Overtime (OT) pay is a requirement for employees who are paid on an hourly basis, termed non-exempt employees.  The law requires that any employee who works more than 40 hours per week is paid time and one-half for any hours over 40.  OT cannot be waived by an agreement between the employer and employee, and any workplace rule that “overtime is not allowed” will not mitigate the employer’s obligation to pay OT if the employee worked more than 40 hours.  The burden of monitoring work hours and preventing OT from occurring rests on the employer.

Some employers, especially small medical practices whose office hours may vary or small/young companies, attempt to classify workers as exempt (salaried) to avoid paying OT.  The DOL has very specific criteria for the positions that qualify for this exemption and many workers would be incorrectly classified as exempt.

Recordkeeping can also be a hot issue for small employers who are notorious for operating rather informally and resisting the use of time cards or time sheets.  It would be difficult for an employer to defend against an accusation of owed wages if the employee is not required to complete a document listing the actual hours worked.  The emphasis in the previous sentence is intentional as some employees enter on the timesheet the same 8:30 am to 5:00 pm for each day regardless of the real hours worked.  It’s not uncommon for an employee to begin work early and ‘clock in’ much later because the employer “won’t pay overtime.”

The last hot-potato issue for employers is the distinction between employees and independent contractors (I/C).  The IRS has very specific and strict criteria for the classification of an I/C; in a nutshell, “The more control a company exercises over how, when, where, and by whom work is performed, the more likely the workers are employees, not independent contractors.” Employers who erroneously classify employees as I/C are subject to fines and unpaid payroll taxes.

Wage and hour issues can quickly put a business in hot water and result in monetary penalties, embarrassment and loss of employee goodwill.  It’s advisable to re-assess your company’s activities to ensure compliance with these important regulations.

• No Medicare Secondary Payer (MSP) reason code on a primary claim.

• Lack of drug units when a National Drug Code (NDC) is present.

• No detailed description of an unlisted service.

• ZIP codes listed with only 5 digits.

• Billing provider address is a PO Box.

Read the entire article to find out how to correct these denials and make sure that your cash flow stays on track.

Hiring a new employee will often shed light on an outdated or outgrown process.  When you explain how to do things to a newcomer, if you step outside yourself for a time and listen with a third ear – as it were – you will hear yourself question it.  If you’re lucky, the new employee will be astute, forthright and assertive enough to ask good questions that highlight a convoluted process.  Most of the time, though, new people keep quiet because you’re the boss and you know your business; they figure they’re new so they’re hardly in a position to opine without coming across as argumentative from the start.  Another reason, and a sad one at that, is that they’re just not emotionally invested enough to want to find a better way.  These walking-dead remain employed a very long time, satisfied to collect a paycheck and if the process requires them to go around their elbow to get to their ear, well, they figure they’re getting paid to do that. The result is never good for the company.

Is there a process in your organization that’s taking longer today than it used to?  Something that needs correction or more increased oversight than it used to? Why not ask the people involved in the process to find a smarter, more efficient way to get things done?  As long as the goal and your particular standard for accomplishment or excellence are communicated in advance, let the individuals themselves –or those inclined to – sort through the steps and identify resource-savers that accomplish the objective.  This can be done via brief, group brainstorming sessions – ideally with no bosses in the room – or by small teams with a contest-type approach.  Even individual employees can give a thorny issue some thought during non-peak time and outline a new process.  You can ask the teams or people to present their ideas to a group for refinement (and even a vote for the winning idea), and/or consider empowering them to test their solution for a short time and then present the information.

I can boldly guarantee that a few things will happen:

1. You will learn of a great solution (or several!) that just might be better than the current process and be truly outside the box;

2.  You will refine a current process, replacing a few steps with a more efficient way; or

3.  You will reinforce that, really, the current process is just fine the way it is (as long as everyone’s been truly open-minded and not just adopted ‘group-think’)

Regardless of which result above eventually reigns, you will enjoy a more engaged, motivated workforce because your employees were asked their opinions and feel heard.  People want to contribute if we will only let them. They want to feel valued, and part of something beyond themselves.  Unfortunately, years of hitting the brick wall of the ‘way we’ve always done it’ sends the message that no one’s interested in their opinions. The key is to acknowledge the contributions and avoid making this another useless exercise where ideas are ignored or minimized.

Let’s begin with phrases that’ll be sure to make your customer happy.  Customers want the opportunity to explain themselves. So simply asking, “How can I help you” invites discussion.  Remember to always start your conversation on a positive note. Another important tip to keep in mind is to never let your customers forget you. The article lists several effective ways to follow up on your customers, such as letting your customers know what you are doing for them. As explained, this can be in the form of a newsletter mailed to existing customers, or it can be more informal, such as a phone call. One colleague calls them “Howdy Calls.”  The end of the article gives some real-life examples on dealing with unsatisfied customers and creating a positive outcome.

This article outlines six simple steps that will help to make change and transition in your office as smooth as possible:

Be an Open Book

• Communicate early and often.

Explain Yourself

• Offer reasons as to why the proposed change is necessary.

Alleviate Fears

• Reassure your staff that they are an important part of the office team and you will do what needs to be done to accommodate them individually during the transition.

Plan Ahead

• Stay organized and allow yourself ample amounts of time for planning.

Face Resistance

• Make sure you have the support you need and be prepared to address the concerns of those who view the change as negative.

Show Commitment

• Maintain strong leadership and remain positive.

FAQs: Additional Medical Review Projects and CERT

To help reduce the Comprehensive Error Rate Testing (CERT) program error rates, Palmetto GBA was recently funded by CMS to undertake additional medical review projects that involve medical review of and education for certain E/M coded claims, advanced imaging claims, major procedure claims, inpatient hospital claims and home health claims that contributed to the majority of the J11 MAC CERT payment errors. Providers selected for education and/or medical review are selected based on the frequency of their billings for the services/codes mentioned above.

Palmetto GBA’s educational and review efforts will primarily focused on reducing payment errors from insufficient documentation and improper coding. Providers will receive written results of the project’s findings if being selected for medical review

The following FAQs are developed to help clarify what the additional medical reviews involve and how providers can help in the process. For more information, please refer to the article The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests.

1.            Will the reviews be done on claims that have already paid? Claims review is focused on prepayment review at this time; however, post payment review will be initiated if necessary.

2.            Who will be selected for review and/or education for the additional medical review projects? All providers who bill the identified codes may be included in the review projects.

3.            Did I do something wrong to be included in this small sample review? Not necessarily. Providers were selected on the basis of their utilization of certain procedure codes. Being selected for review does not necessarily that a provider has done anything wrong.

4.            How will I know what claims have been selected for review? Providers will receive additional documentation requests (ADR letters) requiring medical records for each claim. The ADR will state the claims were selected as a result of a “special study” or “increased medical review.”

5.            How much time do I have to submit the requested documentation? It is important to provide the requested documentation within 30 days. If no documentation is received by our office within 30 days from the date noted on your ADR letter, the claim determination will be made based on the information present. Failure to respond to the documentation requests may result in further scrutiny by Palmetto GBA.

6.            How do I submit the requested documentation? Submit complete documentation as requested to the fax number or address located on the ADR letter. If you do not have the original ADR letter, please submit your documentation with the applicable fax cover sheet. Documentation for Part A claims should be faxed to (803) 462-2576. Documentation for Part B claims should be faxed to (803) 462-2577. Documentation for HHH claims should be faxed to (803) 462-2578.

7.            If I miss the deadline to submit the requested documentation, can I just resubmit the claim? Claims that were denied due to lack of documentation cannot be resubmitted as a new claim. Resubmitting a denied claim as a new claim is considered fraudulent billing practice. If you miss the deadline for the documentation request and you receive a remittance advice indicating a denial due to missing information (remark code N102), you may submit the requested complete documentation along with a Redetermination and Reopening Request form located on the Palmetto GBA J11 Part A, J11 Part B and J11 Home Health and Hospice website.

8.            What can I do if I disagree with the medical review decision on a claim? If you disagree with a claim decision, you may request a redetermination within 120 days from the date of the remittance advice.

9.               How will I learn of the review results? Providers will receive results in writing once all of their selected claims have been reviewed and results have been calculated.

10.            What are some common reasons for claim denials?How can I avoid these denials? Some common reasons claim denials to occur are:

• Missing or illegible provider signature or use of a signature stamp
  • Verify all documentation is signed prior to submission.
  • If a signature may be deemed illegible, print or type the provider’s full name near the signature.
  • For information regarding acceptable and unacceptable signature practices, please refer to the article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices.
• Missing or unsigned physician’s orders
  • Verify that any necessary orders are legibly signed and submitted with the requested documentation.

• Illegible documentation
  • Print or clearly write progress notes and all medical documentation if dictation is not used.
  • If you feel documentation may be deemed illegible, you may submit typed or dictated exact copies of any written documentation.  Make sure that any typed or dictated copies include the complete date of service and are signed legibly by the provider.
  • Ensure that documentation is clean and dark enough to be legible when received as a fax transmission.
• Failure to provide documentation for all dates of service requested.
  • Review the ADR letters closely to ensure that documentation is submitted for all dates of service requested.

Learn More

For additional information regarding redeterminations, please refer to the Appeals section of the J11 Home Health and Hospice website.

For tips on Home Health Billing or more info regarding this article, contact Imark Consulting, Inc. or www.homehealthbilling.com

Providers selected for probe reviews would have approximately 20- 40 claims selected for medical review. Providers that have been progressed to complex medical review would have a percentage of their claims selected for medical review that is commensurate to their charge denial rate. For example, a provider with a 40% charge denial rate on a probe review would likely be progressed to complex review with their edit set to suspend 40% of the claims they bill for medical review. 
 
Providers that have questions or issues related to the volume of claims selected for medical review should contact the phone number listed in their notification letter.  Prepayment medical review is also being performed by the ZPICs. If a ZPIC is performing prepayment medical review of a provider, the ADR letters will be on Palmetto GBA letterhead but will identify that the documentation is being requested by and should be returned to the ZPIC.

For tips on Home Health Billing or more info regarding this article, contact Imark Consulting, Inc. or www.homehealthbilling.com

• Updates technology and specificity.  ICD-9 was developed in 1979 and is now more than 30 years old.
• Improves public health tracking.  ICD-10 makes it easier for public health officials to track diseases and threats, dangerous settings, and even acts of bio-terrorism.
• Discourages up-coding and fraud.  More specificity will make it harder for providers to lump patients into a more severe disease or procedural category.
• Specifies reasons for patient noncompliance.  The current system offers one classification for patients who fail to follow a recommended regimen, while the ICD-10 offers at least eight.
• Detailed data on injuries and accidents.  ICD-10 offers information about injuries such as where they occur, what part of the body was injured, and what implements were used.
• Tracking of healthcare-associated conditions.  ICD-10 allows much greater explanation and accountability for adverse events that occur within healthcare institutions.
• Specifies procedures by degree of difficulty.  ICD-10 allows certain procedures to be subdivided by difficulty.
• Precision in reporting complications from medical devices.  ICD-10 allows providers to be much more precise in describing the nature of the malfunction.
• Creates jobs.  Conversion to ICD-10 will create jobs for coders and trainers.
• Aligns with EHR.  The conversion to ICD-10 will ensure that electronic medical records, value-based purchasing metrics, and meaningful use incentive programs speak the same language.

When It’s Negative

Complaints received about a particular staff member should always be dealt with in private.  When a complaint is more general, it is often beneficial to address it at the next staff meeting.  Your staff needs to know that you are aware of what is going on in the practice even though you may not be there to witness it personally.  In today’s economy, customer service is extremely important and as Mark Huizenga, a medical practice consultant points out, “A 90 percent satisfaction rate is just not good enough anymore.”

Say It Loud

Positive feedback, of any kind, should always be shared with the entire office staff.  Make sure to recognize individuals who receive stellar comments from patients.  Recognition at a meeting and even small rewards are great ways to emphasize to your staff that good customer service is valued at your practice.

Survey Results

Whether you conduct your own customer service surveys or monitor the online rating sites, patient comments, good and bad, should be shared with your staff.  These surveys are great ways of letting your staff know what is important to your patients when they visit your office.

Stay focused on the positive and let patient feedback motivate change in your office.