, out-of-pocket expenditures can be very high, mainly for inpatients. While a large part of the official price is reimbursed, patients are confronted with increased extra billing (supplements). Therefore, the government imposed various restrictions on the amount of supplements to be charged, related to the type of room and the patient's insurance status. We investigate how prices are set and whether the restrictions have been effective. We use an administrative dataset of the Belgian sickness funds for the year 2003 with billing data per hospitalisation and hospital characteristics. Boxplots describe the distribution of several categories of supplements. OLS is used to explore the relationship between hospital characteristics and extra billing. There is a large and intransparent variation in extra billing practices among different hospitals. Given the room type, supplements per day are smaller for patients qualifying for protection, confirming that the regulation is applied quite well. However, because of their longer length of stay this does not result in lower supplements per stay for these patients. Currently the price setting behavior of providers lacks transparency. Protective regulation could be refined by taking into account the longer length of stay of vulnerable groups.

Pricing Practice in the Postal Industry: Current Approaches and Challenges Under Liberalization

Challenges facing the European postal industry are greater then ever before. The approaching full market opening in 2011 and 2013 will be the central factor driving commercial developments, where new market entrants - without the burden of the universal service obligation and additional social responsibilities as one of the largest employers in their domestic markets - will have the possibility to attract large volume B2B/B2C mailers away from incumbent national postal operators, and especially on the high-margin, high-density urban areas. Traditional bulk mailers such as financial service providers, telecom companies and utility service providers, which are themselves under pressure to maintain there revenue streams and/or decrease operational costs, will search for cost efficient mailing alternatives and thereby foster postal competition. Substitution through electronic/hybrid communication is also a continuing major force cutting into transactional mail volumes. Understanding customer demand and the development of customer oriented solutions will become central issues for postal operators. Part of this customer orientation will be a shift in pricing policies, which today are often considered as purely a regulatory determined component in the revenue equation, with the primary focus of commercial activity being on volume development rather than on innovative pricing and billing practices. As postal operators are dominant market players in domestic mail markets, full market opening will not mean the absence of regulation. To the contrary, strong supervision will limit their margins in price definition for universal service products, which have complex interactions with bulk mail products. Thus, a major challenge facing European postal operators besides competition is how to retain market share and price level simultaneously. Price will be an important influencing factor for customers when new entrants with similar service levels appear. Therefore in this study we undertake to analyze current practices of postal operators and, together with the study participants, formulate key lessons on what should be part of preparation for full market opening in terms of market-oriented pricing. The study was realized in three stages. We first overviewed major trends on the European postal market with an eye on the role of pricing in a liberalized environment. As a second step, through structured interviews with selected operators on current and planned pricing practices, we attempted to understand current approaches to pricing strategies. Finally, by a comparison of results on a regional level, we formulated key lessons learned. Marketing, strategy and pricing experts of incumbent postal operators were visited personally or interviewed by phone. In all cases we applied the same interview structure, which was focused on the underlying pricing framework and on pricing processes. Under “pricing framework” we evaluated the pricing strategy, the organizational structure in place for dealing with pricing issues, the methods facilitating pricing decisions and the supporting technology. “Pricing processes” summarized the practices on pricing activities, including market analysis, pricing structures, implementation and monitoring of pricing outcomes. The research scope included European postal operators facing various stages of market opening. Altogether we interviewed 17 incumbents; for confidentiality reasons the study results were synthesized into Eastern and Western European practices in order to disguise the individual responses.

RVU Ready? Preparing Emergency Medicine Resident Physicians in Documentation for an Incentive‐based Work Environment

The emergency medicine (EM) job market is increasingly focused on incentive-based reimbursement, which is largely based on relative value units (RVUs) and is directly related to documentation of patient care. Previous studies have shown a need to improve resident education in documentation. The authors created a focused educational intervention on billing and documentation practices to meet this identified need. The hypothesis of this study was that this educational intervention would result in an increase in RVUs generated by EM resident physicians and the average amount billed per patient. The authors used a quasi-experimental study design. An educational intervention included a 1-hour lecture on documentation and billing, biweekly newsletters, and case-specific feedback from the billing department for EM resident physicians. RVUs and charges generated per patient were recorded for all second- and third-year resident physicians for a 3-month period prior to the educational intervention and for a 3-month period following the intervention. Pre- and postintervention data were compared using Student's t-test and repeated-measures analysis of variance, as appropriate. The evaluation and management (E/M) chart levels billed during each phase of the study were significantly different (p < 0.0001). The total number of RVUs generated per hour increased from 3.17 in the first phase to 3.71 in the second phase (p = 0.0001). During the initial 3-month phase, the average amount billed per patient seen by a second- or third-year resident was 282.82 USD, which increased to 301.94 USD in the second phase (p = 0.0004). The educational intervention positively affected resident documentation resulting in greater RVUs/hour and greater billing performance in the study emergency department (ED).

For a Few Dollars More: the Perplexing Problem of Unethical Billing Practices by Lawyers

The once forbidden subject of unethical billing practices by lawyers is now openly discussed. Reported cases in which lawyers are professionally disciplined or criminally prosecuted for billing abuses are disturbingly routine and press accounts of lawyers' alleged billing and expense fraud are similarly common. These cases have a disproportionately negative effect on the legal profession and are personally ruinous for the lawyers involved. Despite the obvious negative consequences, however, unethical billing practices persist. This article examines this phenomenon. In doing so, it analyzes the reasons for lawyers' misconduct from a practical perspective. These reasons include lawyers' ignorance of, or insensitivity to, applicable standards of conduct; the absence of stable professional bonds; lawyers' competitiveness; law firm compensations systems that directly reward lawyers' productivity based on billable hours; lawyers' perceptions of clients as adversaries; greed and envy; and mental illness, personality disorders, and substance abuse. In discussing fraudulent billing, the article further draws on the psychology and sociology of white collar crime, which is plainly appropriate because billing and expense fraud by lawyers fits neatly within the definition of white collar crime in all respects. Having analyzed the reasons for lawyers' unethical billing practices, the article discusses strategies that law firms may employ to address the problem. The article concludes with a discussion of lawyers' duty to report colleagues who engage in billing and expense fraud to professional authorities under Model Rule of Professional Conduct.

The Most Costly Billing Practices Ever

Accurate coding for proper reimbursement is important to all health care practitioners for many reasons. Nurse practitioners (NPs) are a group that is often involved in billing, either directly for their own services or by checking diagnostic and procedural codes on a billing form used by their employer to bill for their services. The NP or other professional provider is responsible for the accuracy of this coding and billing, as well as for maintaining medical records that verify and amplify the basis for the coding. An NP who knowingly or in deliberate ignorance cheats on coding to enhance his or her reimbursement may be guilty of both civil wrongs (including violation or breach of the insurance contract) and a crime, which can be costly to both the NP and any affiliated physicians or other practitioners.

Concordance of chart and billing data with direct observation in dental practice

The commonly used methods of chart review, billing data summaries and practitioner self-reporting have not been examined for their ability to validly and reliably represent time use and service delivery in routine dental practice. A more thorough investigation of these data sources would provide insight into the appropriateness of each approach for measuring various clinical behaviors. The aim of this study was to assess the validity of commonly used methods such as dental chart review, billing data, or practitioner self-report compared with a 'gold standard' of information derived from direct observation of routine dental visits. A team of trained dental hygienists directly observed 3751 patient visits in 120 dental practices and recorded the behaviors and procedures performed by dentists and hygienists during patient contact time. Following each visit, charts and billing records were reviewed for the performed and billed procedures. Dental providers characterized their frequency of preventive service delivery through self-administered surveys. We standardized the observation and abstraction methods to obtain optimal measures from each of the multiple data sources. Multi-rater kappa coefficients were computed to monitor standardization, while sensitivity, specificity, and kappa coefficients were calculated to compare the various data sources with direct observation. Chart audits were more sensitive than billing data for all observed procedures and demonstrated higher agreement with directly observed data. Chart and billing records were not sensitive for several prevention-related tasks (oral cancer screening and oral hygiene instruction). Provider self-reports of preventive behaviors were always over-estimated compared with direct observation. Inter-method reliability kappa coefficients for 13 procedures ranged from 0.197 to 0.952. These concordance findings suggest that strengths and weaknesses of data collection sources should be considered when investigating delivery of dental services especially when using practitioner survey data. Future investigations can more fully rely on charted information rather than billing data and provider self-report for most dental procedures, but nonbillable procedures and most counseling interactions will not be captured with routine charting and billing practices.

253: A Survey of Emergency Department Radiology Coverage and Contemporaneous Billing Practices

To assess emergency department (ED) radiology coverage in Michigan and to assess awareness of Centers for Medicaid and Medicare Services (CMS) rules regarding payment for contemporaneous provision of services. Current CMS policy encourages a one-time payment for an interpretation, to a physican, regardless of specialty, if the interpretation is contemporaneous with care rendered.

Population Health and Tax-Exempt Hospitals: Putting the Community Back into the 'Community Benefit' Standard

Disputes about tax-exemption are occurring all over the country. The IRS and CBO are engaged in national studies of non-profit hospitals and community benefits. State governments are considering whether to legislate minimum amounts of charity care in exchange for tax-exemption. Congress is debating whether hospitals should remain a part of the non-profit sector at all. At the same time, uninsured individuals are suing hospitals for unfair billing and collection practices. Creative accounting and expansive definitions of free care have led to a variety of non-ideal practices by hospitals in order to balance their bottom line, while at the same time maintain tax-exempt status. This article argues that the longstanding focus on providing individual charity care to meet the community benefit standard for tax-exemption is misguided. Instead, I determine that there are conceptual and practical arguments for requiring hospitals to provide population or public health benefits. I offer a detailed analysis for implementing a new standard, and a framework for quantifying community benefit under that standard. The suggestions set forth should result in better, more expansive benefits for communities; clearer guidance for health care institutions and tax authorities; and fewer problematic incentives for tax-exempt hospitals attempting to meet their community benefit obligations.

We Have an Obligation to Medical Insurers

We Have an Obligation to Medical Insurers

Probe samples and the minimum sum method for medicare fraud investigations

Random sampling of paid medicare claims has been legally acceptable for investigating suspicious billing practices by health care providers since 1986. A population of payments made to a given provider during a given time frame is isolated and a probability sample selected for investigation. A lower confidence bound for the total amount overpaid to the provider is then used as a recoupment demand. Edwards et al. (Health Serv Outcomes Res Methodol 4:241-263, 2005) show that methods based on the Central Limit Theorem can fail badly and propose an alternative method, called the minimum sum method, for fixed sample sizes. In this paper the sampling is performed in two stages. In case of little abuse in the first stage the investigation is stopped; otherwise a second sample is examined. Based on this strategy a lower confidence bound for the total number of universe payments in error and a corresponding lower bound for the total overpayment amount are defined. Criteria for choosing the sampling parameters are considered. Relative efficiencies are studied.

Using ANT to understand the implementation of a billing and patient management system in an IPA

Healthcare organisations in the US are facing the daunting task of trying to stem escalating delivery costs and yet provide higher quality. While the specific solution has yet to be determined, all are agreed that ICT (information communication technology) use holds the key. Therefore, we are seeing the embracing of various billing and practice management systems as well as electronic patient records systems in the US healthcare sector. In such an environment, it becomes critical to understand the key dynamics so that superior operations and, thereby, value driven, patient centric and IT enabled healthcare delivery ensues. The following uses ANT (actor network theory) as a useful lens to support a detailed analysis of the implementation of a billing practice management system in an IPA (independent practice management system).

A Critique of the American Bankers Association's Study on Credit Card Regulation

This Critique takes issue with four of the main assertions of the American Bankers Association's Study on Credit Card Regulation. First, this Critique addresses the ABA Study's claim that credit card pricing is risk-based and demonstrates that only certain elements of card pricing are marginally risk-based; overall, credit card pricing is not risk-based, and risk-based pricing does not explain card issuers' abusive and manipulative billing practices such as unilateral term changes, two-cycle billing, universal cross-default, and retroactive application of higher interest rates. Instead, these practices are merely rent extraction devices that allow card issuers to take advantage of cardholder lock-in. Second, the putative benefits of risk-based pricing?lower costs of credit to creditworthy consumers, and greater availability of credit to subprime consumers?are either illusory or attributable to other causes. To the extent that credit card interest rates have declined over the past two decades, it is attributable to issuers' decreased cost of funds, and overall, credit card pricing may not have decreased for any consumers. Greater subprime access to credit cards is attributable to issuers' ability to pass off risk and increase lending capacity through securitization, and increased credit card access is hardly a boon absent ability to repay debts. Third, this Critique shows that contrary to the ABA Study's claims, credit card debt now supplements, rather than replaces other forms of consumer debt. And fourth, this Critique exposes the flaws in the ABA Study's conclusory assertion that there is no basis for credit card price structure regulation. Instead, seven of the eight standard independent reasons for regulation apply squarely to credit cards, making regulatory intervention in the credit card market a question of how, not whether.

Obesity Impacts Access to Kidney Transplantation

Current billing practices and mandates to report surgical outcomes are disincentives to surgical treatment of obese patients, who are at increased risk for longer hospital stays and higher complication rates. The objective of this study was to quantify the independent association between body mass index (BMI) and waiting time for kidney transplantation to identify potential provider bias against surgical treatment of the obese. A secondary data analysis was performed of a prospective cohort of 132,353 patients who were registered for kidney transplantation in the United States between 1995 and 2006. Among all patients awaiting kidney transplantation, the likelihood of receiving a transplant decreased with increasing degree of obesity, categorized by ranges of BMI (adjusted hazard ratios 0.96 for overweight, 0.93 for obese, 0.72 for severely obese, and 0.56 for morbidly obese, compared with a reference group of patients with normal BMI). Similarly, the likelihood of being bypassed when an organ became available increased in a graded manner with category of obesity (adjusted incidence rate ratio 1.02 for overweight, 1.05 for obese, 1.11 for severely obese, and 1.22 for morbidly obese). Although matching an available organ with an appropriate recipient requires clinical judgment, which could not be fully captured in this study, the observed differences are dramatic and warrant further studies to understand this effect better and to design a system that is less susceptible to unintended bias.

Abstract 1779: The Negative Impact of Diagnostic Testing Performed Prior to Adult Congenital Heart Disease Referral - Financial Burden and Cost to the Patient

Adult congenital heart disease (ACHD) patients (pts) are an underserved, complex, rapidly expanding population and, despite surpassing the volume of pediatric CHD pts, neither IM or pediatric cardiology fellowship fully prepares physicians to care for this group. The diagnostic studies recommended, technical skills required, and unique data interpretation requires specialized training in both disciplines. Therefore, we sought to determine whether pts referred to our ACHD program underwent appropriate and complete testing prior to referral and evaluated the financial impact of unnecessary and repeat testing. Methods: We reviewed diagnostic testing before and after referral to the ACHD program for consecutive new pts (&gt;18 yo). All cardiovascular testing prior to referral and subsequent testing were recorded. Unnecessary testing was defined as those performed outside of guidelines or inappropriate for their CHD. Incomplete testing was defined as that which required repeating. Financial cost of unnecessary and repeat testing was estimated based on usual insurance billing practice. Results: From 2/06 to 4/07, 200 new pts were referred to the ACHD program, mean age 33.2 ± 12.7 yrs (range 18.1–72.9 yrs). Common diagnoses included ASD (17%), TOF (14%), bicuspid aortic valve (11%) and COA (10%) with 81% classified as moderate or complex CHD. Unnecessary testing consisted of 35 stress studies (25 nuclear and 10 echo), 5 TEEs, and 14 cardiac caths. Repeat studies for incomplete testing were necessary in 65/81 TTEs (80%), 9/39 TEEs (23%), 0/5 cardiac CTs, 8/12 CMRs (67%) and 16/31 caths (51%). Overall,105/200 pts (52%) endured unnecessary or repeat testing carrying a conservative financial burden of $456,980; 916 patient hours: and 114 patient work days lost. Conclusions: Diagnostic testing in ACHD requires specialized training from technician to physician. Repeat testing was necessary in 58% of studies, and 52% of the pts were affected by unnecessary or repeat testing. Therefore, ACHD pts frequently endure unnecessary and repeat testing which carries a financial burden to the patient and health care system and medical risk to the patient. Adults with moderate and complex CHD should be referred to appropriately trained ACHD providers prior to diagnostic testing.

Price Transparency: Building Community Trust

With the push from policymakers, payers, and consumers for hospitals to make their prices public, healthcare executives need to recognize two central issues related to price transparency: 1) meaningful price transparency involves helping patients and consumers understand their financial obligation for an episode of care, and 2) price transparency is key to the most critical success strategy for healthcare providers: building trust. This article reviews the history of pricing and billing practices and explores why price transparency is not easily achieved in today's environment. Pricing is a mystery even to those of us who work in the field, yet despite its complexity, the call for price transparency is not going to go away. For transparency, the goal should be to establish a rational pricing system that is easily explainable and justified to all stakeholders. Healthcare executives must make pricing a priority, understand cost, develop a pricing philosophy, understand the overall revenue requirements, examine market conditions and prices, and set up systems for review. A rational process of price setting should enhance community trust. In this matter there is nothing less at stake than the hearts of our community members.

Clinical Documentation in Speech-Language Pathology

Clinical Documentation in Speech-Language Pathology

Third‐party billing of multifamily customers presents new challenges to water providers

Third‐party billing for water and wastewater in the multifamily housing sector is growing at an estimated rate of 25% per year, but many water providers are unaware of the effect, implications, administrative issues, and potential water savings of this practice. The National Multiple Family Submetering and Allocation Billing Program Study evaluated the merits of separate billing programs including the potential water savings, costs, and benefits from the perspectives of utilities, property owners, and residents and analyzed the accompanying administrative and regulatory issues. Properties equipped with submeters or that have undergone a billing system conversion were identified and compared against control properties in which water and wastewater fees are included as part of the rent. It was found that the practice of installing individual water meters (submetering) in multifamily properties and billing based on actual consumption results in substantial water savings. Water billing practices based on allocation methods (ratio utility billing systems) did not effect savings in water consumption.

Institutional Civil Disobedience: a case study in unintended outcomes

As industry-wide incentives and mandates increasingly influence entrepreneurial organisations to adopt efficiency-generating practices, the power of inter-organisational consensus can become ingrained to the point where illegal or unethical behaviour may become widely accepted. Using the healthcare industry as a natural experiment, we suggest that forces that promote technology adoption can also have unforeseen negative consequences as they become part of the professional institution, and may serve to have undesirable effects across a given industry. In the USA, industry-specific technology adoption mandates related to healthcare billing practices have met with some resistance from managers and professional groups, who have openly accepted a type of 'institutional civil disobedience', or ICD, in response to perceived unfair or ambiguous reimbursement policies. There is evidence, however, that such behaviour can lead to unforeseen outcomes (i.e., underbilling) that ultimately cause more harm than good for professional stakeholders. This study highlights the phenomenon of ICD and its role in generating unforeseen consequences.