7 Good Questions

I was visiting with an HME client recently and, while talking about the challenges her company faced, she expressed a feeling of isolation. She said she felt all alone in her little HME world in Rural Town USA. She wondered if other HME companies faced similar challenges and had similar feelings, and asked what others would do in her situation.

Of course, I know her feelings and questions aren’t unique. After all, I spend my life traveling to all corners of this country consulting with all types of HME providers, and I get the same questions everywhere I go.

No matter where you are, or what kind of company you have, many of the challenges you face are the same as those of your peers. Here’s a list of the most common questions providers ask me and the answers that can help.

1. What should I do about additional documentation for Medicare patients? What about chart notes? How much is enough? According to Medicare, “neither a physician’s order nor a CMN nor a DIF nor a supplier-prepared statement nor physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. “There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier-prepared statement or physician attestation (if applicable). “There must be clinical information in the patient’s medical record which supports the medical necessity for the item and substantiates the answers on the CMN (if applicable), or information on a supplier prepared statement, or physician attestation (if applicable).” Medicare goes on to say: “The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or home health agency records and records from other professionals including, but not limited to, nurses, physical and occupational therapists, prosthetists, and orthotists.” This really places you in a vulnerable position since Medicare can arbitrarily decide in a post-payment audit that the medical necessity information you gathered is simply not enough. If the auditors don’t believe the patient’s medical record substantiates the patient’s need for the item(s), they can recoup your money. (You can’t ask the patient to pay unless you have a valid ABN.) Knowing this, I would recommend that you make a business decision by evaluating each of the product categories covered under Medicare and determine how far you will go. Ultimately, you have to feel comfortable with the amount and appropriateness of the documentation you receive. To think that the doctor is going to memorize the Medicare coverage guidelines is ludicrous. Rather, what you should hope for is that the doctor’s chart notes match those of the CMN/written order. At a minimum, the doctor’s notes should state why the patient needs the item.
2. How many staff members should I expect to man my billing department? It truly depends upon your product and payer mix, your company’s size and the tasks performed in the billing department. But as a general rule, the ratio is $500,000 to $750,000 per biller. Keep in mind that the variables mentioned above will dramatically impact this figure.
3. How do I set goals for my staff? Sit down with individual members of the department and determine how much time they spend on their tasks. Come up with a weekly number of hours spent for the department. Reallocate as appropriate: If someone is carrying a 50-hour-a-week burden while a coworker is really only putting in 30 productive hours per week, reassign tasks to make the jobs 40 hours each. Once you have allocated the right number of hours for employees, look for the average amount/number of each task they should perform. Rank them accordingly, either 1-5 (where 5 = 100 percent of a task completed, 4 = 95 percent completed, etc.), or by some other measure that works for your staff.

1. Reward those who exceed expectations. Rewards can be monetary or motivational (pizza lunch, paid time off, recognition in front of superiors and coworkers or promotions). Make sure that goals are measured and accomplished relatively quickly (short-term goals work better) and retool/tweak the goals as needed. Consistency and follow-through are imperative to the success of this type of measure. Improved productivity should follow.
2. How do I know when it is time to switch computer systems? This is a hard question to answer. I recognize that the cost of a new automated billing solution is more than the cost of the software; it is also the time spent learning the system, or the learning curve. This can take three, six or even 12 months to overcome and may actually be more costly than the cash outlay for the software. So, it is far easier not to switch software systems if this is a possibility. Even so, when your vendor stops updating the system, when you can’t get your billing out, when you can’t track your company’s progress at all (with no valid or accurate reports to gauge your performance), it may be time to switch systems. Remember that the learning curve is typically greater and longer than you anticipate, and you will always encounter certain dislikes with your new system. If you can manage to obtain 80 percent of what you are looking for in a new system and you have a compelling reason to change, you should do so. Attending Medtrade is a perfect way to take a glance at the various software vendors. Create a list of what features you would like to see in your software solution, which are “musts” and which ones you can live without.
3. Is it better to centralize or decentralize operations? As a general rule, it makes sense for companies to perform like activities together. For companies with more than one location, I am often asked if it is more advantageous to use a centralized or decentralized approach. While I have seen both ways work, to have experts in every branch location doing the same billing functions usually doesn’t promote maximum control and productivity. People tend to work autonomously in their respective offices and without consistent and constant supervision by the same manager, productivity wanes. Therefore, it makes sense to handle billing at one location, such as the corporate office, where you can reach more economies. On the other hand, activities such as retrieving medical necessity documentation and order intake require relationships with referral sources that are typically forged at a local branch level. That is why you often find order intake and even documentation retrieval at the branch location. But by having as many functions as possible performed at the corporate office, productivity should result.
4. How do I keep better track of inventory? Inventory tracking should be automated in today’s environment. Everything from minimums and maximums as well as automated purchasing and receiving complete with bar coding and much more should be available. Performing manual counts and manual serial tracking is difficult, at best. This typically leads to items that sit waiting for repair because nobody has a report to see how many are out of service. Outages and loss occur more frequently when you have no automated way of tracking inventory. If your billing software doesn’t have an adequate inventory package, look to purchase outside software. Optimally, your software solutions should all be integrated, but if you know you won’t be able to get inventory software with your billing software, work with an outside package. If and when competitive bidding is revamped, you will absolutely need inventory management reports to submit a bid. Moreover, one of your biggest expenses is your cost of goods. You should be in a position to improve efficiencies by gaining control over inventory through automation.
5. Once I regain control over my A/R, how do I keep it from growing out of control again? The best way to maintain control over your accounts receivable is to work denials immediately upon receipt and check the status of your claim/invoice the minute it is past due.

There’s no need to check before it is time, but staying on top of this will prevent you from growing A/R like in the past. This means that if you expect an insurance company to pay a claim in 30 days, by day 31 you should be checking the whereabouts of your payment.

Assign each of your larger payers their own timeline/deadline after which you begin checking status of your payment. Typically your staff’s work is segregated by insurance type, and as such, they should be able to manage this.

The ultimate goal is for the employee to arrive at work in the morning with his/her list of “to-dos,” including which claims require follow up that day and which denials need to be resolved. Together, these two primary tasks should help keep A/R under control.

Miriam Lieber is president of Lieber Consulting, Sherman Oaks, Calif., specializing in operations management and reimbursement for the HME industry. You can reach her at 818/789-0670 or by email at [email protected].