Placing the billing in the correct bins for echocardiography
Garris said the billing for echocardiography starts with classifying the service provided as diagnostic or therapeutic. It is then coded as transthoracic echo (TTE), transesophageal echo (TEE) or interventional echo to help guide structural heart procedures.
The site of service is also coded by the medical billers, as the fees paid are different if a service is at a hospital or an outpatient center. Some on the more advanced echo services, including contrast echo, can only be performed and billed by a hospital or other center with support services due to the risk of complications.
The echo exam is also also further classified by the medical billers for professional fees and technical fees. The technical fees are for costs related to obtaining the exam and any supplies used.
Professional fees are billed for the physician's time to read the exam; these are based off the latest physician fee schedule. Depending on their site of service, they would bill under the current procedural terminology (CPT) code for office-based services, or an ambulatory payment classification (APC) code for a hospital or outpatient location.
The role of medical billers in echocardiography reimbursement
The medical billing office receives the information to bill for any services provided. The physician will always write in their notes in the medical record the services they performed, and coders then need to match up these details with the proper billing codes. If something is missing from the notes, it will not be billed or paid for.
"We always say documentation, documentation and documentation. That must be there for any service provided or else you will not get paid for it," Garris said.
After filing the billing claims to the proper insurance providers, the medical coders also need to review remittance forms from payers to double check what is paid and what was rejected, missed or underpayed. For rejected or underpaid items, the coder then needs to appeal.
Rejection of medical billing claims and insurance company delaying tactics
If a billing claim is rejected due to a discrepancy, the billing can be amended and may require additional medical documentation. This can usually be done through a portal with the payer, but it sometimes requires a paper claim. Garris said some of the big insurance companies are no longer accepting large documents through their portals, so it requires paper documentation to be gathered and sent to them through the mail.
Garris said this is also a common tactic where insurance companies deliberately add more layers of red tape and slow the claims process down to make it less efficient. Payers hope that if may not be worth the time and added expense of medical providers to go through the extra efforts, which saves the insurance companies money. Garris said the back office that needs to do all the leg work to find the additional documentation, copy it and mail it off spend a large amount of time dealing with these types of rejected claims.
Another thing happening more and more recently is the rejection or underpayments by insurance companies because the providers charged for the full amount and not a contracted reimbursement amount. She said this is when payers try to sneak in a lower reimbursement amount as part of their contract with a health system.
Prior authorization for echocardiography
Nearly all payers require a prior authorization form be submitted first before a cardiac ultrasound exam is performed. This pre-review of the reasons for the exam are to ensure the test is medically necessary before the insurance company will agree to pay for the test.
While the argument or prior authorization on echo exams is to reduce healthcare costs and ensure the test is really needed, physicians and patients generally see prior authorizations as added hoops they are required to jump through by insurance companies. Providers and medical societies often say insurance companies require pre authorizations to deliberately make access to healthcare more cumbersome. In addition, it is often argued that these increase the costs for healthcare instead of decreasing them due to the fact that they require additional resources to manage on a daily basis.
"Prior authorization is required by nearly all payers except Medicare. Prior authorization requests are usually done via a portal or telephone call to make sure the diagnostic test meets the requirements. Usually, there is an entire team that is just doing prior authorizations for practices. Prior authorizations have definitely increased in recent years, and there is a lot more red tape in getting those prior authorizations completed," Garris explained.
Healthcare providers often have no idea what insurance companies are looking for in a patient profile when it comes to prior authorizations. This is often referred to as a "black box" because rejections for some prior authorizations are a complete mystery to the medical provider. She said this then requires even more time to be spent by support staff to go back and forth with the payer to get the prior authorization approved.
"There is an impact on healthcare systems, because every time you touch a claim, there is a cost at the physician's office," Garris explained.
The role of the RUC and RVUs in physician payments
The Relative Value Update Committee (RUC) is made up of physicians who make recommendations to CMS on how to create relative valve units (RVU), which are used as the basis for how CMS pays for physician services. The committee sends out an RUC survey to physicians to find out how much time, thought, materials and other costs go into diagnosing or treating a patient. This information is used to update the RVUs.
However, the RUC surveys are largely ignored by physicians, because they can take time to fill out. Garris said only about 10% of echocardiographers respond to the RUC surveys, so more than 1,000 physicians need to be contacted to get 100 responses.
"The survey asks very specific questions such as, 'What is the intensity of the service?' or 'How much mental capacity is used to perform the service?' ... Other questions will ask about the supplies used, the equipment and clinical staff that are used to provide the service. We want to make sure that we account for everything, so everything is included in the payment rate," Garris explained.
Impact of budget neutrality on Medicare payments
Under law set by Congress, CMS must stay within its budget, so any increases in one area of the CMS budget means cuts elsewhere in what is referred to as "budget neutrality." As more patients enter the Medicare system as the populations ages, or as the cost of providing services increase due to inflation, CMS needs to cut reimbursements across the board to ensure it stays within its budget.
Each year, CMS makes cuts in reimbursements for this very reason, and those cuts generally have a heavy impact on physicians. Cardiology societies have all called for Medicare payment reform and the elimination of these annual cuts because they say it will eventually impact care for Medicare patients. This includes discussion in some health systems about no longer providing services to medicare patients because the reimbursements do not cover the costs of providing the services.
"I think a lot of practices are getting to that point where it is just not feasible for them to see Medicare patients any longer. Medicare has a fixed pot, so when you add more patients and services each year, everyone's slice of that pie gets slimmer and slimmer. I think everyone would agree that the current fee-for-service model is not working appropriately and there needs to be a fix," Garris explained.